High Acuity: Sexually Transmitted Diseases

Gonorrhea

*Gonorrhea is the second most frequent* reported STD in the U.S. (*chlamydial infections are the most common)*. Since 2006 the national gonorrhea rate has increased and today more than 700,000 new cases are diagnosed yearly. The rates are highest in *adolescents* of all racial and ethnic groups and among African Americans. Most states have enacted laws that permit examination and treatment of minors without parental consent. Gonorrhea is caused by Neisseria gonorrhoeae, a gram negative diplococcus. *priority is to contact sexual partners*

Diagnostics of Genital Warts

Appearance of the lesions. Serologic and cytological testing HPV DNA test *Currently, HPV cannot be confirmed by culture.*

STD's

Are infectious diseases transmitted most commonly through sexual contact. Historically they have been referred to as venereal diseases. Many of the agents causing STDs are easily inactivated by drying, heating, and washing. These infections can be bacterial (gonorrhea, chlamydia, syphilis) or viral (genital herpes, genital warts).

Gonorrhea Treatment

Because men seek treatment early they are less likely to develop complications. The complications that do occur in men are; prostatitis, urethral strictures, and sterility from orchitis or epididymitis. Because women who are asymptomatic seldom seek treatment, complications are more common and usually constitute the reason for seeking medical attention. Pelvic inflammatory disease (PID), Bartholin's abscess (glands within the vagina), ectopic pregnancy, and infertility are the main complications of gonorrhea in women. Almost all states have a health department regulation or law requiring the instillation of a prophylactic drug such as erythromycin (0.5%) ophthalmic ointment or silver nitrate (0.1%) aqueous solution into the eyes of all newborns in a single application. Untreated leads to *blindness.*

Chlamydia manifestations

Chlamydia is known as a *silent disease because symptoms may be absent or minor* in most infected women and many men. *Fishy odor* to the drainage

Chlamydial Infections

Chlamydial infections are the *most commonly* reported *STD* in the U.S., recently reached their highest level ever with 1.1 million cases reported. Part of this increase may be due to better and more intensive screening for the disease. *difficult to distinguish from gonorrhea* Three times *higher in women* than men, may be due to the larger numbers of women screened for the disease. Underreporting is substantial because *most people are asymptomatic* and do not seek testing. Chlamydial infections are a major contributor to PID, ectopic pregnancy (inflammation obstruction), infertility among women, and nongonococcal urethritis in men. Caused by Chlamydial trachomatis, a gram negative bacterium. Women *younger than 25 years old* are 5 times *more likely* to have a chlamydial infection than women over age 30. Women with chlamydia may also be at *high risk for acquiring HIV* from an infected partner. Because chlamydial infections are *closely associated* with gonococcal infections, *clinical differentiation may be difficult.*

syphilis complications

Complications of the disease occur mostly in *late syphilis.* The *Gummas* (destructive skin, bone, and soft tissue *nodular lesions*) may produce irreparable damage to bone, liver, or skin but seldom results in death. In *cardiovascular syphilis*, the resulting aneurysm (bulging, weak area in the wall of an artery that supplies blood) may press on structures such as the intercostal nerves, causing pain. *hoarseness if pushing against the larynx.* The possibility of a rupture exists as the aneurysm increases in size. Scarring of the aortic valve results in aortic valve insufficiency and eventual heart failure. *Neurosyphilis* is responsible for degeneration of the brain with mental deterioration. *patient will go to surgery to have anuerism repaired once reaches 5mm*

Factors Affecting Incidence

Earlier reproductive maturity and increased longevity have resulted n a longer sexual life span. The increase in the total population has resulted in an increase in the number of susceptible hosts. Other factors include greater sexual freedom, lack of barrier methods during sexual activity, and an increased emphasis in the media on sexuality. Increased leisure time, more national and international travel, and urbanization have brought together people with varying social behaviors and value systems. Changes in contraceptive methods. *The condom is considered to be the best form of protection against STDs. Don't keep condom in pocket, use oil-based lubricant, don't wash and reuse*

Genital Herpes

Genital herpes is *not a reportable disease* in most states, and its true incidence is difficult to determine. Approximately 1.7 million new cases of herpes virus type 2 (HSV-2) are required each year, and more than 50% of these cases are *asymptomatic or unrecognized.* The CDC estimates that at least 45 million people in the U.S. have had genital HSV infection.

Genital Warts

Genital warts (condylomata) are caused by the human papillomavirus. There are over 100 types of papillomaviruses, and about 40 of these affect the genital tract. Visible *genital warts* are usually caused by HPV *types 6 and 11.* They can also cause warts on the *anus, urethra, and vagina* Most individuals who have *HPV infection* do not know they are infected because *symptoms are often not present.* Minor trauma during intercourse can cause abrasions that allow HPV to enter the body. The epithelial cells infected with HPV undergo transformation and proliferation to form a warty growth.

manifestations of genital warts

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. There are usually no other signs or symptoms. *During pregnancy, genital warts tend to grow rapidly. An infected mother may transmit the condition to her newborn.* Cesarean delivery is not routinely indicated unless the birth canal becomes blocked by massive warts. *HPV infection has been linked with cervical and vulvar cancer in women and with anorectal and squamous cell carcinoma of the penis in men*

Gonorrhea: The disease confers no immunity to subsequent reinfection

Gonococcal infection elicits an inflammatory response, which, if left untreated, leads to the formation of fibrous tissue adhesions. This fibrous scarring is subsequently responsible for many complications in women such as strictures and tubal abnormalities, which can lead to tubal pregnancy, chronic pelvic pain, and infertility

A teenage boy comes to the office complaining of intense burning while urinating and gray green discharge coming from his penis. The nurse recognizes these as symptoms of what problem?

Gonorrhea Gonorrhea in men is the most symptomatic; with urethritis, dysuria, and purulent drainage.

Gonorrhea Diagnostics

Gram stain smear of the purulent discharge. Nonculture test (NAAT) *culture looking at secretions* EIA and DFA-detect chlamydial antigens Management; Single IM dose of Rocephin, Suprax, Cipro (anitbiotics). Contact all sexual contacts Counseling *priority before treating patient is to contact sexual partner*

The nurse receives a report on a client's Pap smear. The result is reported in the cervical intraepithelial neoplasia (CIN) classification. The client's results are CIN grade III. What is the nurse's interpretation of this report?

Highly suggestive of malignancy Pap smear that reveals a classification of CIN grade III is highly suggestive of malignancy. A definitive diagnosis of malignancy would require a biopsy

syphilis diagnostics

History and physical Dark field microscopy Nontreponemal and/or treponemal serologic testing *(VDRL)-diagnoses syphilis* Testing for other STDs Nontreponemal tests (indirect method of blood test) are suitable for screening purposes. The treponemal serologic testing (detect antibodies against specific antigens ) that detect specific antibodies are suitable for confirming the diagnosis.

Chlamydia diagnostics

History and physical NAAT DFA and EIA Testing for other STDs Culture (Same as gonorrhea)

Two different strains of HSV cause infection

In general, HSV *type I* (HSV-I) causes infection *above the waist*, involving the gingiva, the dermis, the upper respiratory tract, and the CSN. HSV *type 2* (HSV-) most frequently infects the genital tract and the perineum (*location below the waist).* *Either strain* can cause disease on the *mouth or the genitals*. The majority of genital herpes cases are from HSV-2 infection. The incidence of genital herpes caused by HSC-1 is on the rise. *more people practicing oral sex*

Genital Herpes Complications

May involve the CNS causing aseptic meningitis and lower motor neuron damage. Neuronal damage may result in atonic bladder, impotence, and constipation. Also autoinoculation of the virus to the lips, breast, and fingers (*herpetic whitlow).*

Persons at high risk for acquiring syphilis are also at an increased risk for acquiring HIV

Often, both infections may be present in the same person. The presence of syphilic lesions of the genitalis enhances HIV transmission. HIV infected clients with syphilis appear to be at greatest risk for clinically significant CNS involvement and may require more intensive treatment with PCN-*(penicillin)* than do other clients with syphilis. Therefore the evaluation of all cleints with syphilis should *also include testing for HIV with the clients consent.*

Genital Herpes managment

Suppressive therapy with antiviral agents can reduce but *not eradicate* asymptomatic shedding.

syphilis manifestations

Syphilis has a variety of signs and symptoms that can mimic a number of other diseases. It is more difficult to recognize. The primary stage of bacterial invasion chancres appear. *on the tongue* Chancres are painless indurated lesions on the penis, vulva, lips, mouth, and rectum. The chancres last 3 to 6 weeks, eventually healing on its own. During this time the draining of microorganisms into the lymph nodes causes regional lymphadenopathy. Genital ulcers may also be present. Without treatment stage one will progress to stage two. The secondary stage of syphilis is systemic. The stage begins a few weeks after the chancres are first seen, and blood borne bacteria spread to all major systems. Manifestations include flu like symptoms, such as fever, sore throat, headaches, fatigue, and generalized lymphadenopathy.

After examining a painless sore on the penile shaft, the doctor asks the nurse to order a fluorescent treponemal antibody absorption Test (FTA-ABS). The nurse knows that the purpose of this test is to diagnose what condition?

Syphilis stage I. The florescent treponemal antibody absorption test is used to identify the spirochete treponema pallidum which causes syphilis

Which of the following groups has experienced the greatest rise in the incidence of sexually transmitted diseases (STD's) over the past two decades

Teenagers Statistics reveal that the incidence of STD's is rising more rapidly among teenagers than among any other age group.

Genital Herpes Manifestations

The initial episode of genital herpes the client may complain of burning or tingling at the site of inoculation. Multiple small, vesicular lesions may appear on the penis, scrotum, vulva, perineum, perianal region, vagina, or cervix. The vesicles contain large quantities of infectious particles. The lesions rupture and form shallow, moist ulcerations. Finally, crusting and epithelialization of the erosion occurs. *Primary infections* tend to be associated with local inflammation and pain, accompanied by *systemic manifestations* of fever, headache, malaise, myalgia, and regional lymphadenopathy. Urination may be painful from the urine touching active lesions. Urinary retention may occur as a result of HSV urethritis or cystitis. A purulent vaginal discharge may develop with HSV cervicitis.

Gonorrhea Clinical manifestations

The initial site of infection for men is usually the urethra. Symptoms of urethritis consist of dysuria and profuse, purulent urethral discharge. *peeing razor blades* Painful or swollen testicles. Men generally seek medical evaluation early in the disease because their symptoms are usually obvious and distressing. It is unusual for men to be asymptomatic. Women may be asymptomatic or have minor symptoms that are often overlooked, making it possible for them to remain a source of infection. A few may complain of vaginal discharge, dysuria, or frequency of urination. After the incubation period, redness and swelling occur at the site of contact, which is usually the cervix or urethra. A greenish yellow purulent exudate often develops with a potential for abscess formation. May spread to the uterus, fallopian tubes, and ovaries, vulva and vagina.`

Management of Genital Warts

The primary goal when treating visible genital warts is the *removal of symptomatic warts.* TCA or Pondophyllin *topically* applied to the warts. Vaccines are now available to protect against HPV types *6, 11, 16, and 18.* HPV types *6 and 11* cause most *cervical cancers.* The *vaccine* is given in three IM doses over a 6 month period and has few side effects. It is currently recommended for females ages *9 to 26.* *Not recommended during pregnancy.*Due to reported cases of syncope during vaccine administration, the client should *remain seated or lying down and be closely observed for 15 minutes* following vaccination *Gardasil*

HSV Drug therapy

Three *antiviral agents* are available for the treatment of HSV-2; acyclovir, valacyclovir and famciclovir. They inhibit viral replication and are prescribed for primary and recurrent infections *if ends in VIR, it is an antiretroviral drug*

Syphilis managment

Treatment cannot reverse damage that is already present. *Penicillin G* remains the treatment of choice for all stages of syphilis.

Herpes Simplex Virus diagnostics

Usually based on the client's symptoms and history. Can be confirmed through isolation of the virus from active lesions by means of tissue cultures. CDC recommends a serologic test for HSV-2 in addition to cultures.

A client has been diagnosed with genital herpes. The nurse would explain to the client that she is most contagious at what stage?

Vesicles rupture and release exudate Herpes virus type II is concentrated in the vesicles, and therefore the infection is highly contagious when this fluid is released.

Chlamydia management

Vibramycin or Azithromycin (antibiotics) Abstinence from sexual intercourse for 7 days after treatment *Treatment of all sexual partners*

HSV in Pregnancy

Women with a *primary episode* of HSV near the time of delivery have the *highest risk of transmitting genital herpes to the neonate.* An active genital lesion at the time of delivery is usually an indication for cesarean section delivery because most infections to neonates occur during birth.

Not all people who are exposed to syphilis acquire the disease

about one third become infected after intercourse with an infected partner. Syphilis can also be spread through contact with an infectious lesion, and sharing needles among IV drug users. It is an extremely fragile organism and easily destroyed by drying, heating, or washing.

Ongoing clinical trials of Genital Warts

are assessing the effectiveness of *Gardasil* in *male* clients. The vaccines do *not* treat *active* HPV infection.

syphilis Cutaneous eruptions

can also occur, and include a bilateral, symmetrical rash that typically begins on the trunk and also involves the palms and soles; mucous patches in the mouth, tongue, or cervix, and *condylomata lata (moist weeping papules) in the anal and genital area.*

Different STDs

can coexist within one person *(gonorrhea and chlamydial infection may be present at the same time).* In the U.S. all cases of gonorrhea and syphilis, and in most states chlamydial infection, must be reported to the state local public health authorities. An estimated 65 million Americans are currently infected with one or more STDs. Every year an additional 19 million Americans are newly infected with an STD. About 50% of these new cases are in persons 15 to 24 years old. Diseases that are associated with sexual transmission can also be contracted by other routes such as through the blood, blood products, and autoinoculation.

Gonorrhea disease is spread by

direct physical contact with an infected host, usually during sexual activity (vaginal, oral, or anal). Mucosal tissues present in the genitalia, the rectum, and the oropharynx are especially sensitive to gonococcal infection. Neonates can develop a gonococcal infection during delivery from an infected mother. The delicate gonococcus is easily killed by drying, heating, or washing with an antiseptic solution. Consequently, indirect transmission by instruments or linens is rare.

The latent or hidden stage of syphilis

follows the secondary stage and is a period during which the immune system is able to suppress the infection. There are no signs and symptoms of syphilis during this time. During this stage diagnosis is established by a positive specific treponemal antibody test for syphilis together with a CSF exam. *test for syphilis using a VDRL (Venereal Disease Research Laboratory)*

The duration of symptoms of Genital Herpes

is longer and the frequency of complications is greater in women. Primary lesions are generally present for 17 to 20 days, but new lesions sometimes continue to develop for 6 weeks. Recurrent genital herpes occurs in about 50% to 80% of individuals during the year following the primary episode. Stress, fatigue, sunburn, and menses are common noted trigger factors.

Congenital syphilis

is transmitted from an infected mother to the fetus in utero after the tenth week of pregnancy. An infected pregnant woman has a high risk of a *stillbirth or having a baby who dies shortly after birth.* There is an association between syphilis and HIV.

Most infections start as

lesions on the genitalia and other sexually exposed mucous membranes. Wide dissemination to other areas of the body can then occur. A latent or subclinical phase is present with all STDs. This can lead to a long term persistent infection and the transmission of disease from an asymptomatic (but infected) person to another contact person.

Genital herpes Viral reactivation

may *occur* when the virus *descends down to the initial site of infection*, either the mucous membranes or skin. When a person is infected with HSV, the virus usually persists within the individual for *life.* *Transmission* of HSV occurs through direct contact with skin or mucous membranes when an infected individual is *symptomatic or through asymptomatic viral shedding.*

Anorectal gonorrhea

may be present and is usually caused by anal intercourse. *homosexual population* Symptoms include soreness, itching, and discharge of the anus. A small percentage of individuals develop gonococcal pharyngitis resulting from orogenital sexual contact. *tongue*

The incubation period of genital warts

of the virus is generally 3 to 4 months, but may be longer. Prevention is hampered by a high proportion of asymptomatic infections and lack of curative treatment. In most states, genital warts are *not a reportable disease.*

Chlamydia in men and women

proctitis (inflammation of the anus) may occur in both diseases. In women, bartholinitis ( inflammation of one or both of the two Bartholin's glands, which are located one on either side of the opening of the vagina), cervicitis, and salpingitis (fallopian tubes), can occur in both chlamydial and gonococcal infections. Both are usually treated concurrently even without diagnostic evidence.

Other HPV types in the genital region

region (types 16, 18, 31, 33, and 35) are associated with vaginal, anal, and cervical dysplasia. HPV is a highly contagious STD seen frequently in young, sexually active adults. An estimated 20 million Americans are currently infected with HPV. HPV is the *most common STD* in the U.S..

The incidence of syphilis

reported in the U.S. is increasing and there are about 11,500 cases reported annually. This increased rate is *mainly due to men who have sex with men.* The causative organism of syphilis is Treponema pallidum, a spirochete. This bacterium is thought to enter the body through very small breaks in the skin or mucous membranes. Its entry is facilitated by the minor abrasions that often occur during sexual intercourse. It is a complex disease in which many organs and tissues of the body can become infected. *patches on the soles of the hands and feet are very contagious, so WEAR GLOVES* The infection causes the production of antibodies that also react with normal tissues. After a short period of protection, the antibody levels decrease, and a person is susceptible to reinfection. *If pregnant and diagnosed with syphilis, mom and baby can both be cured with a shot of penicillin*

The third stage of syphilis

syphilis (also called late or tertiary syphilis) is the most severe stage of the disease. Because antibiotics can cure syphilis, manifestations of late syphilis are rare. When it does occur, it is responsible for significant morbidity and mortality rates. *Third world countries*

The HSV enters through

the mucous membranes or breaks in the skin during contact with an infected person. HSV then reproduces inside the cell and spreads to the surrounding cells. The virus next enters the peripheral or autonomic nerve endings and ascends to the sensory or autonomic nerve ganglion, where it often *becomes dormant.*

HSV infection of the eye

usually resolves within 1 to 2 weeks, but it can progress, resulting in the development of ulcers. It is the *most common cause* of corneal ulceration and *blindness* in the U.S. Symptoms include blurred vision, acute pain, and conjunctivitis. Treatment is topical antivirals.