Sexually Transmitted Infections (STIs) Chapter 52 Copyright © 2017, Elsevier Inc. All Rights Reserved. LEARNING OBJECTIVES • 1. Identify factors contributing to the high rates of sexually transmitted infections (STIs) in the United States. • 2. Describe the etiology, clinical manifestations, complications, and diagnostic studies for chlamydia, gonorrhea, trichomoniasis, genital herpes genital warts, and syphilis. • 3. Compare and contrast primary genital herpes with recurrent genital herpes. • 4. Explain the interprofessional care and drug therapy of chlamydia, gonorrhea, trichomoniasis, genital herpes, genital warts, and syphilis. • 5. Integrate the nursing assessment and nursing diagnoses for patients who have an STI. • 6. Describe the nursing management of patients with STIs including the teaching and counseling appropriate for each STI. • 7. Summarize the nursing role in the prevention and control of STIs. Copyright © 2017, Elsevier Inc. All Rights Reserved. Sexually Transmitted Infections • Infectious diseases most commonly transmitted through sexual contact • Can also be transmitted by • Skin-to-skin (HPV) • Via blood or blood products (HIV or mother to baby) • Autoinoculation (spread through touch of infection) • Cannot typically be transmitted from inanimate objects Copyright © 2017, Elsevier Inc. All Rights Reserved. Factors Affecting Incidence of STIs • High risk populations • High risk behaviors • High risk health history Copyright © 2017, Elsevier Inc. All Rights Reserved. Chlamydial Infections • Most commonly reported STI in the United States • About 3 million new cases per year. • Caused by Chlamydia trachomatis • Gram-negative bacterium • Intracellular pathogen • Transmitted through exposure to sexual fluids • 1-3 week incubation period • Treatment does not confer immunity Copyright © 2017, Elsevier Inc. All Rights Reserved. Chlamydial Infections Etiology and Pathophysiology • Caused by Chlamydia trachomatis • Transmitted during vaginal, anal, or oral sex • “Silent disease” • Symptoms often absent or minor • Infection often is not diagnosed until complications appear. • Associated with gonococcal infections making differentiation difficult Copyright © 2017, Elsevier Inc. All Rights Reserved. Chlamydial Infections Etiology and Pathophysiology • Most common site in men • Urethra (urethritis) • Most common site in women • Cervix (cervicitis) • Women are most vulnerable • Vagina is a natural reservoir for infection • Rectum is also susceptible Copyright © 2017, Elsevier Inc. All Rights Reserved. Chlamydial Infections Clinical Manifestations • Symptoms of both chlamydial and gonococcal infections • Men • Urethritis, epididymitis, proctitis • Women • Urethritis, Bartholinitis, cervicitis, salpingitis Copyright © 2017, Elsevier Inc. All Rights Reserved. Chlamydial Infections Clinical Manifestations • May not have symptoms • Women • • • • Mucopurulent discharge Bleeding Dysuria Pain with intercourse Copyright © 2017, Elsevier Inc. All Rights Reserved. Chlamydial Infections Diagnostic Studies • Laboratory tests • Nucleic acid amplification testing • NAAT is used to identify small amounts of DNA or RNA in test samples • Endocervical or vaginal swabs (women) • Urethral swabs (men) • Urine (both) Copyright © 2017, Elsevier Inc. All Rights Reserved. Chlamydial Infections Interprofessional Care • Regular screening in high-risk populations • Retest 3 months after treatment • Must treat sexual partner(s) • CDC recommends EPT (expedited partner therapy) • Can provide medication without exam • Drug Therapy • Doxycycline (Vibramycin) • 100 mg bid for 7 days • Azithromycin (Zithromax) • 1 g in single dose • High rate of recurrence Copyright © 2017, Elsevier Inc. All Rights Reserved. Gonococcal Infections Etiology and Pathophysiology • 2nd most common STI • Caused by Neisseria gonorrhoeae • Gram-negative diplococcus bacterium • Transmitted by exposure to sexual fluids • Incubation period from a few days to 1 week Copyright © 2017, Elsevier Inc. All Rights Reserved. Gonococcal Infections Etiology and Pathophysiology • Infection does not confer immunity to subsequent reinfection • Most common site • Men – urethra • Women – cervix • Can also get infection in rectum and oropharynx Copyright © 2017, Elsevier Inc. All Rights Reserved. Gonococcal Infections Clinical Manifestations • Symptoms of rectal gonorrhea • Mucopurulent rectal discharge, bleeding, pain, pruritus, painful bowel movements • Symptoms of oral gonorrhea • Few, if any symptoms • Some complain of a sore throat Copyright © 2017, Elsevier Inc. All Rights Reserved. Gonococcal Infections Complications • Men often seek treatment early due to symptoms • Less likely to develop serious complications • Women often asymptomatic • Serious complications from lack of care • Infection in Bartholin’s glands • PID • Neonates can develop gonococcal conjunctivitis (opthalmia neonatorum) • From exposure to an infected mother during delivery • Can result in permanent blindness Copyright © 2017, Elsevier Inc. All Rights Reserved. Gonococcal Infections Diagnostic Studies • Accurate sexual history • Physical exam • Lab tests • NAATs • Culture • Gram stains Copyright © 2017, Elsevier Inc. All Rights Reserved. Gonococcal Infections Interprofessional Care • Drug therapy • Often started before test results return • IM ceftriaxone • Oral azithromycin • N. gonorrhoeae resistant to many classes of antibiotics • Treat with 2 antibiotics • Antibiotic sensitivity testing for patients who do not respond to 1st round of treatment (7 days) • Treat sexual partners Copyright © 2017, Elsevier Inc. All Rights Reserved. Trichomoniasis • One of most common STIs in world • Caused by a flagellate protozoan parasite, Trichomonas vaginalis • Transmitted by exposure to sexual fluids • Most common site for infection • Men – urethra • Women – cervix Copyright © 2017, Elsevier Inc. All Rights Reserved. Trichomoniasis Clinical Manifestations • Most do not have symptoms • Men • Women • Complications • Diagnostic Studies • • • • NAAT testing Culture Point of care testing Direct visualization of trichomonads under a microscope. Copyright © 2017, Elsevier Inc. All Rights Reserved. Trichomoniasis Interprofessional Care • Drug Therapy • • • • • Metronidazole (Flagyl) or tinidazole (Tindamax) Abstain from sex for 7 days after treatment Treat all sexual partners within past 60 days Use barrier methods Repeat testing in 3 months Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Herpes Infections • Life-long, incurable infection • Very common • 2 strains • Herpes simplex virus type 1 (HSV-1) • More commonly associated with oral lesions • Herpes simplex virus type 2 (HSV-2) • More common in the genitals Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Herpes Infections Clinical Manifestations • Primary episode • 2 days to 2 week incubation period • Primarily asymptomatic • • • • Prodromal stage Vesicular stage Ulcerative stage Final stage • Prodrome to healing varies and can take about 3 weeks Copyright © 2017, Elsevier Inc. All Rights Reserved. 22 Genital Herpes Infections Recurrent Episodes • Recurrence can occur in year following primary episode • Symptoms are less severe • Lesions usually heal more quickly • HSV-1 genital infections recur less frequently than HSV-2 infections • Over time, both decrease in frequency Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Herpes Infections Complications • Rare but serious complications • Blindness • Encephalitis • Aseptic meningitis • Genital ulcers ↑ risk of acquiring HIV • Transmission mom to baby during birth • Impact on psychologic well-being, relationships, sexual lives Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Herpes Infections Diagnostic Studies • Diagnosis • Reported symptoms • Confirmed by visual exam • Cultures of lesion sample can differentiate between HSV-1 and HSV-2 • Blood tests for antibodies are highly accurate • Usually appear by 12 weeks after exposure Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Herpes Infections Interprofessional Care • Drug Therapy-Antiviral medications • • • • Shorten duration of viral shedding Shorten healing time of lesions Reduce frequency of outbreaks by 75% 3 antiviral agents are available: • Acyclovir (Zovirax) • Valacyclovir (Valtrex) • Famciclovir (Famvir) Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Herpes Infections Interprofessional Care • Teach patients to keep lesions clean and dry • Putting water on perineum during urination can reduce pain • Local anesthetics: lidocaine gel • Analgesics: ibuprofen, acetaminophen, aspirin, acetaminophen with codeine • Ice packs Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Warts • Condylomata acuminata • Caused by human papillomavirus (HPV) • HPV is transmitted • Skin-to-skin contact • HPV is transient • Resolves spontaneously usually after 1-2 years • Can persist when warts or no longer visible after treatment Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Warts Clinical Manifestations/ Diagnostic Studies • Symptoms often not present. • Itching may occur with anogenital warts. • Bleeding on defecation may occur with anal warts. • Definitive diagnosis is only done through biopsy Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Warts Complications • Few long-term complications • 90% of warts caused by noncancerous strains of HPV • Certain strains can lead to cancer • Psychosocial burden Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Warts Interprofessional Care • 3 HPV vaccines currently available • Gardasil • Cervarix • Gardasil 9 • Given in 3 IM doses over a 6-month period • CDC recommends all children be vaccinated at ages 11-12 Copyright © 2017, Elsevier Inc. All Rights Reserved. Genital Warts Interprofessional Care • Primary goal of treatment • Removal of symptomatic warts • Chemical or ablative methods • Patient applied topical treatments • May not decrease infectivity • Does not destroy virus, just infected tissue • Recurrence and reinfection are possible • Long-term follow-up is advised Copyright © 2017, Elsevier Inc. All Rights Reserved. Syphilis Etiology and Pathophysiology § 55,000 cases reported annually in the United States • Caused by Treponema pallidum • Sexually transmitted • Rates highest 20-29 year old young men • Can be transmitted from an infected pregnant woman to her fetus during pregnancy • High risk for still birth Copyright © 2017, Elsevier Inc. All Rights Reserved. Syphilis Clinical Manifestations • Mimics a number of other diseases • More difficult to recognize • 4 specific clinical stages • Progresses to next stage if not diagnosed and treated • Can take weeks to years to progress through all stages Copyright © 2017, Elsevier Inc. All Rights Reserved. Syphilis Complications • Occur mostly in late syphilis • • • • Irreparable damage to skin, bone, liver Cardiovascular aneurysm Aortic valve insufficiency Invasion of CNS • Chancres on genitalia enhance HIV transmission Copyright © 2017, Elsevier Inc. All Rights Reserved. Syphilis Diagnostics • Most commonly diagnosed by blood test • Performed for screening • VDRL and RPR tests • Performed for confirmation of a positive screening test • FTA-Abs and TP-PA tests Copyright © 2017, Elsevier Inc. All Rights Reserved. Syphilis Interprofessional Care • Early treatment • Eradicating syphilitic organisms • • • • Penicillin G recommended for all stages Treatment cannot reverse damage Treat all sexual contacts from preceding 90 days Reexamination and follow-up testing every 6 months for up to 2 years Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Nursing Assessment • Subjective Data • Sexual health history • Objective Data • Possible Diagnostic findings • Nursing Diagnoses • Ineffective Health Maintenance Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management • Planning • Overall goals • Health Promotion • Discuss safer sex • Sexual abstinence is the only certain method of avoiding all STIs • Limit sex to well-established, monogamous relationships • Address issues related to drug and alcohol dependence • Address issues of special populations Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management • Measures to prevent infection • • • • Teach to inspect partner’s genitals Remind that most STIs may have no symptoms Proper use of mechanical barriers Assess risk for contracting an STI through a respectful, compassionate, and nonjudgmental conversation Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Case Finding • Locate and examine all contacts as soon after exposure as possible. • Educational and research programs • Psychologic support Copyright © 2017, Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation • Hygiene measures • Never douche • Sexual activity • Ambulatory and Home Care • Because treatment is not involved, many take a casual approach to STIs. Copyright © 2017, Elsevier Inc. All Rights Reserved. Reflection Question • You find yourself getting disgusted and frustrated with the number of patients with STIs coming into the clinic where you work • How might this influence your patient care? • What should you do? Copyright © 2017, Elsevier Inc. All Rights Reserved.
