Chapter 7: Sexually Transmitted and Other Infections

High risk individuals to have SEXUALLY TRANSMITTED DISEASES

● 15-24 - cervical ectopy, barriers to services for adolescents (costs, transportation, discomfort, confidentiality worry) ● Multiple partners ● Sex partners with multiple sexual contacts ● History of STD or Sex partner(s) with STD ● History childhood sexual abuse

Management of women with Genital Herpes.

● Genital herpes is a chronic and recurring disease for which there is no known cure. ● Management is directed toward specific treatment during primary and recurrent infections, prevention, self-help measures, and psychologic support. ● Systemic antiviral medications partially control the symptoms and signs of HSV infections when used for the primary or recurrent episodes or when used as daily suppressive therapy. However, these medications do not eradicate the infection nor do they alter subsequent risk or frequency of recurrences after the medication is stopped. ● Three antiviral medications provide clinical benefit: acyclovir, valacyclovir, and famciclovir. ● acyclovir may be used to reduce the symptoms of HSV if the benefits to the woman outweigh the potential harm to the fetus. ● Cleaning lesions twice a day with saline helps prevent secondary infection. ● Bacterial infection must be treated with appropriate antibiotics. ● Measures that may increase comfort for women when lesions are active include warm sitz baths with baking soda; keeping lesions dry by blowing the area dry with a hair dryer set on cool or patting dry with a soft towel; wearing cotton underwear and loose clothing; using drying aids such as hydrogen peroxide, Burow solution, or oatmeal baths; applying cool, wet, black tea bags to lesions; and applying compresses with an infusion of cloves or peppermint oil and clove oil to lesions. ● Oral analgesics such as aspirin, acetaminophen, or ibuprofen may be used to relieve pain and systemic symptoms associated with initial infections. ● Because the mucous membranes affected by herpes are extremely sensitive, any topical agents should be used with caution. ● Nonantiviral ointments, especially those containing cortisone, should be avoided. ● A thin layer of lidocaine ointment or an antiseptic spray may be applied to decrease discomfort, especially if walking is painful. ● The nurse should explain that each woman is unique in her response to herpes and emphasize the variability of symptoms. ● Some authorities recommend consistent use of condoms for all persons with genital herpes. Condoms may not prevent transmission, particularly male-to-female transmission; however, this does not mean that the partners should avoid all intimacy. ● Women can be encouraged to maintain close contact with their partners while avoiding contact with lesions. ● They should be taught how to look for herpetic lesions using a mirror and good light source and a wet cloth or finger covered with a finger cot to rub lightly over the labia. ● The nurse should ensure that women understand that when lesions are active, sharing intimate articles (e.g., washcloths or wet towels) that come into contact with the lesions should be avoided. ● Only plain soap and water are needed to clean hands that have come into contact with herpetic lesions; isolation is neither necessary nor appropriate. ● Stress, menstruation, trauma, febrile illnesses, chronic illnesses, and ultraviolet light have all been found to trigger genital herpes. ● Women may wish to keep a diary to identify stressors that seem to be associated with recurrent herpes attacks so that they can then avoid these stressors when possible. ● The role of exercise in reducing stress can be discussed. Referral for stress-reduction therapy, yoga, or meditation classes may be indicated. ● Avoiding excessive heat and sun and hot baths and using a lubricant during sexual intercourse to reduce friction also may be helpful. ● Acyclovir does enter breast milk but the amount of medication ingested during breastfeeding is very low and is usually not a health concern. ● Because neonatal HSV infection is such a devastating disease, prevention is critical. ● Recommendations include carefully examining and questioning all women about symptoms at onset of labor. ● If visible lesions are not present at onset of labor, vaginal birth is acceptable. Cesarean birth is recommended if visible lesions are present. ● Infants who are born through an infected vagina should be carefully observed and cultured.

Diagnosis of women with Pelvic Inflammatory Disease (PID).

● PID is difficult to diagnose because of the accompanying wide variety of symptoms. ● The CDC recommends treatment for PID in all sexually active young women and others at risk for STIs if the following criteria are present and no other cause or causes of the illness are found: lower abdominal tenderness, bilateral adnexal tenderness, and cervical motion tenderness. ● Other criteria for diagnosing PID include an oral temperature of 38.3° C or above, abnormal cervical or vaginal discharge, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.

1. Describe reduction measures of sexually transmitted infections in women.

● Primary prevention is counseling women regarding risk-reduction practices, including knowledge of her partner, reduction of the number of partners, low risk sex, avoiding the exchange of body fluids, and vaccination ● No aspect of prevention is more important than knowing one's partner. ● Reducing the number of partners and avoiding partners who have had many sexual partners decreases a woman's chance of contracting an STI. ● Deciding not to have sexual contact with casual acquaintances also may be helpful. ● Discussing each new partner's previous sexual history and exposure to STIs augments other efforts to reduce risk; however, sexual partners may not always be truthful about their sexual history. ● Critically important is whether male partners resist or accept wearing condoms. This is crucial when women are not sure about their partners' history. ● Women should be cautioned against making decisions about a partner's sexual and other behaviors based on appearances and unfounded assumptions such as the following: • Single people have many partners and risky practices. • Older people have few partners and infrequent sexual encounters. • Sexually experienced people know how to use risk-reduction measures. • Married people are heterosexual, low risk, and monogamous. • People who look healthy are healthy. • People with good jobs do not use drugs ● carefully examining a partner for lesions, sores, ulcerations, rashes, redness, discharge, swelling, and odor before initiating sexual activity. ● Teach women about low risk sexual practices ● motivate clients to use condoms by initiating a discussion with them. This gives women permission to discuss any concerns, misconceptions, or hesitations they may have about using condoms. Information to be discussed includes the importance of using latex or plastic male condoms rather than natural skin condoms for STI protection. The nurse should remind women to use a condom with every sexual encounter, to use each one only once, to use a condom with a current expiration date, and to handle it carefully to avoid damaging it with fingernails, teeth, or other sharp objects. ● Condoms should be stored away from high heat. ● the consistent use of condoms for every act of sexual intimacy when there is the possibility of transmission of disease. ● Condoms lubricated with N-9 are not recommended for prevention of HIV and STIs. ● A key issue in condom use as a preventive strategy is to stress to women that in sexual encounters men must comply with a woman's suggestion or request that they use a condom. ● Preexposure vaccination is an effective method for the prevention of some STIs such as hepatitis B and human papillomavirus (HPV). ● Hepatitis B vaccine is recommended for women at high risk for STIs. ● Two HPV vaccines are available for females aged 9 to 26 years to prevent cervical precancer and cancer. ● Gardasil also prevents genital warts. ● Routine vaccination of females ages 11 or 12 years is recommended with either vaccine, as is catch-up vaccination for females ages 13 to 26 years.

Nurses' role of preventing STD's

Assessment •Ascertain risks - https://iwtk-app.iwantthekit.org/quiz •Number of partners; Sexual behaviors including condom use; Individual's assessment of partner risk and/or symptoms Counsel/Educate to change behavior •Abstain •Delay intercourse •Vaccination (HPV, Hep B) •Use barrier method •Mutual monogamy •Reduced number of partners •Pubic hair grooming increases risk of transmission Testing and Treatment •CDC - www.cdc.gov/STD

Diagnosis of women with Bacterial Vaginosis (BV).

● A focused history may help distinguish BV from other vaginal infections if the woman is symptomatic. ● Reports of fishy odor and increased thin vaginal discharge are most significant, and a report of increased odor after intercourse is also suggestive of BV. ● Microscopic examination of vaginal secretions is always performed. Both normal saline and 10% potassium hydroxide (KOH) smears are made. ● The presence of more than 20% clue cells (vaginal epithelial cells coated with bacteria) on wet saline smear is highly diagnostic because the phenomenon is specific to BV. ● Vaginal secretions are tested for pH and amine odor. ● Nitrazine paper is sensitive enough to detect a pH of 4.5 or greater. ● The fishy odor of BV will be released when KOH is added to vaginal secretions on the lip of the withdrawn speculum.

Diagnosis of women with Genital Herpes.

● A history of exposure to an infected person is important, although infection from an asymptomatic individual is possible. ● A history of having viral symptoms such as malaise, headache, fever, or myalgia is suggestive. ● Local symptoms such as vulvar pain, dysuria, itching or burning at the site of infection, and painful genital lesions that heal spontaneously also are highly suggestive of HSV infections. ● The nurse should ask about a history of a primary infection, prodromal symptoms, vaginal discharge, and dyspareunia. ● Women should be asked whether they or their partner(s) have had genital lesions. ● During the physical examination the nurse should assess for inguinal and generalized lymphadenopathy and elevated temperature. ● The entire vulvar, perineal, vaginal, and cervical areas should be carefully inspected for vesicles or ulcerated or crusted areas. ● A speculum examination may be very difficult for the woman because of the extreme tenderness often associated with herpes infections. ● Any suggestive or recurrent lesions found during pregnancy should be cultured to verify HSV. ● Although a diagnosis of herpes infection may be suspected from the history and physical, it is confirmed by laboratory studies. ● A viral culture is obtained by swabbing exudate during the vesicular stage of the disease. ● Type-specific serologic tests for HSV-2 antibodies are also available

Management of women with Candidiasis/Yeast Infection.

● A number of antifungal preparations are available for the treatment of C. albicans. ● Many of these medications (e.g., miconazole [Monistat] and clotrimazole [Gyne-Lotrimin]) are available as over-thecounter (OTC) agents. ● Exogenous lactobacillus (in the form of dairy products [yogurt] or powder, tablet, capsule, or suppository supplements) and garlic have been suggested for prevention and treatment of ● The first time a woman suspects that she may have a yeast infection, she should see a health care provider for confirmation of the diagnosis and treatment recommendations. If she has another infection, she may wish to purchase an OTC preparation and self-treat. ● If she elects to do this, she should always be counseled to seek care for numerous recurrent or chronic yeast infections. If vaginal discharge is extremely thick and copious, vaginal debridement with a cotton swab followed by application of vaginal medication may be effective. ● Women who have extensive irritation, swelling, and discomfort of the labia and vulva may find sitz baths helpful in decreasing inflammation and increasing comfort. ● Adding colloidal oatmeal powder to the bath may also increase the woman's comfort. ● Not wearing underpants to bed may help decrease symptoms and prevent recurrences. ● Completing the full course of treatment prescribed is essential to removing the pathogen. ● Instruct women to continue the medication even during menstruation. ● Explain that they should avoid using tampons during menses because the tampon will readily absorb the medication. ● If possible, women should avoid intercourse during treatment; if abstinence is not feasible, the woman's partner should use a condom to prevent the introduction of more organisms.

Diagnosis of women with HPV/Genital Warts.

● A woman with HPV lesions may complain of symptoms such as a profuse irritating vaginal discharge, itching, dyspareunia, or postcoital bleeding. She also may report "bumps" on her vulva or labia. ● Physical inspection of the vulva, the perineum, the anus, the vagina, and the cervix is essential whenever HPV lesions are suspected or seen in one area. ● When lesions are visible, the characteristic appearance previously described is considered diagnostic. However, in many instances, cervical lesions are not visible, and some vaginal or vulvar lesions also may be unobservable to the naked eye. ● Viral screening and typing for HPV are available but not standard practice. ● History, evaluation of signs and symptoms, Papanicolaou (Pap) test, and physical examination are used in making a diagnosis. ● The HPV-DNA test can be used in women older than age 30 in combination with the Pap test to screen for types of HPV that are likely to cause cancer or in women with abnormal Pap test results. ● The only definitive diagnostic test for the presence of HPV is histologic evaluation of a biopsy specimen.

Diagnosis of women with Syphilis.

● All women who are diagnosed with another STI or with HIV should be screened for syphilis. ● All pregnant women should be screened for syphilis at the first prenatal visit and again early in the third trimester and at the time of giving birth if high risk. ● Diagnosis is dependent on microscopic examination of primary and secondary lesion tissue and serology during latency and late infection. ● A test for antibodies may not be reactive in the presence of active infection because it takes time for the body's immune system to develop antibodies to any antigens. ● Up to one third of people with early primary syphilis may have nonreactive serologic tests. ● Test results in clients with early primary or incubating syphilis can be negative. ● Seroconversion usually takes place 6 to 8 weeks after exposure, so testing should be repeated in 1 to 2 months when a suggestive genital lesion exists. ● Tests for concomitant STIs (e.g., chlamydia and gonorrhea) should be done (e.g., wet preps and cultures) and HIV testing offered if indicated.

S&S of women with Bacterial Vaginosis (BV).

● Bacterial vaginosis (BV) is the most common cause of vaginal symptoms today. ● The prevalence is most common in women of childbearing age—ages 14 to 49 in the United States. ● Women with new or multiple sexual partners are at higher risk for infection. ● BV can increase susceptibility to STIs such as chlamydia, gonorrhea, genital herpes, and HIV. ● BV is associated with preterm labor and birth. ● The exact etiology of BV is unknown. ● Epithelial cells slough, and numerous bacteria attach to their surfaces (clue cells). ● When the amines are volatilized, the characteristic odor of BV occurs. ● Many women with BV complain of the characteristic "fishy odor." The odor may be noticed by the woman or her partner after heterosexual intercourse because semen releases the vaginal amines. ● When present, the BV discharge usually appears profuse, thin, and white or gray, or milky. Some women also may experience mild irritation or pruritus.

Prevention of women with HPV/Genital Warts.

● Preventive strategies include abstinence from all sexual activity, staying in a long-term monogamous relationship, limiting the number of sexual partners, and prophylactic vaccination. ● Two vaccines, Cervarix and Gardasil, are available and other vaccines continue to be investigated. ● The two vaccines are recommended for 11- and 12-year-old girls and boys and are safe and effective in protecting against some of the most common types of HPV that can lead to genital warts and cancers. ● The vaccines are most effective if given before the woman has her first sexual contact. ● The vaccines can be given to girls as early as 9 years of age and can also be given to young women ages 13 to 26 years if they did not receive the vaccine previously. ● The vaccine is given in three doses over a 6-month period

Reportable STD's

● Syphilis ● Gonorrhea ● Chlamydia ● Chancroid ● HIV ● AIDS

Diagnosis of women with Gonorrhea.

● Because gonococcal infections in women often are asymptomatic, the CDC recommend screening all women at risk for gonorrhe. ● All pregnant women should be screened at the first prenatal visit, and infected women and those not infected but identified with risky behaviors should be rescreened at 36 weeks of gestation. ● Gonococcal infection cannot be diagnosed reliably by clinical signs and symptoms alone. ● Individuals may have "classic" symptoms, vague symptoms that can be attributed to a number of conditions, or no symptoms at all. ● Cultures with selective media are considered the gold standard for diagnosis of gonorrhea. ● Cultures should be obtained from the endocervix, the rectum, and when indicated, the pharynx. ● Thayer-Martin cultures are recommended to diagnose gonorrhea in women. ● NAATs allow testing of the widest variety of specimen types including endocervical swabs, vaginal swabs, and urine. ● Because coinfection is common, any woman suspected of having gonorrhea should have a chlamydial culture and serologic test for syphilis if one has not been done in the past 2 months.

S&S of women with Chlamydia.

● Chlamydia trachomatis (bacteria) is the most commonly reported STI in American women. ● In women, chlamydial infections are difficult to diagnose; the symptoms, if present, are nonspecific, and the organism is expensive to culture. ● Early identification of C. trachomatis is important because untreated infection often leads to acute salpingitis or pelvic inflammatory disease. ● Pelvic inflammatory disease (PID) is the most serious complication of chlamydial infections, and past chlamydial infections are associated with an increased risk of ectopic pregnancy and tubal factor infertility. ● Furthermore, chlamydial infection of the cervix causes inflammation, resulting in microscopic cervical ulcerations, and thus may increase the risk of acquiring HIV infection. ● More than half of infants born to mothers with chlamydia will develop conjunctivitis or pneumonia after perinatal exposure to the mother's infected cervix. ● C. trachomatis is the most common infectious cause of ophthalmia neonatorum. ● Neonatal ocular prophylaxis with silver nitrate solution or antibiotic ointment does not prevent perinatal transmission from mother to infant, nor does it adequately treat chlamydial infection. ● Sexually active women ages 15 to 24 have the highest rates of infection, with women ages 18 to 20 years having the highest rates. ● Women older than 30 years have the lowest rate of infection. Risky behaviors, including multiple partners and nonuse of barrier methods of birth control, increase a woman's risk of chlamydial infection. ● Lower socioeconomic status may be a risk factor, especially with respect to treatment seeking behaviors.

S&S of women with Genital Herpes.

● HSV infection results in painful recurrent genital ulcers and is caused by two different antigen subtypes of herpes simplex virus: herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2). ● Although HSV-1 is more commonly associated with gingivostomatitis and oral labial ulcers (fever blisters; cold sores) and HSV-2 with genital lesions, neither type is exclusively associated with the respective sites. ● HSV infection is not a reportable disease ● Genital HSV is more common in women: approximately 1 in 5 women ages 14 to 49 are infected. ● Many persons infected with HSV-2 are asymptomatic and therefore undiagnosed. They can transmit the infection unaware that they are infected. ● An initial HSV genital infection is characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria and may last 2 to 3 weeks. ● Women generally have a more severe clinical course than men. ● Women with primary genital herpes have many lesions that progress from macules to papules, then forming vesicles, pustules, and ulcers that crust and heal without scarring. ● These ulcers are extremely tender, and primary infections may be bilateral. Women also can have itching, inguinal tenderness, and lymphadenopathy. ● Severe vulvar edema may develop, and women may have difficulty sitting. ● The cervix may appear normal or be friable, reddened, ulcerated, or necrotic. ● A heavy watery-to-purulent vaginal discharge is common. ● Extragenital lesions may be present because of autoinoculation. ● Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root. ● Women with recurrent episodes of HSV infections commonly have only local symptoms that are usually less severe than those associated with the initial infection. ● Systemic symptoms are usually absent, although the characteristic prodromal genital tingling is common. ● Recurrent lesions are unilateral, less severe, and usually last 5 to 7 days. Lesions begin as vesicles and progress rapidly to ulcers. ● During pregnancy, maternal infection with HSV-2 can have adverse effects on both the mother and fetus. ● Primary infections during the first trimester have been associated with increased miscarriage rates. ● The most severe complication of HSV infection is neonatal herpes. ● Most mothers of infants who contract neonatal herpes lack histories of clinically evident genital herpes. ● Risk of neonatal infection is highest among women with primary herpes infection who are near term and is low among women with recurrent herpes

Diagnosis of women with Candidiasis/Yeast Infection.

● In addition to a complete history of the woman's symptoms, their onset, and course, the history is a valuable screening tool for identifying predisposing risk factors. ● Physical examination should include a thorough inspection of the vulva and vagina. A speculum examination is always done. ● Commonly health care practitioners will obtain saline and KOH wet smears and check vaginal pH. ● Vaginal pH is normal with a yeast infection; if the pH is greater than 4.5, trichomoniasis or BV should be suspected.

Diagnosis of women with Trichomoniasis.

● In addition to obtaining a history of current symptoms, a careful sexual history should be obtained. ● Any history of similar symptoms in the past and treatment used should be noted. ● The nurse should determine whether the woman's partner(s) was treated and if she has had subsequent relations with new partners. ● A speculum examination is always done, even though it may be very uncomfortable for the woman; relaxation techniques and breathing exercises may help the woman with the procedure. ● Any of the classic signs can be present on physical examination. ● The typical one-celled flagellate trichomonads are easily distinguished on a normal saline wet prep. ● Trichomoniasis also can be identified on Pap tests. ● Because trichomoniasis is an STI, once diagnosis is confirmed, appropriate laboratory studies for other STIs should be carried out.

Diagnosis of women with Chlamydia.

● The CDC (2010c) strongly recommends screening of asymptomatic women at high risk in whom infection would otherwise go undetected. ● CDC guidelines recommend yearly screening of all sexually active adolescents, women between ages 20 and 25 years, and women older than 25 years who are at high risk (e.g., those with new or multiple partners). In addition, whenever possible, all women with two or more of the risk factors for chlamydia should be cultured. ● All pregnant women should have cervical cultures for chlamydia at the first prenatal visit. Screening late in the third trimester (36 weeks) may be carried out if the woman was positive previously, or if she is younger than 25 years, has a new sex partner, or has multiple sex partners. ● Although chlamydial infections are usually asymptomatic, some women may experience spotting or postcoital bleeding, mucoid or purulent cervical discharge, or dysuria. ● Bleeding results from inflammation and erosion of the cervical columnar epithelium. ● Laboratory diagnosis of chlamydia is by culture (expensive and labor intensive)

S&S of women with Gonorrhea.

● Only a single class of antibiotics now meets CDC's standard for treatment—the cephalosporins. ● Gonorrhea is almost exclusively transmitted by sexual contact. ● The principal means of communication is genital-to-genital contact; however, it also is spread by oral-to-genital and anal-to-genital contact. There also is evidence that infection can spread in females from vagina to rectum. ● Age is probably the most important risk factor associated with gonorrhea. -- highest reported rates of infection are among sexually active teenagers, young adults, and blacks. ● Women are often asymptomatic, When symptoms are present they are often less specific than are the symptoms in men. ● Women may have a purulent endocervical discharge, but discharge is usually minimal or absent. ● Menstrual irregularities may be the presenting symptom, or women may complain of pain—chronic or acute severe pelvic or lower abdominal pain or longer, more painful menses. ● Infrequently, dysuria, vague abdominal pain, or low backache prompts a woman to seek care. ● Gonococcal rectal infection may occur in women after anal intercourse. Individuals with rectal gonorrhea may be completely asymptomatic or, conversely, have severe symptoms with profuse purulent anal discharge, rectal pain, and blood in the stool. Rectal itching, fullness, pressure, and pain also are common symptoms, as is diarrhea. ● A diffuse vaginitis with vulvitis is the most common form of gonococcal infection in prepubertal girls. ● There may be few signs of infection, or vaginal discharge, dysuria, and swollen, reddened labia may be present. ● Gonococcal infections in pregnancy can affect mother and fetus. In women with cervical gonorrhea, salpingitis may develop in the first trimester. ● Perinatal complications of gonococcal infection include premature rupture of membranes, preterm birth, chorioamnionitis, neonatal sepsis, intrauterine growth restriction, and maternal postpartum sepsis. ● Amniotic infection syndrome manifested by placental, fetal, and umbilical cord inflammation after premature rupture of the membranes may result from gonorrheal infections during pregnancy. ● Ophthalmia neonatorum, the most common manifestation of neonatal gonococcal infections, is highly contagious and, if untreated, may lead to blindness of the newborn.

S&S of women with Pelvic Inflammatory Disease (PID).

● Pelvic inflammatory disease (PID) is an infectious process that most commonly involves the uterine (fallopian) tube, uterus, and more rarely, the ovaries and peritoneal surfaces. ● Multiple organisms have been found to cause PID, and most cases are associated with more than one organism. ● In the past, the most common causative agent was thought to be N. gonorrhoeae; however, C. trachomatis is now estimated to cause half of all cases of PID. ● gonorrhea and chlamydia are recognized to cause PID. ● PID encompasses a wide variety of pathologic processes; the infection can either be acute, subacute, or chronic and can have a wide range of symptoms. ● Most PID results from ascending spread of microorganisms from the vagina and endocervix to the upper genital tract. This spread most frequently happens at the end of or just after menses following reception of an infectious agent. ● During the menstrual period several factors facilitate the development of an infection: the cervical os is slightly open, the cervical mucus barrier is absent, and menstrual blood is an excellent medium for growth. ● PID also can develop after a miscarriage or an induced abortion, pelvic surgery, or childbirth. ● Risk factors for acquiring PID are those associated with the risk of contracting an STI, including young age (most cases of acute PID are in women younger than age 25), nulliparity, multiple partners, high rate of new partners, and a history of STIs and PID. ● Women who use intrauterine devices (IUDs) may be at increased risk for PID up to 3 weeks after insertion. ● PID tends to recur. ● Women who have had PID are at increased risk for ectopic pregnancy, infertility, and chronic pelvic pain. ● It may be dull, cramping, and intermittent (subacute) or severe, persistent, and incapacitating (acute). ● Women may also report one or more of the following: fever, chills, nausea and vomiting, increased vaginal discharge, symptoms of a urinary tract infection, and irregular bleeding. Abdominal pain is usually present.

Management of women with Syphilis.

● Penicillin G is the preferred drug for treating clients with syphilis. It is the only proven therapy that has been widely used during pregnancy. ● Intramuscular benzathine penicillin G is used to treat primary, secondary, and early latent syphilis. ● Although doxycycline, tetracycline, and erythromycin are alternative treatments for penicillinallergic clients, both tetracycline and doxycycline are contraindicated in pregnancy, and erythromycin is unlikely to cure a fetal infection. ● Therefore, pregnant women should, if necessary, receive skin testing and be treated with penicillin or be desensitized. ● Monthly follow-up is mandatory so that repeated treatment may be given if needed. ● The nurse should emphasize the necessity of long-term serologic testing even in the absence of symptoms. ● The woman should be advised to practice sexual abstinence until treatment is completed, all evidence of primary and secondary syphilis is gone, and serologic evidence of a cure is demonstrated. ● Women should be told to notify all partners who may have been exposed. They should be informed that the disease is reportable. ● Preventive measures should be discussed.

Management of women with Pelvic Inflammatory Disease (PID).

● Perhaps the most important nursing intervention is prevention. ● Primary prevention includes education about preventing the acquisition of STIs, and secondary prevention involves preventing a lower genital tract infection from ascending to the upper genital tract. ● Instructing women in self-protective behaviors such as practicing risk-reduction measures and using barrier methods is critical. ● Also important is the detection of asymptomatic gonorrheal and chlamydial infections through routine screening of women with risky behaviors or specific risk factors such as age. ● Although treatment regimens vary with the infecting organism, a broad-spectrum antibiotic is generally used (Table 7-3). ● The woman with acute PID should be on bed rest in a semi-Fowler position. ● Comfort measures include analgesics for pain and all other nursing measures applicable to a woman confined to bed. ● The woman should have as few pelvic examinations as possible during the acute phase of the disease. ● During the recovery phase the woman should restrict her activity and make every effort to get adequate rest and a nutritionally sound diet. ● Follow-up laboratory work after treatment should include endocervical cultures for a test of cure. ● Provide contraceptive counseling. Suggest that the woman select a barrier method such as condoms, contraceptive sponge, or a diaphragm. ● A woman with a history of PID may choose an IUD as her contraceptive method: however, the rate of treatment failure and recurrent PID in women continuing to use an IUD is unknown. ● The potential or actual loss of reproductive capabilities can be devastating and can adversely affect a woman's self-concept. ● Because PID is so closely tied to sexuality, body image, and self-concept, the woman diagnosed with it will need supportive care. ● She should be encouraged to discuss her feelings. Referral to a support group or for counseling may be appropriate.

1. Describe prevention of sexually transmitted infections in women.

● Preventing infection (primary prevention) is the most effective way of reducing the adverse consequences of STIs for women and for society. ● Prompt diagnosis and treatment of current infections (secondary prevention) also can prevent personal complications and transmission to others. ● Preventing the spread of STIs requires that women at risk for transmitting or acquiring infections change their behavior. ● Ask questions about a woman's sexual history, risky sexual behaviors, and drug-related risky behaviors as a part of her assessment. ● The Five P's—Partners, Prevention of Pregnancy, Protection from STIs, Practices, and Past History of STIs—approach to obtaining a sexual history is an example of an effective strategy for eliciting information concerning five key areas of interest. ● Providing prevention counseling include using open-ended questions, using understandable language, and reassuring the woman that treatment will be provided regardless of factors such as ability to pay, language spoken, or lifestyle. ● Prevention messages should include descriptions of specific actions to be taken to avoid acquiring or transmitting STIs (e.g., refraining from sexual activity when STI-related symptoms are present) and should be individualized for each woman, giving attention to her specific risk factors. ● To be motivated to take preventive actions, a woman must believe that acquiring a disease will be serious for her and that she is at risk for infection. However, most individuals tend to underestimate their personal risk of infection in a given situation; thus many women, and especially adolescents, may not perceive themselves as being at risk for contracting an STI. Telling them that they should carry condoms may not be well received. ● Nurses have a responsibility to ensure that their clients have accurate, complete knowledge about transmission and symptoms of STIs and behaviors that place them at risk for contracting an infection. ● Primary preventive measures are individual activities aimed at deterring infection.

Management of women with Chlamydia.

● The CDC recommendations for treatment of urethral, cervical, and rectal chlamydial infections are azithromycin or doxycycline. ● Azithromycin is often prescribed when compliance may be a problem, because only one dose is needed; however, expense is a concern with this medication. ● If the woman is pregnant, azithromycin or amoxicillin is used. ● Pregnant women should be retested in 3 weeks to determine if treatment was effective; if at high risk for reinfection, the pregnant woman should be retested in the third trimester. ● Women who have a chlamydial infection and also are infected with HIV should be treated with the same regimen as those who are not infected with HIV. ● Because chlamydia is often asymptomatic, the woman should be cautioned to take all medication prescribed. ● All exposed sexual partners should be treated.

Management of women with Trichomoniasis.

● The recommended treatment is metronidazole or tinidazole orally in a single dose. ● Although the male partner is usually asymptomatic, it is recommended that he receive treatment also because he often harbors the trichomonads in the urethra or prostate. ● It is important that nurses discuss the importance of partner treatment with their clients, because if they are not treated it is likely that the infection will recur.

Management of women with Bacterial Vaginosis (BV).

● Treating bacterial vaginosis with oral metronidazole (Flagyl) is most effective. -- Side effects of metronidazole are numerous, including sharp, unpleasant metallic taste in the mouth; furry tongue; central nervous system reactions; and urinary tract disturbances. ● When oral metronidazole is taken, the woman is advised not to drink alcoholic beverages or she will experience the severe side effects of abdominal distress, nausea, vomiting, and headache. ● Gastrointestinal symptoms are common but less severe if alcohol is not consumed. ● Treating sexual partners is not recommended routinely. ● Metronidazole is not recommended if the woman is breastfeeding. However, if it is necessary to prescribe it, the woman can suspend breastfeeding (pump and discard to maintain milk supply) during treatment and for 12 to 24 hours after the last dose to reduce the infant's exposure to metronidazole.

S&S of women with Trichomoniasis.

● Trichomonas vaginalis is almost always an STI and is also a common cause of vaginal infection (5% to 50% of all vaginitis) and discharge. ● Trichomoniasis is caused by T. vaginalis, an anaerobic one-celled protozoan with characteristic flagellae. ● Although trichomoniasis may be asymptomatic, commonly women have characteristically yellowish to greenish, frothy, mucopurulent, copious, malodorous discharge. ● Inflammation of the vulva, the vagina, or both may be present, and the woman may complain of irritation and pruritus. ● Dysuria and dyspareunia are often present. Typically the discharge worsens during and after menstruation. ● Often the cervix and the vaginal walls will demonstrate the characteristic "strawberry spots" or tiny petechiae, and the cervix may bleed on contact. In severe infections, the vaginal walls, the cervix, and occasionally the vulva may be acutely inflamed.

Management of women with HPV/Genital Warts.

● Untreated HPV infection resolves spontaneously in young women because their immune systems may be strong enough to fight the HPV infection. However, if the virus persists, depending on the type of virus, genital warts or cancer can develop months or years after the person has been infected with HPV. ● No therapy has been shown to eradicate HPV. ● The goal of treatment for genital warts is removal of warts and relief of signs and symptoms. ● None of the treatments is superior to all other treatments, and no one treatment is ideal for all warts. ● Available treatments are outlined in Table 7-2. Imiquimod, podophyllin, podofilox, and sinecatechins should not be used during pregnancy. Because the lesions can proliferate and become friable during pregnancy, many experts recommend their removal by using cryotherapy or various surgical techniques during pregnancy. ● Women with discomfort associated with genital warts may find that bathing with an oatmeal solution and drying the area with a cool hair dryer provides some relief. ● Keeping the area clean and dry also decreases growth of the warts. ● Cotton underwear and loose-fitting clothes that decrease friction and irritation also may decrease discomfort. ● Women should be advised to maintain a healthy lifestyle to aid the immune system; women can be counseled regarding diet, rest, stress reduction, and exercise. ● Women need to know that HPV infection is very common, and in most cases, will clear up spontaneously. ● Because HPV is highly contagious, the majority of partners of women with HPV will be infected even if they are asymptomatic. ● All sexually active women with multiple partners or a history of HPV should be encouraged to use latex condoms for intercourse to decrease the risk of acquisition or transmission of genital HPV. ● Instructions for all medications and treatments must be detailed. ● Women should be told that treatments are for the conditions caused by the virus but not HPV itself. ● Annual health examinations are recommended to assess disease recurrence and screening for cervical cancer. ● Women should be counseled to have regular Pap screening, as recommended for women without genital warts.

S&S of women with Candidiasis/Yeast Infection.

● Vulvovaginal candidiasis (VVC), or yeast infection, is the second most common type of vaginal infection in the United States. ● Although vaginal candidiasis infections are common in healthy women, those seen in women with HIV infection are often more severe and persistent. ● Genital candidiasis lesions may be painful coalescing ulcerations necessitating continuous prophylactic therapy. ● The most common organism is Candida albicans; estimates indicate that more than 90% of the yeast infections in women are caused by this organism. ● Numerous factors have been identified as predisposing a woman to yeast infections, including antibiotic therapy, particularly broad-spectrum antibiotics such as ampicillin, tetracycline, cephalosporins, and metronidazole; diabetes, especially when uncontrolled; pregnancy; obesity; diets high in refined sugars or artificial sweeteners; use of corticosteroids and exogenous hormones; and immunosuppressed states. ● Clinical observations and research have suggested that tight-fitting clothing and underwear or pantyhose made of nonabsorbent materials create an environment in which a vaginal fungus can grow. ● The most common symptom of yeast infections is vulvar and possibly vaginal pruritus. ● The itching can be mild or intense, interfere with rest and activities, and may occur during or after intercourse. ● Some women report a feeling of dryness. Others may experience painful urination as the urine flows over the vulva, which usually occurs in women who have excoriations resulting from scratching. ● Most often the discharge has a thick, white, lumpy, and cottage cheese-like consistency. The discharge may be found in patches on the vaginal walls, cervix, and labia. ● Commonly, the vulva is red and swollen, as are the labial folds, vagina, and cervix. Although there is not a characteristic odor with yeast infections, sometimes a yeasty or musty smell is noted.

S&S of women with HPV/Genital Warts.

● is the most common viral STI seen in ambulatory health care settings. But not reportable ● The highest rate of HPV infections occurs in women ages 20 to 24 years ● HPV lesions in women are most commonly seen in the posterior part of the introitus; however, lesions also are found on the buttocks, the vulva, the vagina, the anus, and the cervix. ● Typically the lesions are small—2 to 3 mm in diameter and 10 to 15 mm in height—soft, papillary swellings occurring singly or in clusters on the genital and anorectal region. ● Infections of long duration may appear as a cauliflower-like mass. ● In moist areas such as the vaginal introitus, the lesions may appear to have multiple, fine finger-like projections. Vaginal lesions are often multiple. ● The lesions are often painless but may be uncomfortable, particularly when very large, inflamed, or ulcerated. ● Chronic vaginal discharge, pruritus, or dyspareunia can occur. ● HPV infections are thought to be more frequent in pregnant than in nonpregnant women, with an increase in incidence from the first trimester to the third. ● Lesions can become so large during pregnancy that they affect urination, defecation, mobility, and fetal descent, and can obstruct the birth canal, necessitating a cesarean birth.

S&S of women with Syphilis.

● one of the earliest described STIs ● Transmission is thought to be by entry in the subcutaneous tissue through microscopic abrasions that can occur during sexual intercourse. ● The disease also can be transmitted through kissing, biting, or oral-genital sex. ● Transplacental transmission can occur at any time during pregnancy ● The rates of primary and secondary syphilis were highest among women ages 20 to 24 years. ● The rates were highest in black women. ● can lead to serious systemic disease and even death when untreated. ● Infection manifests itself in distinct stages with different symptoms and clinical manifestations. ● Primary syphilis is characterized by a primary lesion, the chancre, that appears 5 to 90 days after infection. -- This lesion often begins as a painless papule at the site of inoculation and then erodes to form a nontender, shallow, indurated, clean ulcer several millimeters to centimeters in size. ● Secondary syphilis occurs 6 weeks to 6 months after the appearance of the chancre and is characterized by a widespread, symmetric maculopapular rash on the palms and soles and generalized lymphadenopathy. ● The infected individual also may experience fever, headache, and malaise. Condylomata lata (broad, painless, pink-gray wartlike infectious lesions) may develop on the vulva, the perineum, or the anus. ● If the woman is untreated, she enters a latent phase that is asymptomatic for the majority of individuals. Latent infections are those that lack clinical manifestations but are detected by serologic testing. ● If the infection was acquired in the preceding year, the infection is termed an early latent infection. ● If it is left untreated, tertiary syphilis will develop in about one third of these women. ● Neurologic, cardiovascular, musculoskeletal, or multiorgan system complications can develop in the third stage.

Management of women with Gonorrhea.

● usually rapid with appropriate antibiotic therapy (IM ceftriaxone and or azithromycin orally). ● Single-dose efficacy is a major consideration in selecting an antibiotic regimen for women with gonorrhea. ● A test of cure in 3 to 4 weeks after treatment is not recommended for pregnant women. ● All women with both gonorrhea and syphilis should be treated for syphilis according to CDC guidelines. ● Gonorrhea is a highly communicable disease. It is important to notify partners if a woman is diagnosed with a gonorrheal infection. ● Recent (past 30 days) sexual partners should be examined, cultured, and treated with appropriate regimens. ● Most treatment failures result from reinfection. ● The woman must be informed of this, as well as of the consequences of reinfection in terms of chronicity, complications, and potential infertility. ● Women are counseled to use condoms. ● All clients with gonorrhea should be offered confidential counseling and testing for HIV infection.