Sexually Transmitted Infections (STIs)

• Sexually transmitted infections (STIs) are infectious diseases spread through sexual contact (penis, vagina, anus, mouth) or sexual fluids.
• Mucosal tissues in the urethra (men), vagina (women), rectum, and mouth are susceptible to STI-causing bacteria and viruses.

Common STIs

• Genital human papillomavirus (HPV) spreads via direct skin contact.
• Human immunodeficiency virus (HIV) contracts via blood/blood products or from mother to baby during pregnancy/delivery.
• STIs spread through autoinoculation (transferring infection by touching/scratching an infected area).
• STIs cannot typically spread via casual contact or inanimate objects.

Diseases and Causes

• Bacterial Infections:
• Chlamydial: Chlamydia Trachomatis
• Gonorrhea: Neisseria Gonorrhoeae
• Syphilis: Treponema pallidum
• Viral Infections:
• Genital herpes: Herpes simplex virus (HSV 1 or 2)
• Genital Warts: Human papillomavirus (HPV)
• Human Immunodeficiency virus infection (HIV): Human immunodeficiency virus (HIV)
• Hepatitis B and C: Hepatitis B and C viruses
• Molluscum: Molluscum contagiosum
• Parasitic/Protozoan Infection:
• Trichomoniasis: Trichomonas vaginalis

Risk Factors for STIs

• High-Risk Behaviors:
• Alcohol or drug use (inhibits judgment)
• New/multiple sexual partners
• Having >1 sexual partner
• Sexual partners with multiple partners
• Inconsistent/incorrect use of condoms/barrier methods
• Sharing needles for injected drugs
• High-Risk Medical History:
• Having 1 STI is a risk factor for getting another
• Not being vaccinated for STIs or other infections spread through sexual activity (HPV, hepatitis A/B).
• Receiving multiple courses of non-occupational post-exposure prophylaxis for HIV infection
• High-Risk Populations:
• Adolescents/young adults (<25)
• Ethnicity
• Men who have sex with men
• Persons in correctional facilities
• Transgender persons
• Victims of sexual assault
• Women

Chlamydial Infections

• Chlamydial infections are caused by Chlamydia trachomatis, a gram-negative bacterium.
• Chlamydia transmits through sexual fluids during vaginal, anal, or oral sex.
• Ejaculation is not required for transmission.
• The incubation period for chlamydia: 1-3 weeks.
• Common infection site for men: urethra (urethritis).
• Common infection site for women: cervix (cervicitis).
• Both men/women can get chlamydia of the rectum (receptive anal sex) or oropharynx (oral sex).
• Vagina acts as a natural reservoir for infectious secretions; STI transmission is more efficient from men to women.

Clinical Manifestations

• No symptoms are common
• Pain with urination
• Urethral discharge
• Pain/swelling of testicles
• Mucopurulent (mucus with pus)
• Bleeding
• Dysuria
• Pain with intercourse

Symptoms of Rectal Chlamydia

• Anorectal pain
• Discharge
• Bleeding
• Pruritus
• Tenesmus
• Mucus-coated stools
• Painful bowel movements

Diagnostic Studies

• Accurate sexual history
• Physical examination
• Laboratory tests specific to infection
• Nucleic acid amplification test (NAAT):
• Identifies small amounts of DNA/RNA in test samples

Treatment

• Azithromycin (Zithromax) as a single dose
• Doxycycline (Vibramycin) twice a day for 7 days

Role of Nurse in Treatment (Drug alert)

• Patients should avoid prolonged/excessive sunlight exposure.
• Take doses on an empty stomach - 1 hour before or 2 hours after eating.
• Avoid taking with antacids, iron, or dairy products.
• Pregnant women should not take doxycycline

Gonococcal Infections

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

Etiology

• Gonorrhea transmits via exposure to sexual fluids during vaginal, anal, or oral sex.
• Ejaculation does not have to occur for it to be transmitted. Incubation period: 1-14 days.

Pathophysiology

• 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.

Clinical Manifestations

• Male:
• Dysuria
• Purulent urethral discharge
• Epididymitis
• Female:
• Increased vaginal discharge
• Dysuria
• Frequency of urination
• Bleeding after sex
• Redness/swelling at cervix/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.

Diagnostic Studies

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

Treatment

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

Trichomoniasis

• Trichomonas transmits via exposure to sexual fluids during vaginal, anal, or oral sex, even without ejaculation.
• Incubation period: usually 1 week to 1 month but can be much longer.
• The most common infection site for men is the urethra and in women is the cervix.

Clinical Manifestations

• Men:
• Burning with urination and ejaculation
• Urethral discharge
• Women:
• Painful urination
• Vaginal itching
• Painful intercourse
• Bleeding after sex
• Yellow-green discharge with a foul odor
• The cervix can have a "strawberry" appearance.

Diagnostic Evaluations

• NAAT testing of vaginal/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

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/until all sexual partners complete treatment and abstinent for 7 days.
• Tell patients to return for persistent/recurring symptoms.
• Treat any sexual partner within the preceding 60 days.
• Teach patients to use condoms/barrier methods with every sexual contact.
• Because of a high recurrence rate, repeat testing is recommended 3 months after.

Genital Herpes Infections

• Genital herpes is a common, lifelong, incurable infection.
• Two strains of herpes:
• Herpes Simplex Virus Type 1 (HSV-1):- Associated with oral lesions.
• Herpes Simplex Virus Type 2 (HSV-2):- More common in the genitals/anus.

Pathophysiology

• The virus enters through the mucous membranes or breaks in the skin during contact with an infected person.
• Reproduces inside the cell and spreads to the surrounding cells.
• Then the virus enters the peripheral or autonomic nerve endings and ascends to the sensory or autonomic nerve ganglion near the infection site
• Viral reactivation occurs when the virus descends to that initial site of infection, either the mucous membranes or skin.

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 can occur.

Recurrent Episodes

• Occurs in many people during the year after the primary episode.
• 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.

Diagnostic Assessment

• History and physical examination
• Antibody assay for HSV type
• Viral isolation by tissue culture

Treatment

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

Genital Warts

• Genital warts (condylomata acuminata) are caused by 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.

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.

Clinical Manifestations

• Asymptomatic.
• Genital/anal warts are discrete single/multiple papillary growths (white to gray, pink-flesh colored, or 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

Diagnostic Evaluations

• Visual examination Biopsy
• Pap smear test
• Viral markers

Treatment

• Trichloroacetic acid (TCA)
• Bichloroacetic acid (BCA)
• Podofilox liquid/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,
• surgical excision may be needed

Syphilis

• Syphilis is caused by Treponema pallidum, a bacterial spirochete.
• 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.

Stages of Syphilis

Primary:

• Infectivity: Highly infectious
• Duration of stage: 3-6 wk
• Single/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 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

Latent:

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

Late:

• Infectivity: Noninfectious

• Duration of stage: Chronic (without treatment) occurs 1-20 years after initial infection

• Gummas (chronic, destructive lesions affecting any organ of the 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).

Diagnostic Assessment

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

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.

Nursing Management: STIs

Nursing Diagnoses

• Impaired sexual functioning
• Risk for infection
• Lack of knowledge

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 the 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.
• 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.

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.