Chapter 49

1. Chapter 49 Sexually Transmitted Infections

2. Learning Objectives • List infectious diseases classified as sexually transmitted infections. • Explain the importance of the nurse’s approach when dealing with patients who have sexually transmitted infections. • Describe tests used to diagnose sexually transmitted infections and the nursing considerations associated with each. • Explain why specific sexually transmitted infections must be reported to the health department.

3. Learning Objectives • Describe the pathophysiology, signs and symptoms, complications, and medical treatment for selected sexually transmitted infections. • Design a teaching plan on the prevention of sexually transmitted infections. • List nursing considerations when a patient is on drug therapy for a sexually transmitted infection. • Identify data to be collected when assessing a patient with a sexually transmitted infection. • Assist in developing a nursing care plan for a patient with a sexually transmitted infection.

4. Sexually Transmitted Infections (STIs) Serious public health problem in the United States despite medical advances Spread primarily through sexual contact and may have serious and permanent consequences Some people resist taking preventive measures Infected people do not always inform sexual partners; disease continues to be passed on Nurses must be aware of their feelings about working with people who have STIs

5. Diagnostic Tests and Procedures Serologic tests Hepatitis A, B, C, D, and E Syphilis Human immunodeficiency virus (HIV) Herpes simplex Cytomegalovirus Smears and cultures Discharge and exudate from lesions can be collected and studied to determine the exact infecting organism

6. Reporting STIs Confirmed cases of HIV, AIDS, gonorrhea, syphilis, chlamydia, chancroid, and viral hepatitis must be reported to the local health department Investigator asks patient to name sexual contacts Those individuals contacted and advised that they have been exposed to the disease and encouraged to seek medical evaluation Process is to identify and treat infected people so transmission of disease can be slowed

7. Chlamydial Infection Most common bacterial STI in the United States Estimated 2.8 million diagnosed each year Organism virus-like bacterium Chlamydia trachomatis; infects men and women Transmitted by contact with the mucous membranes in the mouth, eyes, urethra, vagina, or rectum

8. Chlamydial Infection Signs and symptoms Most people have no symptoms Males: penile discharge; painful or frequent urination Females: vaginal discharge, painful urination, nausea, fever, painful intercourse, bleeding between menstrual periods, and lower abdominal pain

9. Chlamydial Infection Complications Sterility Risk of ectopic pregnancy is increased Women with chlamydia are approximately 5 times more like to become infected with HIV if exposed to it

10. Chlamydial Infection Medical diagnosis and treatment Laboratory studies Chlamydia antigen test Cell tissue culture Treated with a single dose of azithromycin (Zithromax) or 7-day course of doxycycline (Vibramycin) Repeat culture in 4-7 days; confirms successful treatment Patient to avoid all sexual contact (genital, oral, anal) until cured

11. Gonorrhea Commonly reported STI in the United States Most often through direct sexual contact Caused by Neisseria gonorrhoeae Affects pharynx, rectum, urethra, prostate, epididymis, uterus, and fallopian tubes With systemic (disseminated) infection: heart, joints, skin, and meninges

12. Gonorrhea Signs and symptoms Many people have no symptoms Males: whitish or greenish discharge from penis; often a burning sensation during urination Females: vaginal discharge, redness and swelling of the external genitalia, a burning sensation during urination, abdominal pain, or abnormal menstruation Rectal infection: discharge, anal itching, soreness, bleeding, or painful bowel movements Throat infections: usually no symptoms, but sore throat

13. Gonorrhea Complications Sterility in both sexes and infections may lead to damage to heart tissue and joints Males may develop epididymitis and prostatitis Females may develop pelvic inflammatory disease (infection of the ovaries, fallopian tubes, pelvic area) Medical diagnosis Health history and physical examination findings as well as laboratory analysis of exudate from infected body parts or urinalysis

14. Gonorrhea Medical treatment Single dose of IM ceftriaxone (Rocephin), oral cefixime (Suprax), ciprofloxacin (Cipro), ofloxacin (Floxin) If concurrent chlamydial infection, initial drug followed with 7 days of oral doxycycline (Vibramycin) Erythromycin ophthalmic ointment for the newborn to prevent eye infection caused by exposure to gonococci during delivery

15. Syphilis Caused by microscopic organism, a spirochete (coiled bacterium) called Treponema pallidum Organism transmitted by sexual contact; also spread through breaks in skin Also passed through the placenta, thus causing an infant to be born with the disease (congenital syphilis)

16. Syphilis Signs and symptoms Primary stage Chancre: first sign of syphilis Reddish papule appears where the organism entered the body, usually on genitals, anus, or mouth Within a week, papule becomes a painless red ulcer Lymph nodes near chancre enlarged but not tender Chancre may last from 1 to 5 weeks When it disappears, patients assume they are cured, but in fact organism has moved into the blood

17. Figure 49-1

18. Syphilis Signs and symptoms Secondary stage Occurs 1 to 6 months after contact Rash on extremities, chest or back, palms, soles Pustules containing highly contagious material often develop Fever, sore throat, and generalized aching Patient contagious during first and second stages

19. Syphilis Signs and symptoms Latent stage There are no symptoms Organisms are invading major organs Disease is not spread by sexual contact during the latent stage but may be transmitted by blood exposure

20. Syphilis Signs and symptoms Late stage Generally 3 years after contact before late syphilis develops, although it may be decades Arthritis, numbness of the extremities, ulcers of the skin and internal organs, and pain due to damage to the heart, blood vessels (especially the aorta), spinal cord, or brain

21. Syphilis Complications Blindness, mental illness, paralysis, heart disease Easier for a person to contract HIV Medical diagnosis Physical examination findings Venereal Disease Research Laboratory (VDRL) test and rapid plasma reagin (RPR) test Fluorescent treponemal antibody absorption test (FTA-ABS) and the microhemagglutination test

22. Syphilis Medical treatment Parenteral penicillin G, unless contraindicated Advise follow-up appointment with physician to see whether treatment was effective Advise not to engage in sexual activity until 1 month after completing treatment for primary or secondary syphilis

23. Herpes Simplex Cold sores Caused by herpes febrilis or herpes simplex virus 1 (HSV-1) Transmitted through contact with open lesions, usually on the lips or inside the mouth Genital herpes Caused by herpes simplex virus 2 (HSV-2) Vaginal or anal intercourse and oral-genital contact but also can be by hand contact

24. Herpes Simplex Signs and symptoms Painful, itching sores on or around the genitals approximately 2 to 20 days after infection Symptoms last about 2 to 3 weeks Rash appears first, then small blisters that ulcerate Complaints of flulike symptoms and a burning sensation during urination Active symptoms may recur; frequently precipitated by anxiety

25. Figure 49-2

26. Herpes Simplex Complications Increased risk of cervical cancer Obstetricians recommend cesarean sections for infected women who have active lesions to decrease risk of transmission to the baby

27. Herpes Simplex Medical diagnosis and treatment Diagnosed by Appearance of genital lesions Exudate from lesions examined under a microscope and cultured Herp-Check No cure for HSV infection, but oral antivirals acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir) partially control signs and symptoms

28. Trichomoniasis Caused by the protozoan parasite Trichomonas vaginalis Usually sexually transmitted Parasite can survive for hours on damp cloths and clothing CDC estimates 7 million new cases per year Affects vagina in women, urethra in men

29. Trichomoniasis Signs and symptoms Women Frothy, yellowish discharge that has a foul odor Vaginal irritation and itching Urinary frequency/burning: infection in urethra Chronic infection: bladder and anal involvement Men Usually no symptoms; a mild discharge or slight burning after urination or ejaculation

30. Figure 49-3

31. Trichomoniasis Medical diagnosis and treatment Detected by microscopic study of vaginal discharge or urine (in males) Discharge can be cultured to reveal organism Metronidazole (Flagyl) is drug of choice Important that patient and sexual partners be treated at the same time to avoid reinfection

32. Condylomata Acuminata (Genital Warts) Caused by the human papillomavirus Affect genital, anal regions of men and women Transmission by vaginal, anal, or genital contact Incidents of transmission from people who had no visible signs of infection Incubation period: 3 weeks to 8 months

33. Condylomata Acuminata (Genital Warts) Signs and symptoms Males Glans, foreskin, urethral opening, penile shaft, or scrotum Females In/around vulva, vagina, cervix, perineum, anal canal, urethra Also on labia, deep within the vaginal canal and endocervix Homosexual and bisexual men and women who engage in anal intercourse, common in anal area Oral, pharyngeal, and laryngeal lesions as well Warts are generally pink or red and soft, with a cauliflower-like appearance

34. Figure 49-4

35. Condylomata Acuminata (Genital Warts) Medical diagnosis Observation of the warts Biopsy necessary to make a definitive diagnosis Medical treatment No cure Removal provides symptomatic relief Application of podofilox or imiquimod by the patient Cryotherapy, topical trichloroacetic acid or podophyllin resin, surgical removal, and injection of interferon into the lesions

36. Bacterial Vaginosis Caused by Gardnerella vaginalis and other anaerobic bacteria Infectious bacteria emerge when normal bacteria in vagina are suppressed Associated with having multiple sex partners and douching; unclear if actually transmitted sexually Signs and symptoms Genital irritation and itching, thin gray discharge, and a fishy odor, but some women report no symptoms

37. Bacterial Vaginosis Diagnosed by microscopic examination of the discharge fluid and by culture Treated with metronidazole (Flagyl) administered orally or vaginally or clindamycin vaginal cream Combination of alcohol and metronidazole may trigger a disulfiram-like reaction, with vomiting, tachycardia, and hypotension

38. Human Immunodeficiency Virus Infection HIV gradually destroys T4 lymphocytes, which are essential for resisting pathogens As lymphocytes decline, patient increasingly susceptible to opportunistic infections Opportunistic infection thrives when immune system is impaired When immune system ceases to function, patient has acquired immunodeficiency syndrome (AIDS)

39. Care of the Patient with a Sexually Transmitted Infection

40. Assessment History of present illness Patient’s reason for seeking medical care. With an STI, common reasons: pain, fever, lesions, or genital discharge. Obtain a thorough description of the signs and symptoms, including onset, duration, and severity Past medical history Serious conditions or chronic illnesses; obstetric history may be significant If childbearing age, date of last menstrual period Recent/current medications and drug allergies

41. Assessment Review of systems Elicits potentially significant signs and symptoms, including weight change; fever; weakness; fatigue; skin rashes or lesions; oral lesions; dysuria; whether the patient is sexually active; pain, lesions, or lumps in the genitals; vaginal or penile discharge; and altered sexual functioning A history of blood transfusions is important

42. Assessment Functional assessment Frequency and variety of sexual behaviors, IV drug use, past infections with STIs, and sexual contact with a person known to have an STI Determine if classified as at risk because age, sexual preference, or habits place patient at a higher risk for acquiring STI Victims of sexual abuse (of all ages) may have been exposed to STIs Occupation significant if contact with infected body fluids

43. Physical Examination Skin for rashes and lesions Mouth is inspected for lesions Neck palpated for enlarged lymph nodes Abdomen is inspected for distention and palpated for tenderness Depending on your specialized education, you may examine the genitals or assist the physician/nurse practitioner with examination

44. Physical Examination In cases of sexual assault, it is especially important that the examiner be specially trained If discharge present, its color, amount, and consistency are recorded. Specimens may be collected for laboratory study

45. Interventions Impaired Skin Integrity Pain Risk for Injury Anxiety Situational Low Self-Esteem Impaired Social Interaction Sexual Dysfunction Ineffective Coping Ineffective Therapeutic Regimen Management

46. Condom Use Condoms do not provide 100% protection against disease transmission Latex preferred because some pathogens can pass through natural membrane condoms Protect from heat and sunlight to keep them from deteriorating Do not use condoms that are brittle, discolored, or in damaged packages

47. Condom Use Use only water-based lubricants; others can cause condom to break; spermicides may be used To put a condom on, hold it by the tip and unroll it onto the penis. Leave a space of about 1 inch at the tip for semen Withdraw penis carefully after ejaculation to keep condom from slipping off and spilling the contents and to avoid unprotected contact Always discard used condoms