Chapter 53: Nursing Management: Sexually Transmitted Diseases

• • • • Sexually transmitted diseases (STDs) are infectious diseases transmitted most commonly through sexual contact. Types of STD infections include bacterial (gonorrhea, chlamydia, syphilis) and viral (genital herpes, genital warts). Most infections start as lesions on the genitalia and other sexually exposed mucous membranes. Wide dissemination to other body areas can then occur. A latent, or subclinical, phase is present with all STDs. This can lead to a long-term persistent infection and transmission of disease from asymptomatic (but infected) person to another contact. Different STDs can coexist within one person.

GONORRHEA • Gonorrhea is the second most frequently reported STD in United States. • • • • • It is caused by Neisseria gonorrhoeae, a gram-negative diplococcus. Gonorrhea is spread by direct physical contact with an infected host, usually during sexual activity (vaginal, oral, or anal). The initial site of gonorrhea infection in men is usually the urethra. Symptoms of urethritis consist of dysuria and profuse, purulent urethral discharge developing 2 to 5 days after infection. Women with gonorrhea are often asymptomatic or have minor symptoms that are often overlooked. A few women may complain of vaginal discharge, dysuria, or frequency of urination. Complications of gonorrhea in men are prostatitis, urethral strictures, and sterility from orchitis or epididymitis. Because women with gonorrhea who are asymptomatic seldom seek treatment, complications are more common and include pelvic inflammatory disease (PID), Bartholin’s abscess, ectopic pregnancy, and infertility. Typical clinical manifestations of gonorrhea, combined with a positive finding in a Gramstained smear of the purulent discharge from the penis, gives an almost certain diagnosis in men. A culture must be performed to confirm the diagnosis in women. The most common treatment for gonorrhea is a single IM dose of ceftriaxone (Rocephin). Patients with coexisting syphilis are likely to be cured by same drugs used for gonorrhea. All sexual contacts of patients with gonorrhea must be evaluated and treated to prevent reinfection after resumption of sexual relations.

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SYPHILIS • The cause of syphilis is Treponema pallidum, a spirochete which enters the body through very small breaks in skin or mucous membranes. • •

In addition to sexual contact, syphilis may be spread through contact with infectious lesions and sharing of needles among IV drug users. If syphilis is not treated, specific stages are characteristic of disease progression. In the primary stage, chancres appear. During this time, draining of microorganisms into lymph nodes causes regional lymphadenopathy. Genital ulcers may also be present. Without treatment, syphilis progresses to a secondary (systemic) stage. Manifestations include flu-like symptoms of fever, sore throat, headaches, fatigue, and generalized adenopathy. The third stage is most severe stage. Manifestations include gummas, aneurysms, heart valve insufficiency, and heart failure, and general paresis. Syphilis is commonly diagnosed by a serologic test. Benzathine penicillin G (Bicillin) or aqueous procaine penicillin G remains the treatment for all stages of syphilis.

CHLAMYDIAL INFECTIONS • Chlamydial infections are the most commonly reported STD in the United States.

They are caused by Chlamydia trachomatis, a gram-negative bacterium that is transmitted during vaginal, anal, or oral sex. Chlamydial infections are associated with gonococcal infections, which makes clinical differentiation difficult. In men, urethritis, epididymitis, and proctitis may occur in both diseases. In women, bartholinitis, cervicitis, and salpingitis (inflammation of the fallopian tube) can occur in both diseases. Therefore, both Chlamydia and gonorrhea are usually treated concurrently even without diagnostic evidence. Complications from chlamydial infections in men result in epididymitis with possible infertility and reactive arthritis. Complications from chlamydial infections in women may result in PID, which can lead to chronic pelvic pain and infertility. DNA amplification tests are the most sensitive diagnostic methods available to detect chlamydial infections. Chlamydial infections respond to treatment with doxycycline (Vibramycin) or azithromycin (Zithromax).

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GENITAL HERPES • Genital herpes is caused by herpes simplex virus type 2 (HSV-2). • The virus enters through mucous membranes or breaks in skin during contact with infected person.

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In general, HSV type 1 (HSV-1) causes infection above waist, involving gingivae, dermis, upper respiratory tract, and CNS. HSV type 2 (HSV-2) most frequently infects the genital tract and perineum (locations below waist). In a primary episode of genital herpes the patient may complain of burning or tingling at the site of inoculation. Multiple small, vesicular lesions may appear on penis, scrotum, vulva, perineum, perianal region, vagina, or cervix. Recurrent genital herpes occurs in 50% to 80% of individuals during the year following the primary episode. Stress, fatigue, sunburn, and menses are noted triggers. Symptoms of recurrent episodes are less severe, and lesions usually heal within 8 to 12 days. The diagnosis of genital herpes is confirmed through isolation of the virus from active lesions by means of tissue culture. Three antiviral agents are available for treatment: acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir). These drugs inhibit herpetic viral replication and are prescribed for primary and recurrent infections.

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GENITAL WARTS • Genital warts are caused by the human papillomavirus (HPV). There are over 100 types of papillomaviruses, and about 40 of these affect the genital tract. • • Most individuals who have HPV infection do not know they are infected because symptoms are often not present. Some HPV types appear to be harmless and self-limiting, whereas others are linked to cervical and vulvar cancer in women and anorectal and squamous cell carcinoma of the penis in men. Genital warts are discrete single or multiple papillary growths that are white to gray and pink-flesh colored. They may grow and coalesce to form large, cauliflower-like masses. In men, warts may occur on the penis and scrotum, around the anus, or in the urethra. In women, warts may be located on the vulva, vagina, or cervix and in the perianal area. Diagnosis of genital warts can be made on the basis of gross appearance of lesions. Genital warts are difficult to treat and often require multiple office visits with a variety of treatments. Treatment consists of chemical or ablative (removal with laser or electocautery) methods. Because treatment does not destroy the virus, recurrences and reinfection are possible, and careful long-term follow-up is advised. A vaccine is now available to prevent precancerous genital lesions and genital warts due to human HPV (types 6, 11, 16, and 18).

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Nurses should be prepared to discuss decreasing exposure to STDs with all patients, not only those who are perceived to be at risk. “Safe” sex practices include abstinence, monogamy with the uninfected partner, avoidance of certain high-risk sexual practices, and use of condoms and other barriers to limit contact with potentially infectious body fluids or lesions. Nurses can actively encourage communities to provide better education about STDs for their citizens. Teenagers have a high incidence of infection and should be a prime target for such educational programs. An STD may be met with many emotions, such as shame, guilt, anger, and a desire for vengeance. The nurse should provide counseling and try to help patient verbalize feelings related to the STD.