SEXUALLY TRANSMITTED INFECTIONS (STI) Chlamydia - Chlamydia trachomatis Sexually transmitted infection with an often-asymptomatic clinical course with serious sequelae. Sexually active Risk factors: New sexual partner Multiple sexual partners or partners of person with multiple partners Lower socioeconomic groups Age < 21 years Assessment Findings: FEMALES Often asymptomatic MALES Friable Vaginal Dysuria Urethritis Dysuria Proctitis Epididymitis Prostatitis cervix discharge Nonpharmacologic Management Education PID is a common sequelae of untreated chlamydia Abstinence until treatment completed. Evaluate and Report to local infections. treat sexual health department. partners. Pharmacologic Management: Doxycycline Azithromycin Levofloxacin (One Erythromycin if -Pregnancy: (BID for 7 (one dose) daily for 7 days) allergies Treat with azithromycin, erythromycin base or amoxicillin. days) Gonorrhea - Neisseria gonorrhea Produces a purulent inflammation of mucous membranes. Transmitted by sexual contact or from infected mother to infant during childbirth. Risk Factors New sexual partners Mucopurulent cervicitis Multiple sexual partners or partners of person with multiple partners Assessment Findings: FEMALES Often asymptomatic Vaginal discharge Dysuria Men having sex with other men Abdominal/Pelvic pain Sexual exposure to an infected individual without barrier protection MALES Dysuria Testicular pain Purulent urethral discharge Asymptomatic Nonpharmacologic Management: Avoid sexual intercourse Treatment of Sexual abuse should be considered for any Report all cases to local Screen for other until treatment completed sexual contacts child with confirmed gonorrhea after neonatal health department STIs period Pharmacologic Management: ceftriaxone (Rocephin) IM cefixime (Suprax) doxycycline Plus--- azithromycin Pregnancy: (Vibramycin) (Zithromax) Ceftriaxone is the treatment of choice Syphilis - Treponema Pallidum Sexually transmitted disease characterized by sequential stages and involving multiple systems. Syphilis has the following stages: Primary Secondary Latent (infection present at least 12 months) Tertiary Risk Factors: Men who have sex with men Multiple sexual partners Injecting drug use HIV infection Presence of another sexually transmitted disease Assessment Findings: Primary Syphilis Chancre at site of inoculation begins as papule then ulcerates with a hard edge and clean, yellow base; indurated and painless; usually located on genitalia. May be solitary or multiple Assessment Findings: Secondary Syphilis Rash that is bilaterally symmetrical, nonpruritic, frequently on soles and palms, and usually persists for 2-6 weeks then spontaneously resolves. Persists for 1-5 weeks and heals spontaneously Mucous patches in mouth, throat, cervix. Flu-like symptoms Mild hepatosplenomegaly Generalized lymphadenopathy Assessment Findings: Latent Syphilis Usually, asymptomatic Infectious lesions can recur Assessment Findings: Tertiary Syphilis Benign lesions (gummas) of the Cardiovascular syphilis, usually in the form of Neurosyphilis, causing central nervous system problems skin, mucous membranes, and aortic valvular disease and aortic aneurysms (e.g., meningitis, hearing loss, generalized paresis bones [weakness]) Diagnostic Studies: • Treponemal tests Darkfield microscopy or direct • Nontreponemal tests: • Fluorescent treponemal antibody absorbed (FTA-ABS) fluorescent antibody test of Rapid plasma regains (RPR) • Microhemagglutinatin assay for antibody to T. pallidum (MHA-TP) exudate or tissue. Venereal Disease Research Laboratory (VDRL) Prevention: EDUCATION Safe sex practices are those that reduce the risk for non-intact skin or mucous membranes coming in contact with infected body fluids and blood. Nonpharmacologic Management: Abstinence, mutual monogamy, and decreasing the number of sexual partners. Avoid sexual intercourse until treatment complete Treatment for all sexual partners Evaluate for other STIs Pharmacologic Management: Benzathine penicillin G (Bicillin) given IM as a Patients in the late latent stage single 2.4-million-unit dose is the evidence-based receive the same dose every treatment for primary, secondary, and early latent week for 3 weeks. syphilis. Genital Herpes (Viral) Recurrent, incurable Transmitted by direct contact Herpes simplex virus type cutaneous or mucous with active lesions or by virus1 or 2 (usually HSV-2) membrane infection. After treatment evaluation including blood tests at 6, 12, and 24 months. Repeat treatment patient does not respond to the initial antibiotic. An asymptomatic patient can be infectious while shedding virus containing fluid Assessment Findings: Primary infection: Painful papules followed by Headache vesicles on an erythematous base Malaise that ulcerate, crust, and resolve. Hyperesthesia Report all cases to local health department Usual incubation period is 2-12 days. Recurrent infections: Prodrome of pain, burning, Burning Lesions as above and/or paresthesia over genital pain. that resolve within area of eruption. 7-10 days. Myalgia Dysuria Fever Diagnostic Studies: Viral Culture or polymerase chain reaction assays of the lesions. Serologic assays PCR is more sensitive Usually, positive 4-6 weeks after onset of symptoms Prevention: Use of condoms Cesarean section indicated in women with lesions to prevent infection in newborn. Nonpharmacologic Management: Education/Counseling Cool Good Remind patients to Use of Avoidance of triggers to Natural course of disease compresses hygiene abstain from sexual condoms recurrent infection when Asymptomatic viral shedding activity while GH during all possible. Potential for recurrent episodes lesions are present. sexual Genital trauma, emotional Sexual transmission exposures stress, concurrent infection Implications for pregnancy Pharmacologic Management: Anitviral drugs are used to treat GH acyclovir (Zovirax, Avirax) famciclovir (Famvir) valacyclovir (Valtrex) Human Papilloma Virus (HPV) - Condylomata Acuminata (Genital Warts) HUMAN PAPILLOMA VIRUS (HPV) No Vaginal Birth Viral infection transmitted sexually through an epidermal Generally benign and produce no symptoms HPV Types 6 & 11 most defect that produces warts on genital area. except the cosmetic appearance. commonly cause genital warts. Assessment Findings: Soft, flesh-colored warts Warts are usually painless Surface smooth to very rough Perianal warts usually rough and cauliflower-like Nonpharmacologic Management: Use of Condoms Abstinence until therapy completed Pharmacologic Management: Podophyllin resin Trichloroacetic acid (TCA) TRICHOMONAS Trichomonas. - Trichomonas vaginalis Foul odor Cervical petechiae (“strawberry cervix”) Wet prep: Visualization of trichomonads as flagellated, motile cells slightly larger than WBCs podofilox (Condylox) STD which can infect vagina, skene’s ducts, and lower genitourinary tract in women and lower genitourinary tract in men. Assessment Findings: FEMALES Asymptomatic Vaginal discharge -Frothy, copious -Pale yellow to gray-green in color Diagnostic Studies: CO2 laser Asymptomatic Pap smear Single-celled, flagellated protozoan parasite Urethral discharge Culture imiquimod (Aldara) MALES Dysuria Epididymitis Prostatitis Vaginal secretion pH: >4.5 (usually 5.56.0) Nonpharmacologic Management Abstinence until treatment is completed Pharmacologic Management: metronidazole (Flagyl) Review safety and drug interactions Abstain from alcohol if taking metronidazole tinidazole (Tindamax) **Treat Sexual partners Bacterial Vaginosis (BV) Clinical syndrome resulting from replacement of the normal vaginal flora, Lactobacillus sp., with high concentrations of anaerobic bacteria. • Prevotella sp. • Mobiluncus sp. • Gardnerella. Vaginalis • Mycoplasma hominis Etiology/Incidence: Cause of the microbacterial overgrowth not completely understood. Assessment Findings: Asymptomatic (sometimes) Grayish-white malodorous vaginal discharge Prevention: Avoid use of feminine pads, liners Good hygiene Most prevalent vaginal infection in women of reproductive age in the U.S. Unpleasant, fishy, or musty vaginal odor Use of condoms Profuse discharge Pruritus and burning of vulvovaginal area (sometimes) Avoid douching as this may reduce recurrences Screen for STIs Nonpharmacologic Management: Avoid sexual intercourse until treatment completed No alcohol if on metronidazole due to a disulfiram-type reaction Stress good personal hygiene Avoid douching to prevent recurrences Pharmacologic Management: metronidazole (Flagyl) Vaginal gel PO Complications/Pregnancy: BV during pregnancy is associated with adverse pregnancy outcomes Preterm labor Premature rupture of membranes Review safety and drug interactions tinidazole (Tindamax) Clindamycin Vaginal Cream Premature birth Candida Vaginitis (Yeast) - Vulvovaginal Candidiasis “Yeast infection.” Candida albicans (gram+) oral contraceptives antibiotics Vulvovaginal Candidiasis Diagnosis potassium hydroxide (KOH) wet mount will show hyphae and spores miconazole • Contributory Factors pregnancy immunosuppression & HIV thick, white, cheese-like discharge. DM Symptoms Severe itching, dysuria, dyspareunia. Abdominal soreness on palpation Vulvovaginal Candidiasis – Treatment (Can still do vaginal birth) tioconazole butaconazole teraconazole clotrimazole fluconazole (one tablet only) orally (prescribed medication) Pelvic Inflammatory Disease (PID) STI caused by ascent of microorganisms from vagina and endocervix to uterus, fallopian tubes, ovaries, and contiguous structures. Age younger than 26 years Risk Factors: Multiple sexual partners Intrauterine device (IUD) placed within the previous 3 weeks Smoking Hx of PID Ph problems OTC treatment options Chlamydia and/or gonorrhea are common causes Chlamydial or gonococcal infection; bacterial vaginosis A hx of (STDs) Assessment Findings: Symptoms begin during or within one week of menses. Diagnostic Criteria: Unusual or new onset of dysmenorrhea Lower abdominal pain Fever, malaise Vaginal discharge Urinary discomfort Nausea and vomiting Abdominal tenderness Diagnostic Studies: Specimens from the cervix, urethra, and rectum to determine the presence of N. gonorrhoeae or C. trachomatis. Nonpharmacologic Management: (WBC) count Erythrocyte sedimentation rate (ESR) Abstinence until treatment is completed Evaluation and treatment of sexual partners Pharmacologic Management: CDC recommends any of several different regimens Antibiotic therapy -IV C-reactive protein Pregnancy test Microscopic examination of vaginal discharge Screen regularly for STDs in at risk patients Abdominal ultrasonography Semi-Fowler’s position Drug therapy is required for 14 days. HIV Human immunodeficiency Virus T-cell affected causing decrease HIV virus can be found in blood, body immune response, making vaginal fluid, and breast milk affected person more susceptible implicated in disease to opportunistic infections. transmission Pregnancy with HIV HIV positive mother should be counsel about the implications of diagnoses HIV screening should be a routine part of all prenatal care. Prevent mother-to child transmission Prenatal Detected screening - EIA (Reactive enzyme immunoassay) Confirmation test-Western blot test or immunofluorescence assay (IFA) Priority focused on maintaining the health of the mother before, during and after the pregnancy. Risk Factors for HIV Perinatal Transmission. Prolonged Breastfeeding Smoking High maternal Vaginal Mother Chorioamnionitis Preterm Chronic diagnosed with CD-4 count viral load rupture of delivery Delivery conditions AIDS membranes Treatment during pregnancy • Antiretroviral therapy Start during the first trimester or delayed until 12 weeks’ gestation Recommended Regardless of Reduce the Zidovudine Suppress viral replication Some ARV medications are Benefit vs. to all infected symptomatic or rate of prenatal to keep viral load (AZT) contraindicated during pregnancy Risk pregnant women asymptomatic transmission undetectable by diagnostic test Treatment during Pregnancy • Under the care of Perinatologist Weekly NST starting at 32 Monitor for early Invasive procedures such as Educating mother about postpartum care weeks and serial ultrasoundssigns of complication amniocentesis are avoided when and promoting adherence to medication IUGR possible therapy HIV labor & delivery Scheduled cesarean birth indicated for mother External electronic Delivery within four hours Primary focus- prevention AZT with HIV a high level of viral RNA or unknown HIV of vertical transmission of administered fetal monitor of Rupture of membrane RNA levels near time of birth. IVBP during HIV labor Postpartum Care HIPAA and confidentiality Community based services with Hospital/Case manager and social worker Postpartum education Counseling Postpartum care Avoid Umbilical cord cleaning Breastfeeding is Initial oral AZT to the newborn: -2mg/kg every 6 hours for 6 circumcision contraindicated weeks Newborn of HIV positive mother • Watch for symptoms of opportunistic infection Low maternal Possible HIV infection Lymphoid interstitial pneumonitis Thrush (candidiasis) Infected newborns likely to be premature, SGA, and show failure to thrive in the newborn/ infant periods. Newborn care Provide Facilitate growth, Protect from Children with symptomatic or Teach the Regular clinical, comfort development, and opportunistic asymptomatic HIV infection should caregiver immunologic and and attachment infections receive all routine vaccines except for live postnatal care virologic monitoring nutrition virus vaccines. Erectile Dysfunction Inability to achieve or maintain an erection for sexual Organic- gradual deterioration of function Functional– psychological intercourse. or cause. Causes of Organic Inflammation Surgical Pelvic Vascular Neurologic Endocrine Smoking Medications Diet AgeProcedures Fractures diseases- HTN conditions disorders- DM and alcohol related Pharmacologic Treatment Phosphodiesterase-5 inhibitors (PDE-5) Use caution • No erection lasting over 4 hours Testosterone and PDE5 drug therapy • Sildenafil (Viagra) (Viagra) (for men with hypogonadism) • Tadalafil (Cialis) • Cardiac symptoms • Side effects Pharmacologic Treatment CONT. Men who take nitrates should PDE-5 Inhibitors Abstain from alcohol Common side effects of these drugs avoid PDE-5 inhibitors because before sexual include dyspepsia (heartburn), sildenafil (Viagra) take 1-1 ½ hours before the vasodilation effects can intercourse because it headaches, facial flushing, and stuffy could impair the nose. If more than one pill a day is being cause a profound hypotension tadalafil (Cialis) take 2 hours before, lasts and reduce blood flow to vital ability to have an taken, leg and back cramps, nausea, organs, can be fatal! 36 hours erection. and vomiting also may occur. Nonpharmacologic Treatment Lifestyle modifications Penile self-injection with Surgery (prosthesis) Vacuum-assisted Providing psychological (e.g., smoking cessation, prostaglandin E1 erection devices support/ therapy weight loss, management • Include Partner of hypertension) • Provide education is important!!!
