SEXUALLY TRANSMITTED INFECTIONS
Sexually transmitted infections (also called sexually transmitted diseases) are contracted through sexual intercourse or other sexual contact with an infected person. STIs are the most commonly reported infectious diseases in the United States today. The increased incidence of STIs cannot be attributed to one cause. Many cases are undiagnosed and therefore unreported. State and national Public Health Departments have requirements for healthcare providers for the reporting of STIs.
Adolescents and young adults, particularly females between the ages of 15 and 29 years, have the highest reported cases of chlamydia and gonorrhea. Risk factors include the likelihood of more sexual partners for shorter durations. These women are more likely to have unprotected sex and to have sex with partners infected with STIs. Younger people often face barriers to receiving STI counseling and protective and treatment services. Confidentiality, embarrassment, lack of finances or insurance, and lack of transportation also factor into the high rates of adolescent infections. Box 70-5 reviews important concerns related to STIs.
STIs and birth control must be considered as connected but separate issues. Certain birth control methods—such as withdrawal, IUDs, and oral or implanted contraceptives— factor into the spread of STIs. These birth control methods have no mechanism to prevent the spread of bacteria, viruses, or other microorganisms.
Many barrier methods (e.g., latex condoms) provide some protection against both STIs and pregnancy. Safer sex, but not safe sex, is possible with the use of condoms. Additional precautions (e.g., spermicides) provide better protection against STIs. Sexual abstinence is the only guarantee of protection against STIs.
Treatment of STIs is often difficult. Resistance to antibiotics is problematic. In addition, no specific antibiotic,antiviral, or other treatment has been found that will prevent or cure HIV/AIDS or herpes simplex virus 1 or 2. Individuals infected with viral STIs are infected for life. A person also may have more than one STI simultaneously, which makes treatment difficult. Antibody immunity does not develop in many of the STIs, such as chlamydia, gonorrhea, syphilis, or trichomoniasis, which leads to the need for continual surveillance and lifetime problems. Individuals may become infected more than once.
BOX 70-5.
Lifetime Considerations Related to STIs
Sexually transmitted diseases may:
• Increase your chances of infection with human immunodeficiency virus (HIV).
• Increase your chances of infection with other STIs (co-infections).
• Have few, inconsistent, confusing, or no symptoms.
• Cause significant side effects and/or death in newborns.
• Cause infections that lead to pelvic inflammatory disease (PID) and/or infertility.
• Cause infections of the mouth, throat, respiratory tract, urethra, and reproductive organs in both men and women.
• Cause infections that reoccur when reexposed by a partner who has not been diagnosed or who had incomplete treatment.
• Can occur at any age, but are most common in sexually active young adults.
• Are less common in individuals who are tested for STIs and are in monogamous relationships
HIV and AIDS
A link connecting HIV and other STIs is known. A person who has an STI and is exposed to HIV is two to five times more likely to acquire HIV than is a person who does not have an STI. HIV/AIDS is discussed in more detail.
Women are more easily infected by unprotected sex because the delicate tissues of the female reproductive tract can become scratched or irritated. These little fissures offer direct routes of invasion for the HIV virus.
Women can transfer the virus to their unborn children during pregnancy, birth, or through breastfeeding. Women with HIV can often prevent the transfer of HIV to their unborn children with proper prenatal care.
Signs and Symptoms
HIV infection can mimic many other illnesses. Diagnosis by laboratory testing is the only accurate HIV detection method. A person who has had any STI should consider getting tested for HIV. Warning signs of possible HIV infection include:
• Rapid weight loss
• Dry cough
• Fever, night sweats
• Profound fatigue
• Enlarged lymph nodes
• Severe diarrhea lasting more than 1 week
• White spots or unusual blemishes on the tongue or mouth, or in the throat
• Pneumonia
• Red, brown, pink, or purplish blotches on or under the skin
• Memory loss, depression
• Neurologic disorders
• History of STI
Symptoms that women have when they are HIV positive frequently differ from the symptoms men have. HIV treatment is delayed because the initial symptoms often appear as common female problems. Most women tend to be occasionally annoyed by “female problems” and often self-treat symptoms at home. However, frequent female problems, such as yeast infections, abnormal Pap smears, or pelvic pain, can be early symptoms of HIV infection.
In keeping with Standard Precautions, nurses wear gloves when coming in contact with any body fluids to protect themselves against the possibility that their clients might be HIV positive or have hepatitis or any other communicable disease.
Chlamydia
Chlamydia trachomatis is the bacterial species that is the leading cause of preventable infertility in women and the most common STI in the United States. Chlamydia is transmitted during vaginal, anal, or oral sex, leading to infections in the associated tissues of these areas. Lymphogranuloma venereum (LGV) is an STI that results from the three strains of Chlamydia trachomatis.
Signs and Symptoms
Approximately 50% of affected individuals are asymptomatic. Chlamydia may be called a “silent STI.” Symptoms may be mild, absent, or misdiagnosed. Three of four women have no symptoms and half of men have no symptoms. If symptoms occur, they typically occur 1 to 3 weeks after exposure. Often the infection is not diagnosed until complications or damage occurs. Box 70-6 presents the many signs and symptoms of chlamydial and LGV Infections.
For men, the symptoms of chlamydial infection include painful urination, a watery penile discharge, and pain and swelling in the testicles. Untreated chlamydia infection generally causes urethral infections, epididymitis, and potential infertility.
Women initially may have dysuria (burning, painful, or difficult urination), vulvar itching and burning, grayish-white or abnormal vaginal discharge, or spotting between menstrual periods. Although symptoms may begin in the urethra and cervix, which ascend to the fallopian tubes, recognizable problems may start with abdominal pain, low back pain, fever, and dyspareunia (painful sex). PID happens in about 40% of women who do not get treatment for chlamydia. PID often results in chronic pelvic pain, permanent damage to the female reproductive organs, ectopic pregnancies, and infertility. Chlamydia and LGV can be the cause of preterm births, newborn pneumonia, and conjunctivitis (“pink eye”).
BOX 70-6. Signs and Symptoms of Chlamydial and Lymphogranuloma venereum (LGV) Infections
♦ Absent, mild, or nonexistent symptoms
♦ Burning or itching with urination in men or women
♦ Urinary discharge in men or women
♦ Vaginal discharge
♦ Low back pain
♦ Nausea
♦ Fever
♦ Dyspareunia
♦ Abnormal menstrual cycles
♦ Pelvic inflammatory disease
♦ Infertility
♦ Epididymitis
♦ Rectal pain, discharge, or bleeding in men or women
♦ Genital papules
♦ Rectal ulcers
♦ Swollen lymph glands in infected areas
♦ Infertility
FIGURE 70-2 · The nurse is assisting the practitioner during a pelvic examination. Notice that the nurse holds the microscope slide on the frosted portion so that the practitioner can smear the clear portion with vaginal secretions.
Diagnosis and Treatment
Diagnosis is made with a stained smear test that includes urine or specimen collection from the penis or cervix. Because of the reinfection frequency, retesting when changing partners is highly recommended (Fig. 70-2).
Treatment includes the medications azithromycin and doxycycline. For clients who are pregnant or allergic to tetracycline (doxycycline), erythromycin is used. Because 40% to 60% of clients with gonorrhea also are infected with chlamydia, treatment with ceftriaxone may also be indicated. People with chlamydia must use condoms when engaging in sexual activity, and all sexual partners must be treated simultaneously to avoid reinfection, which is common.
Nursing Alert etracyclines (doxycycline) are contraindicated in pregnancy or in infants because they permanently stain teeth. Alternative antibiotics such as erythromycin or azithromycin are used when necessary
Gonorrhea
Gonorrhea is caused by invasion of the bacteria Neisseria gonorrhoeae, also known as gonococcus (GC). It is spread through vaginal, oral, or anal sexual contact between partners. Gonorrhea can be spread from one part of the body to another, such as by touching infected genitals and then the eyes.
During delivery, a mother can infect her infant with gonorrhea. Untreated infection in a newborn can lead to blindness, joint infection, or sepsis. Healthcare facilities have standard criteria, such as administration of antibiotic eye drops to newborns, to prevent gonorrheal eye infections. Prenatal care and STI screening are important teaching considerations for the nurse.
Signs and Symptoms
Typical symptoms in men when initially infected with Neisseria gonorrhoeae are a burning sensation during urination and a yellowish-white discharge from the penis. Painful or swollen testicles are common. Prostatitis, infection of the seminal vesicles, and sterility may develop.
Without treatment, the disease progresses to the epididymis. Gonorrhea can spread to bones, joints, or the bloodstream, resulting in arthritis, heart disease, liver damage, or central nervous system damage.
Approximately 50% of women with gonorrhea are asymptomatic. Clinical findings in women include cervical tenderness, dyspareunia, purulent anal discharge, dysuria, and a yellow-green purulent vaginal discharge. PID is common and sterility may result. Douching, sexual intercourse, and menstruation may spread the infection to the ovaries and cause abscess.
Nursing Alert Having gonorrhea once does not confer immunity; the person is particularly susceptible to reinfection. Tracing and treating all the person’s sexual contacts is important to avoid reinfection ("ping-pong infection"). Reinfection by a carrier with no symptoms is common.
Diagnosis and Treatment
A smear of the discharge is cultured and examined microscopically, obtaining a Gram stain of the gonorrhea bacterium, often referred to as a GC Gram stain (Fig. 70-3A). Some physicians advocate obtaining urethral, vaginal, anal, and throat cultures. One treatment for gonorrhea is intramuscular injection of ceftriaxone (Rocephin) or cefixime (Suprax). Drug-resistant strains are problematic in many areas. Co-infection with chlamydia is very common. Treatment consists of antibiotics that treat both infections. Individuals with gonorrhea should also be tested for other STIs, including HIV.
All sexual partners also must be treated simultaneously to prevent reinfection. When the infection is active, teach the client about the use of Standard Precautions; that is, to wear gloves when coming into contact with his or her own body secretions. Frequent and careful handwashing is critical. Eyes are particularly susceptible to gonorrheal infection.
With an advanced infection, the client needs bed rest and may require sitz baths and massive doses of intravenous antibiotics. The individual is not considered disease free until cultures have been negative for at least 7 days without antibiotics.
Syphilis
Syphilis is caused by a destructive bacterial spirochete (Treponema pallidum) that can have grave consequences throughout the body. It is known as “the great imitator” because its symptoms resemble those of many other diseases. The trend shows a significant explosion of cases of syphilis.
Syphilis is spread by direct contact with a syphilitic lesion (sore) via vaginal, anal, or oral sex. Lesions generally occur on the external genitals, the vagina, the anus, or in the rectum, on the lips, and in the mouth. The spirochetes can enter through cuts or breaks in the skin. Healthcare workers must use Standard Precautions to avoid infection.
Pregnant women can pass syphilis to a fetus. Spontaneous abortions (miscarriages) are not uncommon in cases of maternal syphilis. An infant born with syphilis may be stillborn (dead at birth) or may die shortly after birth. Some infected newborns do not have symptoms at birth but develop them within a few weeks. These infants tend to have developmental delays or seizures, or they die.
Signs and Symptoms
The spirochetes thrive in moisture and live for a short time outside the human body. After entering the body, the spirochetes immediately multiply and gain access to the bloodstream. Within 10 days to 3 months, the first syphilitic lesion (chancre or primary lesion) appears.
Primary Stage. Within 10 to 90 days of infection, the chancre may appear on the penis, on the anus, inside the vagina, on the nipple, or in a crack at the side of the mouth (Fig. 70-3B). One or more chancres may appear at the spot where syphilis has entered the body. The chancre lasts 3 to 6 weeks and heals with or without treatment. The chancre is deep, painless, hard, and oval-shaped, with serous drainage. It contains millions of spirochetes. Sometimes, enlarged lymph nodes also appear. Blood tests are usually positive during the primary stage (Table 70-1). Without treatment, the disease progresses to the secondary stage.
Nursing Alert A syphilitic chancre is not to be confused with the "blisters" of herpes simplex virus type 1 or 2.
Secondary Stage. Approximately 2 to 4 weeks after the initial infection, the secondary stage begins; it may last 2 to 6 weeks. A macular copper-colored rash can appear on the abdomen, the soles of the feet, or the palms (Fig. 70-3C). Wart-like spots may develop on the mucous membranes or around the anus. These spots are extremely infectious. Patches of the client’s hair may come out, and he or she may have a fever, headache, or sore throat. The person may have none of these symptoms and may feel normal and well. This stage also ends spontaneously.
Nursing Alert During the first and second stages of syphilis, the client is highly infectious, although he or she may show no symptoms. This fact is the main reason for the spread of the disease. The client believes that he or she is cured or decides that he or she never had syphilis.
Late Syphilis or Latent Stage. When the symptoms of the secondary stage disappear, the latent (hidden) stage begins. This stage may last anywhere from several years to several decades. Serologic laboratory tests may or may not be positive for the disease. The individual may not be infectious to others during the later stages. Tertiary syphilis is the end stage of the disease. Internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints, begin to show the accumulated damage of the years without treatment. Lack of muscle coordination, paralysis, gradual blindness, dementia, and death occur.
The lack of muscle coordination with syphilis, called tabes dorsalis (locomotor ataxia), involves the nervous system. It is accompanied by a sharp, burning pain in the legs;legs feel numb, and then cold or warm. The person seems not to know where his or her legs are and cannot walk without watching them closely. The gait is jerky, and the individual cannot find his or her way in the dark. Joint function is lost.
FIGURE 70-3 · (A) Gonococcal urethritis is the most common symptom of gonorrhea seen in men. Note the purulent penile discharge from the meatus and the gonorrheal lesions on the foreskin (Porth, 2007). (B) The painless chancre of primary syphilis seen on a penis (Rubin, 2005). (C) The rash of secondary syphilis is often seen on the palms of the hands or the soles of the feet (Rubin, 2005). (D) Herpes simplex virus is seen as shiny, small blisters in the vulva area (Nettina, 2006). (E) Genital human papillomavirus, also known as condyloma acuminatum (pl. condyiomata acuminata), causes genital warts, as seen here in the vulva region (Nettina, 2006). (F) Genital human papillomavirus of the penis. Note the raised, round lesions on the shaft of the penis.
Diagnosis and Treatment
Tests for syphilis and gonorrhea are always done as part of antepartal care. Some states also require premarital blood tests for these disorders.
TABLE 70-1. Blood Tests for Syphilis
|
BLOOD TEST |
USE |
|
Venereal Disease Research Laboratory (VDRL) |
Used for first-line screening; can give both false-negative and false-positive results; results are not conclusive until at least 2 weeks after infection. Multiple causes of false-positive results. |
|
Rapid Plasma Reagin (RPR) |
Used for first-line screening and confirming syphilis |
|
Enzyme Immunoassay (EIA) |
Rapid, simple test used for first-line screening; results are not conclusive until at least 2 weeks after infection. Checks for antibodies of syphilis. Should be confirmed with VDRL or RPR. |
|
Treponema Pallidum Particle Agglutination assay (TPPA) |
Used to confirm a syphilis infection after another method tests positive for the syphilis bacteria. Detects antibodies to the bacteria in all stages of the disease except the initial third to fourth week. Not done on spinal fluid. |
|
Fluorescent Treponemal Antibody Absorption (FTA-ABS) |
Checks for antibodies and can be used to detect syphilis except during the first 3-4 weeks after exposure; more difficult to do and may be used to confirm a syphilis infection after another method tests positive for the syphilis bacteria. Can be done on a sample of blood or spinal fluid. |
|
Darkfield microscopy |
Used to diagnosis syphilis using fluid sample from chancre (open sore) to see the corkscrewshaped bacteria on a microscopic slide. Used mainly as diagnostic tool in early weeks of infection. |
|
Wasserman test |
Original test for syphilis; sometimes still used. |
A smear taken from a syphilitic lesion can provide diagnostic information. More commonly, diagnosis comes from several types of blood tests (see Table 70-1).
A common treatment for syphilis at any stage is large doses of intramuscular benzathine penicillin G (Bicillin LA). Treatment can destroy the syphilis organisms at any stage of the disease; however, drugs cannot reverse any damage already present. Syphilitic damage is irreversible.
Herpes Simplex Virus (Genital Herpes)
Herpes simplex virus type 1 (HSV-1 ) and the more common STI, herpes simplex virus type 2 (HSV-2), are the causes of genital herpes, sexually transmitted viral infections. It is often difficult to differentiate between HSV-1 and HSV-2, which both appear as one or more blisters, typically around the genitals or rectum. The blisters are loaded with the virus and are the cause for transfer of infections because they tend to break, resulting in painful ulcers. The first infection can take 2 to 4 weeks to heal and, commonly, other outbreaks will appear within weeks or months. After the initial outbreak, the following outbreaks tend to be less severe and heal more rapidly. The frequency of outbreaks may decrease in the following decades, but the virus typically remains indefinitely. The virus is small enough to penetrate a condom.
Genital herpes infection makes individuals more susceptible to HIV infection. Persons with existing HIV infection are more likely to become infected with HSV, as well as other STIs (Box 70-7).
Pregnant women can shed the virus at the time of delivery, causing potentially fatal infections in the newborn. A cesarean delivery is commonly scheduled if a mother has active, or a history of, genital herpes.
HSV-1 is more commonly associated with common canker sores, “cold sores,” or “fever blisters” of the mouth and lips. HSV-1 is mainly associated with nongenital lesions, but sometimes does involve the genital tract. Direct contact with the saliva of an infected person, such as by kissing, can transmit the infection from one person to another. HSV-1 infection of the genitals is most often caused by oral-genital sexual contact. HSV-2 is transferred from one partner to another during sexual contact. HSV-2 outbreaks occur more frequently than HSV-1
BOX 70-7. Considerations Related to Herpes Simplex Virus (HSV)
Predisposing and Precipitating Factors to HSV-1 and HSV-2 Infection
• Existing oral, anal, or vaginal lesions (blisters)
• Multiple sexual partners
• Anxiety or fatigue
• Vaginal or labial irritation
• Sunburn
• Tight clothes, especially synthetics or wet bathing suits
• Fever
• Certain time of menstrual cycle
• Birth control pills
• Hormonal imbalance
Other Considerations
• HSV-2 closely associated with cervical cancer
• HSV-2 closely associated with prostatic cancer
• HSV-2 closely associated with Hodgkin’s disease and lymphosarcoma
• Great danger to the newborn if mother has active HSV
• Disease is very contagious at certain times
• The virus can penetrate a condom outbreaks.
Risk factors for genital herpes infections include:
• Multiple sexual partners
• Age ranging from 14 to 50 years
• Low socioeconomic status
• Minority ethnic origin
• Female gender
• Male homosexual activity
• HIV infection
Signs and Symptoms
Symptoms of HSV range from none to mild to severe. The initial lesions of HSV-2 resemble HSV-1 such as fever blisters (common canker sore; see Fig. 70-3D). Commonly, HSV-2 infected individuals may never develop the viral-filled ulcers or have other symptoms. The initial lesions will heal without treatment, although the condition usually recurs. Two-thirds of people who have an initial outbreak will have a recurrence. HSV can also be released between episodes of blisters, from skin or mucous membranes that do not have a blister.
In women, the lesions begin on the external genital labia approximately 6 days after exposure. From there, they spread and usually become painful. However, they may be painless if they spread into the vagina. The lesions often look like pimples surrounded by a reddened area; they then progress to papules, vesicles, and finally crusts. This sequence lasts 1 to 3 weeks.
Systemic flu-like symptoms, such as headache, general malaise, fever, and node tenderness, often exist concurrently. Other symptoms of primary infection in women include dysuria, vaginal discharge, perineal discomfort, and dyspareunia. The lesions may be extremely painful. However, a significant number of all people infected are unaware of being infected.
In men, the major symptom is a painful lesion, usually on the penis, which may be mistaken for the chancre of syphilis. The uncircumcised man may carry the herpes simplex virus in the smegma, a secretion that collects under the foreskin.
Secondary infections usually are localized, causing painful lesions. Precipitating factors include anxiety, fatigue, excessive sexual activity, excessive vaginal or labial irritation, sunburn, tight clothes (especially synthetics), and fever. Recurrence also seems to be related to hormonal imbalance and to the menstrual cycle. Birth control pills increase the possibility of infection. Oral contraceptives alter vaginal secretions, enabling the virus to grow faster and to be transmitted more easily.
