adult acute unit 8 module 7
genital herpes
Genital herpes is a common, chronic STI caused by herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2) majority of genital herpes is caused by HSV-2. Herpes simplex virus 2 is more commonly diagnosed in females than males because the female genitalia are more susceptible to skin breaks. Genital herpes is more easily transmitted from males to females than from females to males.
pathophysiology of genital herpes
Genital herpes is a highly contagious infection caused by HSV. can occur through minute breaks such as a scratch or abrasion through uninfected skin Herpes simplex virus travels from the site of infection (skin or mucous membrane) via the lymphatic, blood, or ascending nerves to the sacral ganglion cells and remains latent genital herpes is transmitted by direct skin-to-skin contact during the prodromal stage of infection (onset of the infection) can occur through oral-to-oral, oral-to-genital, genital-to-genital, or anal contact Transmission can also occur during childbirth when the child is passing through the birth canal
pathophysiology of gonorrhea
Gonorrhea is caused by the bacterium N gonorrhoeae, also known as gonococcus, a gram-negative intracellular diplococcus gonococci attach to the surface of columnar mucosa epithelial cells. Local invasion occurs and attacks the mucosal surfaces of the genitourinary tract, eyes, throat, and rectum gonococci replicate and invade host immune cells, leading to dissemination and systemic infection. transmitted genital to genital, oral to genital, and anal to genital. Perinatal transmission (mother to infant) during delivery may also occur Disseminated gonococcal infection may lead to systemic complications such as arthritis, tenosynovitis (common), and skin lesions. Rare complications include endocarditis and meningitis
clinical manifestations of genital herpes
HSV outbreaks occur episodically. Between outbreaks, HSV lies dormant in the sacral area in the CNS becomes reactivated as a result of stressors or triggers The primary or initial outbreak presents as one or several clear vesicles, or blisters, that erupt in the genital area. The vesicle then ruptures and forms a painful ulcer several days later ulcer may last up to 2 to 4 weeks if untreated
pathophysiology of HPV
Human papillomavirus tends to be grouped into "low-risk," "intermediate-risk," and "high-risk" strains. "Low-risk" strains cause 90% of condyloma acuminata (condylomas), or genital warts. Genital warts may appear as soft, fleshy, flat, raised lesions that may resemble cauliflower in appearance and usually occur in clusters Certain strains of the "intermediate- and high-risk" types have been known to lead to cervical cancer. "High-risk" strains are linked to 70% of squamous cell carcinomas of the cervix There are 13 different "high-risk" strains in total, and all are considered oncogenic High-risk HPV is a double-stranded deoxyribonucleic acid (DNA) virus that invades the cells through microabrasions of the basal epithelium in the epithelial tissue of the cervix, making the host susceptible to attack
complications of chlamydia
In women: infertility tubal abscesses ectopic pregnancy chronic pelvic pain Fitz-Hugh-Curtis syndrome (perihepatitis, or inflammation of the peritoneal covering of the liver) Other complications include Reiter's syndrome, also known as reactive arthritis rare autoimmune arthritic condition that causes urethritis, or inflammation in the urinary genital tract, and conjunctivitis, inflammation of the mucous membranes lining the eyes.
diagnosis of HPV
Papanicolaou (Pap) test remains the most cost-effective tool to screen females for cervical cancer used as the first line to detect an abnormal growth in the cervix or vagina. In this test, cells are scraped from the surface and internal opening of the cervix. The cells are examined under a microscope to view for abnormalities Human papillomavirus DNA testing, an evaluation of cells scraped from the cervix, is used to detect high-risk oncogenic HPV can be used as a reflex check in females under 30 years of age who are diagnosed with atypical (abnormal) cells on a Pap test. A colposcopy is a magnified examination of the cervix, vagina, and vulva. A colposcopy and biopsy may be indicated if HPV DNA testing is positive. Current guidelines suggest that cervical cancer screening begin at 21 years of age because cervical carcinoma is relatively rare under the age of 20 years. females under the age of 21 who are exposed to oncogenic HPV are highly likely to clear the infection.
suppressive therapy for genital herpes
*regular daily dosing with an antiviral, is used to reduce the incidence of outbreaks*. Suppressive therapy may be encouraged for individuals *who have six or more outbreaks in a year*
clinical manifestations of gonorrhea
Approximately 50% of females and males experience clinical manifestations clinical manifestations of females: Vaginal discharge Intermenstrual bleeding Anorectal discomfort Dysuria Cervicitis—inflammation clinical manifestations of males: Dysuria (which occurs before purulent discharge) Copious purulent urethral discharge (gold standard manifestation for gonococcal urethritis) Rectal pain, bleeding
pathophysiology of chlamydia
C trachomatis is an obligate intracellular bacterium that cannot grow outside a living cell; it needs the metabolism of the host to reproduce incubation period is between 7 and 21 days. Chlamydia primarily infects the urethra and cervix. It is transmitted through vaginal, anal, or oral sexual intercourse via bodily secretions Transmission may occur during childbirth, mother to child, and may lead to conditions such as conjunctivitis, pharyngitis, and pneumonia.
drug therapy for syphilis
Drug therapy for all stages of syphilis is penicillin Patients who are allergic may undergo desensitization for treatment with penicillin. Desensitization is a procedure where, under close observation in the hospital, a penicillin dose is administered after administration of both methylprednisone (anti-inflammatory) and diphenhydramine (antihistamine) to counteract the potential reaction
clinical manifestations of PID
Lower abdominal pain Uterine tenderness Adnexal tenderness, which is pain in the ovaries or fallopian tubes noted during examination Cervical motion tenderness
primary syphilis
Primary syphilis initially manifests as a chancre. chancre is a painless, hard lesion that can develop into a painless open lesion, located at the site of exposure Lymphadenopathy (abnormally large lymph nodes, usually a result of a disease) often occurs in combination with the chancre.
medical management of oncogenic HPV
Prophylactic HPV management in the form of vaccines has been recommended to females and males recommends routine vaccination with the quadrivalent vaccine (also referred to as HPV4) for females at an early age The quadrivalent is available to females (9-26 years of age)
psychosocial impact of genital herpes
Psychosocially, genital herpes may have implications that can lead to depression, withdrawal from relationships, poor coping skills and self-confidence, shame, guilt, and perceived poor body image may feel or be stigmatized or stereotyped individuals are concerned they may transmit the infection to others. This can lead to overall detrimental effects on quality of life
medications for gonorrhea
Quinolone-resistant strains of gonorrhea have been detected medications called *fluoroquinolones SHOULD NOT be administered to patients to treat gonorrhea* an antimicrobial classification of medications called *cephalosporins is recommended by the CDC to treat gonorrhea*
pelvic inflammatory disease
Risk factors for PID are similar to those of other STIs unprotected sexual intercourse sexual intercourse at 25 years old or younger oral contraceptive use multiple sexual partners, and previous history of PID Bacterial vaginosis douching sexual intercourse during menses intrauterine devices may contribute to the onset of PID by causing a disturbance in the cervical barrier may aid in the movement of bacteria through the pelvic cavity.
clinical manifestations of HPV
Typically, HPV infections cause no symptoms, hence the need for adequate screening Females with non-oncogenic HPV may experience symptoms of genital warts. Most patients who have genital warts claim they do not have other associated symptoms. Few patients complain of itching, burning, and tenderness, but genital warts can be painful and bothersome. They may also cause emotional distress.
secondary syphilis
Without treatment, secondary syphilis symptoms may develop within 3 to 6 weeks after the appearance of the chancre. Chancre lesions tend to resolve as the infection travels systemically. A maculopapular rash may develop on the palms, soles, buttocks, and upper thighs rashes may appear macular (flat discolored spot), papular (elevated hard skin that does not contain pus), or pustular (skin that contains pus) or a combination of all Lesions called condylomata lata (warty growths on the skin) may also develop at this time along with mucous patches in the mouth. These lesions are considered infectious Other symptoms may include fever or malaise, alopecia, joint pain, and headaches primary and secondary stages are the MOST INFECTIOUS
Early latent syphilis develop
after the secondary symptoms reduce in intensity, typically 1 year after exposure in the latent period, the risk of sexual transmission is low. Within the late latent period, three situations may occur: 1) The patient spontaneously resolves the infection; 2) the patient remains in a latent state; 3) the patient progresses to late or tertiary syphilis
risk factors for chlamydia
age, *particularly 25 years or younger* low socioeconomic status multiple sexual partners, history of STIs unmarried *immature cervix, and a diagnosis of mucopurulent inflammation of the cervix*. high risk are sexually active females under the age of 25 persons over the age of 25 who frequently engage in sexual intercourse with a new partner MSM
risk factors for gonorrhea
age—particularly under 25 years old low socioeconomic status multiple sexual partners history of STIs including PID unmarried status The CDC suggests high-risk groups be screened annually.
pathophysiology of pelvic inflammatory disease
an acute infection that originates from the vagina or cervix and ascends to the upper genital tract infecting the uterus, fallopian tubes, and ovaries. a polymicrobial infection caused by an STI such as chlamydia or gonorrhea or by pathogenic microorganisms comprising normal vaginal flora
pathophysiology of syphilis
an ulcerative genital disease caused by the anaerobic spirochete T palladium bacterium invades the mucous membranes and becomes systemic by entering the blood and lymphatic system CNS is invaded early in the disease
All HPV strains are transmitted by
direct skin contact during vaginal, anal, and oral sexual intercourse, so risk factors are related to sexual behavior. multiple sexual partners sexually active unmarried females onset of sexual intercourse at an early age immunosuppressive conditions (HIV) chronic conditions requiring long-term immunosuppressive therapy (transplant recipients), oral contraceptives smoking STIs, particularly herpes and chlamydia.
diagnosis of genital herpes
can be performed clinically through visual inspection of the oral, genital, and anal areas. confirmed by laboratory testing *gold standard for confirmatory testing is an HSV culture.* In order to obtain a culture from an ulceration, the top layer is removed and the sample is retrieved from the underside. Fluid from a ruptured vesicle can be collected and sent off in a culture medium. The *IgM enzyme-linked immunosorbent assay (ELISA) antibody test may be used to determine a primary infection, an acute event, or an outbreak* *IgG ELISA antibody test may be used to determine the presence of a pre-existing infection and distinguish between HSV-1 and HSV-2 antibodies*. Knowing the HSV type may be more helpful for treatment management Patients infected with HSV-1 in the genital area may experience few to rare and generally milder outbreaks than HSV-2.
complications of PID
chronic pelvic pain, infertility, and ectopic pregnancy *females with PID may be diagnosed with tubo-ovarian abscess (TOA)*, an inflammatory mass involving the fallopian tubes, ovaries, and neighboring organs ruptured TOA can lead to peritonitis
syphilis
classified into four stages; primary, secondary, latent (early and late), and tertiary The tertiary stage is also classified as cardiovascular and gummatous transmitted through genital and oral sexual intercourse and congenitally from mother to fetus Populations most at risk are persons 15 to 24 years of age and homosexual men.
diagnosis of syphilis
confirmed by serologic (blood testing) and microscopic testing most commonly used serological procedure is done in two stages, the nontreponemal and treponema-specific tests Nontreponemal tests look for indirect markers of infection such as biomarkers released as a result of cellular damage due to the spirochetes of syphilis Treponemal tests look for direct markers of infection such as antibody production Darkfield microscopy is a quick traditional method of testing for primary and secondary syphilis form of microscopy can illuminate the slim bacterium T pallidum that is not readily visible utilizing other types of stains
medications of chlamydia
consists of *doxycycline or azithromycin as first-line treatment of C trachomatis* for nonpregnant females, males, and HIV-infected individuals. If *doxycycline is chosen, it is important to warn against excessive sun exposure* *Erythromycin is the alternative medication to treat pregnant* females.
medications for genital herpes
consists of antiviral medications to suppress the infection and provide symptom relief Antiviral medications can also help to decrease the duration and severity of the infection. *Currently, there is no cure for genital herpes*
Diagnosis of Chlamydia
done through a *swab specimen taken from the vagina, cervix, penis, urethra, rectum, or other involved orifice* done *utilizing a highly sensitive assay called the nucleic acid amplification test (NAAT)* If a urine sample is obtained, the most sensitive sample is obtained during the first void in the a.m. Many reports describe the coexistence of Chlamydia infection with gonorrhea; therefore, patients should be routinely tested for both infections simultaneously. Individuals *diagnosed with chlamydia should be rescreened in 3 months after completion of prescribed therapies because there is a high risk for reinfection*.
diagnosis of PID
done through clinical observation of the presence of lower abdominal pain in combination with one or all of the clinical manifestations indicative of PID criteria that can reinforce a diagnosis of PID are Oral temperature greater than or equal to 100.9°F (38.3°C) Abnormal cervical or vaginal mucopurulent discharge Vaginal fluid neutrophils on saline microscopy greater than or equal to 1 per 400 x field Elevated C-reactive protein level Elevated erythrocyte sedimentation rate Laboratory-confirmed diagnosis of chlamydia or gonorrhea Radiological imaging such as transvaginal ultrasound and magnetic resonance imaging (MRI) can be used as an aid in diagnosing PID endometrial biopsy and laparoscopy
episodic therapy for genital herpes
episodic therapy is used to treat symptoms that occur intermittently most effective when treatment begins in the prodromal stage or within the first 24 hours
chlamydia
is the *most common sexually transmitted bacterial infection* Frequency and morbidity of chlamydia infections are reported to be greater in females. *Simultaneous Chlamydia infection often occurs with gonorrhea*, but the incidence of chlamydia is greater. If left untreated in females, the *Chlamydia infection may travel to the uterus and fallopian tubes and cause a condition called pelvic inflammatory disease (PID)* *In males, if the Chlamydia infection spreads*, it may travel *to the epididymis, causing a rare condition, epididymitis (inflammation of the epididymis).*
clinical manifestations of chlamydia
majority of individuals who contract chlamydia, 75% of females and 50% of males, do not show symptoms symptoms in males: Dysuria—painful urination Dyspareunia—painful sexual intercourse Lower abdominal pain Abnormal vaginal bleeding (postcoital/after sexual intercourse or intermenstrual/between menses) Vaginal discharge (clear or cloudy) Cervical abdominalities(friable, tender, inflamed) Proctitis (inflammation of the rectum or anus) or rectal discharge (clear or cloudy) symptoms in females: Dysuria Urethral discharge (clear or cloudy) Meatitis—inflammation of the urinary meatus Proctitis or rectal discharge (clear or cloudy)
risk factors for genital herpes
risk factors include a history of other STIs early age of sexual intercourse homosexual practices multiple partners poor socioeconomic status immune-compromised individuals
risk factors for syphilis
risk factors include unprotected sexual intercourse multiple sexual partners men who have sexual intercourse with men (MSM), history of HIV Infants are at increased risk when they have a mother who has been exposed to syphilis.
treatment for PID
should be initiated as soon as the diagnosis is strongly suspected. Hospitalized patients should receive parenteral or IV antibiotic treatment for a minimal of 24 hours and should be changed to oral antibiotics when clinical symptoms improve. Outpatient treatment includes both a single intramuscular dose of *ceftriaxone and oral antibiotics such as metronidazole or doxycycline*
gonorrhea
the *second most common bacterial STI next to chlamydia* Like chlamydia, gonorrhea tends to be underdiagnosed and underreported, with complications leading to PID, pelvic abscesses, ectopic pregnancy, infertility, and Fitz-Hugh-Curtis syndrome in females and epididymitis in males. increase in incidence with younger persons, with the highest rates in males and females aged 20-24
Late or tertiary syphilis may develop in one-third of patients with syphilis without treatment
three types of tertiary syphilis: neurosyphilis, cardiovascular syphilis, and gummatous syphilis (skin and subcutaneous tissues). tertiary-not treatable *Neurosyphilis* is an infection in which T pallidum invades the CNS. Neurosyphilis can manifest in four forms: asymptomatic, general paresis, meningovascular, and a syndrome called tabes dorsals Cardiovascular syphilis damages the aortic musculature Gummatous syphilis, composed of rubberlike lesions, occurs in the skin, bones, or internal organs
medical management of non-oncogenic HPV
treatments for genital warts include creams (imiquimod 5% cream) or gels (podofilox 0.5% solution or gel) applied directly to the affected area. They work by modifying or enhancing the immune response to the wart or by breaking down the skin on the wart. intralesional interferon, interferon injected directly into the lesion Photodynamic therapy, a treatment that includes the injection of a photosensitizing drug into the bloodstream that, when exposed to light, reacts to produce an active form of oxygen that kills cancer cells Topical cidofovir, a nucleotide analogue that disrupts viral DNA replication
Primary therapy for genital herpes
used to *treat a newly diagnosed outbreak in a patient* It should be *initiated within 72 hours of the initial outbreak* This may help to lessen the severity and duration of symptoms.
human papilloma virus (HPV)
very common STI of the anogenital tract Human papillomavirus is the precursor to cancers of the cervix, vulva, vagina, anus, and penis and some head and neck cancers. the highest prevalence in Africa and the Caribbean. Approximately 75% to 80% of females will develop HPV by the age of 50. Human papillomavirus is very common in women under 30. exposure to oncogenic (high-risk) HPV increases the risk for cervical cancer for women who are past the age of 30.
