Sexually Transmitted Infections

Chlamydia

Delaware online mentions that Delaware jumps to the top 10 for chlamydia and gonorrhea rates - so want to make sure testing is occurring in order to get proper treatment • Most commonly reported bacterial STI in the United States • ~ 2/3 of new infections occur in 15 to 24 year-olds • Spread by sexual contact and to neonate in birth canal of infected mother • Infections include: • -Acute urethral syndrome • -Nongonococcal urethritis • -Mucopurulent cervicitis • -Pelvic inflammatory disease (PID)

Assessment

Observation and patient history - needs to be thorough o Health history o Sexual history o Symptoms of current complaint § Onset, duration, severity § Precipitating or relieving factors § Source of complaint

Gonorrhea

oral and cervical, good to go to dentist because they are doing different screening tools Patho: • Pyogenic bacteria that causes inflammation • Humans are the only host for the organism • Transmitted by sexual intercourse, during delivery through infected birth canal Portal of entry: • Genitourinary tract, eyes, Oropharynx, Anorectum, Skin Incubation period: 1-14 days in men, 10 days in women • Initially targets female cervix, male urethra - Disseminates to other organs: • Men - Acute, painful inflammation of prostate, epididymis, peri-urethral glands, sterility • Women - PID, Endometritis, Salpingitis, Pelvic peritonitis usually asymptomatic or they think they may have a yeast infection so they'll start treating themselves with over the counter yeast infection treatments

Common STDs

· HPV · Herpes simplex virus · Genital herpes · Chlamydia · Gonorrhea · Syphilis

Chlamydia Risk Factors

• -Being female • -Being between ages 14 and 19 • -Personal history of STI or partner with such history • -Cervical ectopy • -Multiple sex partners • -Unprotected sex • -Drug or alcohol use that increases risky sexual behavior

Latent syphilis

• -Period after secondary lesions resolve • -No symptoms • -Sexual transmission of disease possible in early part of this stage • -May last 1 year to a lifetime

Gonorrhea Risk factors:

• -Residence in large urban area • -Being transient • -Early sexual activity • -Multiple serial or consecutive sex partners • -Drug use didn't talk about but was in the packet • -Prostitution • -Previous gonorrheal infection or concurrent STI

Chlamydia Treatment

• A single dose of azithromycin or taking doxycycline twice daily for 7 to 14 days • Antibiotics for men, non-pregnant women • Both sex partners must be treated at same time or before resuming sexual intercourse don't want them to possibly re-infect one another

Prevention

• Abstinence #1 prevention • Male circumcision for STI prevention of HPV and HSV • Vaccinate for HPV prior to sexual initiation/ activity • Condoms • Screen asymptomatic persons because some STDs out there that will not necessarily have telltale signs that you have an STD • Vaccinate for HPV, Hepatitis A and B

Maternal-newborn considerations: (Lifespan)

• All pregnant women should be routinely tested for STIs, including HIV • May be repeated during third trimester if patient is at high risk • Complications • For mother, usually occurs during pregnancy • For child, may occur shortly after birth - Some may not become evident for months or years • Antibiotics for bacterial STIs are safe to take during pregnancy • Antivirals for viral STIs can reduce risk of passing infection to child moms may have to stay on certain antivirals • Cesarean section may be needed

Syphilis Treatment

• Antibiotic therapy- penicillin G 2.4 million units administered intramuscularly in a single dose - works well for this disease • Goals - Inactivate the spirochete, Educate patient to prevent reinfection, further transmission • Identification of partners, referral for testing and treatment • Follow-up testing, education about condom use

Genital Herpes Pharmacologic Therapy

• Antiviral medications reduce length, severity of outbreaks • Acyclovir: treatment of choice - PO and topical - for subsequent outbreaks they will send you home with a prescription for like 60 tablets or 90 tablets, whatever but whenever you start to feel the symptoms you can start taking the Acyclovir for a certain time frame, maybe 3 or 5 days in order to decrease that outbreak • Patient education essential • To prevent spread of disease and to help the patient manage chronic disease

Chlamydia Manifestations

• Asymptomatic in most women until uterus, fallopian tubes have been invaded because of the pain • Treatment may be delayed → long-term complications: -Preventable infertility, ectopic pregnancy because of the scarring -Infants born to untreated mothers at risk for chlamydial conjunctivitis, pneumonia women are usually tested before and during pregnancy • Center for Disease Control and Prevention (CDC) recommends routine screening for sexually active women < 25 years old - because they are asymptomatic • Untreated chlamydial infection in women may ascend to upper reproductive tract: -Complications include PID, possibly with endometriosis, salpingitis → chronic pelvic pain, scarring of fallopian tubes which will lead to infertility • Asymptomatic in 90% of men: -Complications include reactive arthritis, epididymitis, prostatitis, sterility

Adolescents Considerations: (Lifespan)

• At increased risk of STIs, especially girls • May be very concerned about confidentiality ---Confidentiality complicated by insurance requirements like how they're going to be billed and what tests were done and teens might know that this happens and don't get treated because they don't want their parents to know / find out that way • Sexual health more vulnerable in adolescents subject to poverty, unemployment, low education, income inequality • Developmentally appropriate discussions of sexual behavior, infection risk, safer sex practices with all adolescent, young adult patients they do have different classes by HCPs in the schools, and now there are wellness centers in schools, hopefully that is being addressed at the middle and high school level • Screening for hepatitis A and B, C. trachomatis, N. gonorrhoeae • Nonjudgmental, thorough counseling and care to help minimize risk

Syphilis

• Can infect almost any body tissue, organ • Transmitted from open lesions (chancres) during any sexual contact • Incubation period: 12-90 days, averaging 21 days • If untreated, will progress through four stages • Highly contagious in primary, secondary stages even if asymptomatic • Can lead to blindness, paralysis, mental illness, cardiovascular damage could have syphilis of the heart, death • May occur with one or more other STIs

Genital Herpes

• Caused by herpes simplex viruses HSV-1 and HSV-2 • HSV-1: - Associated with cold sores but may be transmitted to genitals - By oral intercourse - By poor hand hygiene → self-inoculation • HSV-2: - Transmitted by sexual activity or during childbirth from infected woman - Causes most cases of genital herpes • Associated with early onset of sexual activity, multiple sex partners • No cure - Antivirals lessen severity of outbreak, shorten its duration

Primary Syphilis

• Chancre - Appears at site of inoculation 3-4 weeks after infectious contact • May go unnoticed in women, disappearing within 3-6 weeks especially because its painless • Regional lymph node enlargement • Little or no pain • Men will report this one because, as you can see (gross picture), it's something that you can see even if it is pain free • But for women if it is internal it might not be something that they notice

Syphilis Diagnosis

• Complex because symptoms mimic other diseases • Most definitive method of diagnosis: dark field microscopy examining specimen from chancre for T. pallidum - rarely used • Requires immediate examination by trained, experienced technician • Most diagnoses made using 2 blood tests

Psychological effects of Pts with a Newly diagnosed STD

• Concern about how it will impact their overall health, sex life, and relationships. • Embarrassment, shame, and stigma associated with a diagnosis that can substantially interfere with relationships. Might not want to disclose • Providers should: give information, provide support & resources, and help define options.

Goals may include that the patient will:

• Describe strategies for reducing risk of STI • Develop plan to contact sex partners • Abstain from sexual activity until STI is resolved • Take appropriate actions to avoid infecting others

Expedited Partner treatment

• EPT is the delivery of medications or prescriptions by persons infected with an STD to their sex partners without clinical assessment of the partners. Clinicians (e.g., physicians, nurse practitioners, physician assistants, pharmacists, public health workers) provide patients with sufficient medications directly or via prescription for the patients and their partners. Most likely not done in private practice, because Delaware is a highly litigious (unreasonably prone to go to law to settle disputes) society, so a lot of private practice won't do it because they're afraid of getting sued • Delaware - Lack of statutory authority stating otherwise, the law does not preclude a physician from prescribing drugs for patient's partner. So it doesn't say whether or not they will or they won't, but if you think about this in the public arena like planned parenthood or in some other clinics they might send out two prescriptions in order for treatment

Prevention and control

• Education, detection, effective diagnosis, treatment of infected individuals • Evaluation, treatment, counseling of infected individuals' sex partners • Ability to get an accurate sexual history is essential • Most effective prevention: avoid sexual intercourse with infected partner • Both partners should be tested for STIs, especially HIV, before having sex thinking of those who are in monogamous relationships, but also have to think about the people who are not, which may have been a one-time thing or maybe somebody is cheating on the other person - everyone needs to be tested, list of contacts and how long it will take for them to get treatment • If partner is infected or infection status is unknown, use new condom for each act of intercourse

Evaluation:

• Expected outcomes may include o Patient is free of STI (for curable) or free of pain, discomfort (for chronic) o Patient explains strategies to prevent infection of others o Patient abstains from sexual activity until STI treated o Patients describes barrier methods to reduce risk of contracting STI

Human Papillomavirus (HPV)

• Family of viruses called papillomavirus • -Effects the skin and mucosa - mouth, throat, cervix, anus, fingernails, and feet • -Over 100 strains of HPV • Highest prevalence found among young women between the ages of 20-24 years - BECAUSE OF THE LARGER MUCOSAL AREA • Recently, there has been a decrease in cervical cancer, but an increase in oropharyngeal, vulva, and anal cancers • People recently have been waiting to have sex until a little bit older in age, but they're doing other forms of sex, so they're doing oral sex and they're still experimenting that way, but they aren't having intercourse • Most common STI in United States • About 40 types that can infect genitals causing malignancies or benign lesions • Malignancies - cervical, vulvar, penile, anal, or oropharyngeal (throat, including the base of the tongue and tonsils) cancer - whenever your dentist is doing their oral assessment they are actually looking for stuff like this too • Benign lesions - Genital warts • Painless, soft, flesh-colored; Raised or flat, large or small • Found in the vaginal/Vulvovaginal area, perineum, penis, urethra, anus, groin, or thigh • Causative agent in many genital cancers • Most sexually active individuals will get at least one type of HPV in their lives our book says that most sexual activity, or active individuals will get at least one type of HPV with 100 different strands out there that is high - Gardasil 9 so it covers nine different strains or types of HPV, there are still 91 out there that you could potentially get • Women at greater risk: larger mucosal surface area exposed in genital area • 90% of cases clear with no intervention within 2 years because our own body produces antibodies to fight off the virus • Persistent HPV → genital warts, cervical cancer - Less often: Doesn't impact fertility • HPV transmitted by vaginal, anal, oral-genital contact • Incubation period 3 weeks to 8 months

HPV treatment

• Gardasil 9 protects against 9 types of cancer-causing HPV types - use to be 3 doses now 2 doses • - 2 doses prior to sexual activity starting at age nine, 3 doses if starting after age 15 Genital warts can be removed with treatment: • Healthcare provider may freeze by cryoprobe or burn with chemicals • Patients may use imiquimod, podofilox, or sinecatechins at home - creams • Extensive warts may require CO2 laser removal - done in the OR

Gonorrhea Treatment

• Goals: • - Eradication of organism, • - Prevention of reinfection or transmission of other STIs • Dual treatment recommended • Single dose ceftriaxone + single dose azithromycin • Administer at the same time if possible • Emphasize importance of abstaining from sexual contact until infection cured in both partners need follow up testing to make sure you're cured for that • Condom use to prevent further infections • Especially for pregnant women whose partners may be infected

Older Adults Considerations: (Lifespan)

• Increasing prevalence of HIV, gonorrhea, chlamydia, other STIs • Face unique barriers to recognition, treatment of STIs • Healthcare providers might not think of older patients as sexually active -Might not assess for STIs or provide education about safer sex -Delays diagnosis of diseases such as HIV that mimic other diseases • Risk factors: -Use of ED drugs may lead men to engage in more, riskier behaviors -Immune system may be less able to fight infection -Important to educate about safer sex practices with new partners older adults might have been in a monogamous relationship for years and years and their loved one dies so they've now found someone new so need to educate them again -Older adults might not believe themselves to be at risk

Responsible Sexual behavior

• Making informed decisions and safer sex choices - it's not safe sex as it was presented 20-30 years ago, it's safer sex because no sex is safe sex • Getting tested at least once a year • Having open communication not only with your partner but also with your healthcare provider • Taking precautions against STI's, HIV and pregnancy

Gonorrhea Manifestations

• May be asymptomatic until disease is advanced: -Men - Dysuria, Serous, milky, or purulent penile discharge, May have regional lymphadenopathy -Women - Dysuria, Urinary frequency, abnormal menses, increased vaginal discharge • Anorectal gonorrhea - Pruritus, Mucopurulent discharge, Bleeding, Pain didn't talk about • Gonococcal pharyngitis - Fever, Sore throat, Enlarged lymph glands didn't talk about Complications: • In both men and women - Blindness; Infection of blood, joints; Increased susceptibility to and transmission of HIV interesting because what this actually does, it forms actually some type of tear in the mucosal lining - where if your skin would be 100% intact that actually acts as a barrier for HIV, where with this STI it actually will allow the HIV a portal of entry for the HIV • In women - PID → internal abscesses, chronic pain, ectopic pregnancy, infertility • In men - Epididymitis, prostatitis → infertility, dysuria

Children Considerations: (Lifespan)

• May be result of perinatal acquired infections • STIs in children <10 years should be considered evidence of sexual abuse if a child under 10 has an STI then this is a reportable event to the state and there will be someone coming out to investigate it • STI testing should be done before initiating treatment • Examine children, collect specimens in a way that minimizes trauma to child • Examination, specimen collection should be done by clinician with experience in area of child sexual abuse so child isn't traumatized again for a second time • Treatment based on test results

Risk factors

• Multiple sex partners or new sex partner • Sex with someone who has sex with one or more others • Exchange of sex for money or drugs • Poverty, unemployment, low education level • Young women age <25 • Drug or alcohol use, that lowers inhibitions • Presence of another STI certain STIs that whenever they test for one they actually test for two because if you have like chlamydia and gonorrhea are the example for that one, if you have one it's more than likely that you have the other one also.

Safer sex

• Mutual monogamy or limit number of sex partners • No unprotected sex, always want to be protected • HIV & STD testing when entering new relationship • Latex condoms for all intercourse • With safer sex you should be educated on where to find these, not just devices but prevention and protection for your patients - there are different dispensaries so students can get them in high school or planned parenthood will give them to them - think about availability and education regarding them - examples are: • Condoms • Female condoms • Finger cots • Dental dams

Genital Herpes Treatment

• Relieve symptoms, and prevent spread of infection • Relieve acute pain using oral analgesics and teach patient to keep HSV blisters clean, dry • For dysuria- suggest pouring water over genitals while urinating to decrease pain • Suggest use of sitz baths 15-30 minutes several times/ day

STD Overview

• Sexually transmitted infections (STIs): disorders transmitted by vaginal, oral, anal contact • Caused by bacteria, viruses, fungi, protozoa, parasites • Portals of entry include mouth, genitalia, urinary meatus, anus, rectum, skin • Most can be prevented by using latex condoms but not all of them • Terms STI and STD often used interchangeably • Bacterial STIs can be cured by early treatment with antibiotics • Viral STIs can be managed but not cured

Genital Herpes manifestations

• Small painful vesicles in genital area 2-12 days after exposure • In or around anus from anal intercourse or oral-anal sexual contact; • Men: glans or shaft of penis, • Women: labia, perineum, vagina, cervix • Blisters break will actually have a shedding phase • Create patches of painful ulcers lasting 2-4 weeks - highly infectious - shedding • Touching blisters, then rubbing or scratching elsewhere can spread infection to other parts of the body • Flulike symptoms, regional lymphadenopathy, Dysuria, urinary retention, Women: vaginal discharge, Men: urinary discharge patients will come in with UTIs and they'll frequently say they'll try and decrease the amount that they're urinating because of the pain • Subsequent occurrences - Outbreaks • Less severe, Shorter in duration, Number of outbreaks decreases over time • Fluctuation in hormones, immunosuppression, stress may lead to outbreaks • Viral shedding can occur between outbreaks - still infectious at this point • Prodromal symptoms of recurrent outbreaks - ex. People saying they can feel a cold sore coming, so that is a symptom • Burning, itching, tingling, or throbbing where lesions commonly appear • Pain in legs, groin, buttocks - it travels through your nerves so it is almost like that nerve pain • Sexual contact should be avoided when prodromal symptoms present

HPV manifestations

• Some individuals with HPV have none • Others have genital warts • Diagnosis made on basis of clinical appearance and Pap Smear

Secondary Syphilis

• Systemic, spreading to all major organ systems • Manifestations appear several weeks after initial chancre / exposure, disappear within 2-6 weeks • - Rash, especially on palms of hands or soles of feet usually these are common areas that rashes do not occur • -Mucous patches in oral cavity, sore throat, generalized lymphadenopathy, condyloma lata • -Flulike symptoms • -Alopecia hair will start to fall out

Sexual Health History

• What would you ask the patient? 5 Ps - Partners, Prevention of pregnancy, Protection from STI, Practice, and Past STI history - (Partners - how many and what type of partners that they've had, Prevention of pregnancy - how have they prevented pregnancy, Protection from STI - what protection have you used from STIs). • Ask them do you currently think you have an STD? • What teaching would you do? So like the question above, do they think they've been exposed to one, that can also lead to the education of safer sex practices • What about minors? She didn't go over this question

Incidence and prevalence

• Women: higher rates of gonorrhea • Men: higher rates of chlamydia, syphilis

Tertiary syphilis

• ~15% of untreated individuals progress to this stage - Two types: Benign late syphilis: • Rapid onset of localized infiltrating tumors in skin, bones, liver • Respond promptly to treatment Diffuse inflammatory response: • Insidious onset involving cardiovascular system syphilis can go straight to the heart