Sexually Transmitted Infections

Sexually Transmitted Infections

1. SEXUALLY TRANSMITTED INFECTIONS

2. Sexually transmitted infections (STIs) are infectious diseases that are spread through sexual contact with the penis, vagina, anus, mouth, or sexual fluids of an infected person.

3. Mucosal tissues in the urethra in men, vagina in women , rectum, and mouth are susceptible to the bacteria and viruses that cause STIs. Common STIs are Genital human papillomavirus (HPV), can spread from direct skin-to-skin contact with an infected person. human immunodeficiency virus (HIV), may be contracted via blood or blood products or be transmitted from mother to baby during pregnancy or labor and delivery. Some STIs can spread through autoinoculation (spread of infection by touching or scratching an infected area and transferring it to another part of the body). STIs cannot typically be transmitted from casual contact or inanimate objects.

4. SI Diseases Causes I Bacterial Infections Chlamydial Chlamydia trachomatis Gonorrhea Neisseria gonorrhoeae Syphilis Treponema pallidum II Viral Infections Genital herpes Herpes simplex virus (HSV 1 or 2) Genital warts ( condylomata acuminata ) Human papillomavirus (HPV) Human immunodeficiency virus infection (HIV) Human immunodeficiency virus (HIV) Hepatitis B and C Hepatitis B and C viruses Molluscum Molluscum contagiosum III Parasitic/Protozoan Infection Tricomoniasis Tricomonas vaginalis

5. Risk Factors for STIs High-Risk Behaviors Alcohol or drug use (inhibits judgment) Having new or multiple sexual partners Having more than 1 sexual partner Having sexual partners who have/have had multiple partners Inconsistent or incorrect use of condoms or other barrier methods Sharing needles used to inject drugs High-Risk Medical History Having 1 STI is a risk factor for getting another Not being vaccinated for STIs or other infections that may be transmitted through some forms sexual activity (HPV, hepatitis A and B) Receiving multiple courses of non occupational poste xposure prophylaxis for HIV infection High-Risk Populations Adolescents and young adults (age <25) Ethnicity Men who have sex with men Persons in correctional facilities Transgender persons Victims of sexual assault Women

6. Chlamydial Infections

7. Etiology and Pathophysiology Chlamydial infections are caused by Chlamydia trachomatis, a gram-negative bacterium and intracellular pathogen. Chlamydia is transmitted through exposure to sexual fluids during vaginal, anal, or oral sex. Ejaculation does not have to occur for it to be transmitted. The incubation period for chlamydia is 1 to 3 weeks. The common site for infection in men is the urethra. Infections in the male urethra are called urethritis. The common site for infection for women is the cervix. Infections in the female cervix are called cervicitis. Both men and women can get chlamydia of the rectum from receptive anal sex or the oropharynx from giving oral sex. Because the vagina acts as a natural reservoir for infectious secretions, STI transmission is often more efficient from men to women than it is from women to men.

8. Clinical manifestations No symptoms Pain with urination Urethral discharge. Pain or swelling of the testicles Mucopurulent discharge (mucus with pus), Bleeding Dysuria Pain with intercourse. Symptoms of rectal chlamydia Anorectal pain Discharge Bleeding Pruritus Tenesmus Mucus-coated stools Painful bowel movements.

9. Diagnostic Studies Accurate sexual history A physical examination Laboratory tests specific to each infection. Nucleic acid amplification test ( NAAT):- is used to identify small amounts of DNA or RNA in test samples.

10. Treatment The preferred treatment is a single dose of azithromycin (Zithromax) or doxycycline ( Vibramycin ) twice a day for 7 days

11. Role of nurse in Treatment (Drug alert) Patients should avoid prolonged or excessive exposure to sunlight. Take doses on an empty stomach either 1 hour before eating or 2 hours after eating. Avoid taking with antacids, iron products, or dairy products. Pregnant women should not take doxycycline

12. Gonococcal Infections

13. Etiology Gonorrhea is caused by Neisseria gonorrhoeae , a gram-negative, diplococcus bacterium.

14. Pathophysiology Gonorrhea can be transmitted by exposure to sexual fluids during vaginal, anal, or oral sex. Ejaculation does not have to occur for it to be transmitted. The incubation period ranges from 1 to 14 days. The most common site for infection for men is the urethra and for women, the cervix. Both men and women can get gonorrhea of the rectum from anal sex or of the oropharynx from oral sex.

15. Clinical manifestations Male Dysuria Purulent urethral discharge Epididymitis In female Increased vaginal discharge Dysuria Frequency of urination Bleeding after sex Redness and swelling can occur at the cervix or urethra along with a purulent exudate Symptoms of rectal infection include Mucopurulent rectal discharge Bleeding Anorectal pain Pruritus Tenesmus Mucus-coated stools, Painful bowel movements. Patients with gonorrhea in the throat A sore throat within days of performing oral sex.

16. Diagnostic Studies History and physical examination Gram-stained smears of urethral or endocervical exudate Culture for Neisseria gonorrhoeae Nucleic acid amplification test (NAAT) to detect N. gonorrhoeae Testing for other STIs (syphilis, HIV, chlamydial infection)

17. Treatment The first-line treatment is dual therapy with IM ceftriaxone with oral azithromycin as a single dose.

18. Trichomoniasis

19. Trichomoniasis Trichomonas can be transmitted by exposure to sexual fluids during vaginal, anal, or oral sex, even if ejaculation does not occur. The incubation period is usually 1 week to 1 month but can be much longer. The most common site for infection in men is the urethra and in women is the cervix.

20. Clinical Manifestations Men Burning with urination and ejaculation, Urethral discharge. Women Painful urination Vaginal itching Painful intercourse Bleeding after sex A yellow-green discharge with a foul odor. The cervix can have a “strawberry” appearance.

21. Diagnostic Evaluations NAAT testing of vaginal or endocervical secretions or urine. Culture , point-of-care testing, Direct visualization of trichomonads under the microscope. Identification of motile trichomonads in the vaginal secretions confirms infection. Tests can be done on liquid-based cervical Pap samples.

22. Role of nurse in Treatment (Drug alert) Patients and their partners should be treated with either metronidazole or tinidazole . Teach patients to abstain from sexual contact for 7 days after treatment or until all sexual partners have completed a full course of treatment and abstained from sexual contact for 7 days. Tell patients to return if symptoms persist or recur. A ny sexual partner within the preceding 60 days should be treated. Teach patients to use condoms or other barrier methods with every sexual contact. Because of a high rate of recurrence, repeat testing 3 months after treatment is recommended.

23. Genital Herpes Infections

24. Genital herpes is a common, lifelong, incurable infection. There are 2 strains of herpes: Herpes Simplex Virus Type 1 (HSV-1):- HSV-1 is associated with oral lesions. Herpes Simplex Virus Type 2 (HSV-2):- HSV-2 is more common in the genitals or anus.

25. Pathophysiology

26. Clinical Manifestations A primary episode A primary (initial) episode of genital herpes has an incubation of 2 to 12 days. Most people do not have any recognizable symptoms of primary HSV genital infection. Symptoms do occur, they follow a series of stages. Prodromal stage:- the period before lesions appear, the patient may have burning, itching, or tingling at the site of inoculation. Vesicular stage :- few to multiple small, often painful vesicles (blisters) may appear on the buttock, inner thigh, penis, scrotum, vulva, perineum, perianal region, vagina, or cervix. The vesicles have large quantities of infectious viral particles. Ulcerative stage:- the lesions rupture and form shallow, moist ulcerations. In the final stage, spontaneous crusting and epithelialization of the erosions occur Regional (inguinal node) lymphadenopathy and systemic flu-like symptoms, including fever, headache, malaise, and myalgia.

27. Recurrent Episodes It occurs in many people during the year after the primary episode. The symptoms of recurrent episodes are less severe, and the lesions usually heal more quickly. HSV-1 genital infections recur less often than HSV-2 genital infections. Over time, both decrease in frequency. Common triggers of recurrence include stress, fatigue, sunburn, general illness, immunosuppression, and menses. Many patients can predict a recurrence by noticing the prodromal symptoms of tingling, burning, and itching at the site where the lesions will recur.

28. Diagnostic Assessment History and physical examination Antibody assay for HSV type Viral isolation by tissue culture

29. Treatment Primary (Initial) Infection Acyclovir ( Zovirax ), valacyclovir (Valtrex) or famciclovir ( Famvir ) Recurrent Episodic Infection Acyclovir , valacyclovir , or famciclovir for shorter duration

30. Genital Warts

31. Genital warts ( condylomata acuminata ) are caused by the HPV. There are around 100 types of papillomavirus, of which at least 40 strains are sexually transmitted . “ Low-risk” strains of the virus can cause warts on the skin. “ High-risk” strains can lead to cancers of the genital tract, anus, or oropharynx in some patients. HPV types 6 and 11 cause about 90% of genital and anal wart cases.

32. Etiology and Pathophysiology HPV is transmitted by skin-to-skin contact, most often during vaginal, anal, or oral sex. It can be transmitted during nonpenetrating sexual activity. The basal epithelial cells infected with HPV undergo transformation and proliferation to form a warty growth The incubation period can range from weeks to months to years.

33. Clinical Manifestations Asymptomatic . Genital or anal warts are discrete single or multiple papillary growths that are white to gray, are pink-flesh colored, or can be hyperpigmented depending on the skin type. They may grow and coalesce to form large, cauliflower-like masses. In men, warts occur on the penis and scrotum, inside or around the anus, or in the urethra. In women, warts occur on the inner thighs, vulva, vagina, or cervix, in the perianal area, including in the internal anal canal Itching may occur with anogenital warts. Bleeding on defecation may occur with anal warts.

34. Diagnostic Evaluations Visual examination Biopsy Pap smear test Viral markers

35. Treatment Trichloroacetic acid (TCA) Bichloroacetic acid (BCA ) Podofilox liquid and gel Petroleum jelly applied with a cotton swab to the surrounding normal skin can minimize irritation . If the warts do not resolve with topical therapies, treatments such as cryotherapy with liquid nitrogen, electrocautery , laser therapy, local α-interferon injections, or surgical excision may be needed

36. Syphilis

37. Syphilis is caused by Treponema pallidum , a bacterial spirochete. It is transmitted by direct contact with a syphilitic ulcer called a chancre. A chancre can occur externally on the genitals, anus, or lips or internally in the vagina, rectum, or mouth or tongue or through the mucosal membranes of an infected person. Transmission can occur during vaginal, anal, or oral sex. The incubation period can range from 10 to 90 days (average 21 days). An infected pregnant woman can transmit syphilis to her fetus during her pregnancy. There is a high risk for stillbirth or having babies who develop complications after birth, including seizures and death.

38. Stages of syphilis Primary Infectivity : Highly infectious Duration of stage: 3–6 wk Single or multiple chancres (painless indurated lesions) of penis, vulva, lips, mouth, vagina, and rectum) Occurs 10–90 days after inoculation Regional lymphadenopathy (microorganisms drain into the lymph nodes) Exudate and blood from chancre are highly infectious

39. Secondary Infectivity : Highly infectious Duration of stage: Occurs a few weeks after primary chancre heals, lasts 1–2 yr Flu-like symptoms: malaise, fever, sore throat, headaches, fatigue, arthralgia, generalized adenopathy Mucous patches in mouth, tongue , or cervix Symmetric , nonpruritic rash bilaterally that appears on trunk, palms, and/or soles Condylomata lata (moist, weeping papules) in the anogenital area Weight loss, alopecia

40. Latent Infectivity : Early (<1 yr )—infectious; late (≥ 1 yr )—noninfectious Duration of stage: Throughout life or progression to late stage Absence of signs or symptoms Diagnosis based on positive specific treponemal antibody test together with normal CSF and absence of clinical manifestations

41. Late Infectivity : Noninfectious Duration of stage: Chronic (without treatment), occurs 1–20 years after initial infection Gummas (chronic, destructive lesions affecting any organ of body, especially skin, bone, liver, mucous membranes) Cardiovascular: Aneurysms, heart valve insufficiency, heart failure, aortitis Neurosyphilis : Can occur at any stage of syphilis General paresis: Personality changes from minor to psychotic, tremors, physical and mental deterioration Tabes dorsalis (ataxia, areflexia , paresthesias , lightning pains, damaged joints)

42. Diagnostic Assessment History and physical examination Dark-field microscopy Nontreponemal and/or treponemal serologic testing Testing for other STIs (HIV, gonorrhea, chlamydial infection)

43. Management Antibiotic therapy: Penicillin G benzathine ( Bicillin LA) Doxycycline or tetracycline (if penicillin contraindicated) Confidential counseling and testing for HIV infection Surveillance Repeat of nontreponemal tests at 6 and 12 mo Examination of cerebrospinal fluid at 1 yr if treatment involves alternative antibiotics or treatment failure has occurred.

44. Nursing Management: STIs Nursing Diagnoses Impaired sexual functioning Risk for infection Lack of knowledge

45. Health education Explain precautions to take, such as Using condoms and other barrier methods with every sexual encounter Being monogamous, defining what monogamy means with your partner Asking potential partners about their sexual history Asking potential partners if they have been tested for STIs Avoiding sex with partners who have visible oral, inguinal, genital, perineal , or anal lesions or those who use IV drugs Voiding and washing genitalia and surrounding area after sex to flush out/wash away organisms to reduce potential for transmitting infection Explain the importance of taking all antibiotics or antiviral agents as prescribed. Symptoms will improve after 1–2 days of treatment, but organisms may still be present. Teach patients diagnosed with gonorrhea, chlamydia, syphilis, or trichomoniasis that all sexual partners need to be treated to prevent transmission and reinfection .

46. Teach patients to abstain from sexual contact during and for 7 days after treatment and to use condoms or other barrier methods when sexual activity is resumed to prevent spread of infection and reinfection. Explain the importance of follow-up examination and retesting at least once after treatment (if appropriate) to confirm complete cure and prevent relapse. Allow patients and partners to voice their concerns and clarify areas that need explanation. Teach patients about the signs and symptoms of complications and need to report problems to their HCP to ensure proper follow-up and early treatment of reinfection. Tell patients of the infectious nature of these infections to avoid a false sense of security, which may result in careless sexual practices or poor personal hygiene. Tell patients about health department requirements for anonymously reporting certain STIs.

47. Preventing Sexually Transmitted Infections Follow “safer” sex practices every time you have sexual contact and be responsible for your own protection. Have sexual activity only in an established, monogamous relationship. Obtain vaccinations to help prevent some types of HPV. Know your sex partners. Be comfortable saying “no” to sexual activity. Limit alcohol use to moderate levels. If you are at risk, obtain testing regularly and encourage partners to do the same.

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