2. Sexually Transmitted Diseases
• Infectious diseases most commonly transmitted
through sexual contact
• Can also be transmitted by
• Blood
• Blood products
• Autoinoculation
3. National Health Picture on STDs
• As of January 2013, the Department of
Health (DOH) AIDS Registry in the
Philippines reported 10,514 people living
with HIV/AIDS.
• Most Common in the Philippines
- Chlamydia
- Gonorrhea
- Genital Herpes
- HIV / AIDS
- Syphillis
- Ectoparasitic Infections
4. General Overview
• Highest incidence: adolescents &
young adults
• Sexual abuse
• Primary Prevention
• Advocate for adolescent education
re: sex and sexually transmitted
disease. (AAP, 2001)
• Abstinence
• Condoms
4
5. Healthy People 2020
• Goal: Promote healthy
sexual behaviors,
strengthen community
capacity, and increase
access to quality
services to prevent
sexually transmitted
diseases and their
complications.
5
6. Factors contributing to spread
•
•
•
•
Asymptomatic nature of STDs
Gender disparities
Age disparities
Lag time between infection and
complications
• Social, economic and behavioral factors
6
7. Risk Factors
•
•
•
•
•
•
•
•
IV drug use
Other substance abuse
High-risk sexual activity
Younger age at beginning of sexual activity
Inner city residence
Poverty/lower socioeconomic status
Poor nutrition
Poor hygiene
7
10. Gonorrhea
Etiology and Pathophysiology
• 2nd most frequently reported STD in US
• Caused by Neisseria gonorrheae
• Gram-negative bacteria
• Direct physical contact with infected host
• Killed by drying, heating, or washing with
antiseptic
• Incubation: 3-8 days
11. Gonorrhea
Etiology and Pathophysiology
• Elicits inflammatory process that can lead to fibrous
tissue and adhesions
• Can lead to :
• Tubal pregnancy
• Chronic pelvic pain
• Infertility in women
12. Gonorrhea
Clinical Manifestations
• Men
• Initial site of infection is urethra
• Symptoms
• Develop 2 to 5 days after infection
• Dysuria
• Profuse, purulent urethral discharge
• Unusual to be asymptomatic
15. Gonorrhea
Clinical Manifestations
• Women (cont’d)
• After incubation
• Redness and swelling occur at site of contact
• Greenish, yellow purulent exudate often develops
• May develop abscess
• Transmission more efficient from men to
women
18. Gonorrhea
Complications
• Men
• Include prostatitis, urethral strictures, and sterility
• Often seek treatment early so less likely to
develop complications
19. Gonorrhea
Complications
• Women
• Include pelvic inflammatory disease (PID),
Bartholin’s abscess, ectopic pregnancy, and
infertility
• Usually asymptomatic so seldom seek treatment
until complication are present
20. Gonorrhea
Diagnostic Studies
• History and physical examination
• Laboratory tests
• Gram-stained smear to identify organism
• Culture of discharge
• Nucleic acid amplification test
• Testing for other STDs
21. Gonorrhea
Treatment & Nursing Care
• Drug therapy
• Treatment generally instituted without culture
results
• Treatment in early stage is curative
• Most common
• IM dose of ceftriaxone (Rocephin)
22. Gonorrhea
Treatment & Nursing Care cont’d
• All sexual contacts of patients must be evaluated
and treated
• Patient should be counseled to abstain from sexual
intercourse and alcohol during treatment
• Reexamine if symptoms persist after treatment
24. Syphilis
Etiology and Pathophysiology
• Caused by Treponema pallidum
• Spirochete bacterium
• Enters the body through breaks in skin or
mucous membranes
• Destroyed by drying, heating or washing
• May also spread via contact with lesions and
sharing of needles
25. Syphilis
Etiology and Pathophysiology
• Incubation 10 to 90 days
• Spread in utero after 10th week of pregnancy
• Infected mother has a greater risk of a stillbirth or
having a baby who dies shortly after birth
26. Syphilis
Etiology and Pathophysiology
• Association with HIV
• Syphilitic lesions on the genitals enhance HIV
transmission
• Evaluation includes testing for HIV with patient’s
consent
27. Syphilis
Clinical Manifestations
• Variety of signs/symptoms that can mimic other
disease
• Primary stage
• Chancres appear
• Painless indurated lesions
• Occur 10 to 90 days after inoculation
• Lasting 3 to 6 weeks
29. Syphilis
Clinical Manifestations
• Secondary stage
• Systemic
•
•
•
•
•
•
Begins a few weeks after chancres
Blood-borne bacteria spread to all major organ systems
Flu-like symptoms
Bilateral symmetric rash
Mucous patches
Condylomata lata
31. Syphilis
Clinical Manifestations
• Latent or hidden stage
• Immune system is suppressing infection
• No signs/symptoms at this time
• Diagnosed by positive specific treponema
antibody test for syphilis with normal
cerebrospinal fluid
33. Syphilis
Complications
• Occur mostly in late syphilis
• Irreparable damage to bone, liver, or skin from
gummas
• Pain from pressure on structures such as
intercostal nerves by aneurysms
35. Syphilis
Diagnostic Studies
• History including sexual history
• PE
• Examine lesions
• Note signs/symptoms
• Dark-field microscopy
• Serologic testing
• Testing for other STDs
36. Syphilis
Treatment & Nursing Care
• Drug therapy
• Benzathine penicillin G (Bicillin)
• Aqueous procaine penicillin G
37. Syphilis
Treatment & Nursing Care cont’d
•
•
•
•
Monitor neurosyphilis
Confidential counseling and HIV testing
Case finding
Surveillance
38. Chlamydial Infections
Etiology and Pathophysiology
• #1 reported STD in US
• Caused by Chlamydia trachomatis
• Gram-negative bacteria
• Transmitted during vaginal, anal, or oral sex
• Incubation period: 1 to 3 weeks
39. Chlamydial Infections
Etiology and Pathophysiology
• Risk factors
•
•
•
•
•
Women and adolescents
New or multiple sexual partners
History of STDs and cervical ectopy
Coexisting STDs
Inconsistent/incorrect use of condoms
46. Chlamydial Infections
Clinical Manifestations
• Women (cont’d)
• PID
• Abdominal pain, nausea, vomiting, fever,
malaise, abnormal vaginal bleeding,
menstrual abnormalities
• Can lead to chronic pain and infertility
47.
48. Chlamydial Infections
Diagnostic Studies
• Laboratory tests
• Nucleic acid amplification test (NAAT)
• Direct fluorescent antibody (DFA)
• Enzyme immunoassay (EIA)
• Testing for other STDs
• Culture for chlamydia
49. Chlamydial Infections
Treatment & Nursing Care
• Drug therapy
• Doxycycline (Vibramycin)
• 100 mg BID for 7 days
• Azithromycin (Zithromax)
• 1 g in single dose
• Alternatives include erythromycin, ofloxacin
(Floxin), or levofloxacin (Levaquin)
50. Chlamydial Infections
Treatment & Nursing Care cont’d
• Abstinence from sexual intercourse for 7 days after
treatment
• Follow-up care for persistent symptoms
• Treatment of partners
• Encourage use of condoms
51. Chlamydia
• Prevention: limit the number of sexual partner & use
condoms & spermicides
What are the Nursing Implications?
52. Genital Herpes
• Not a reportable disease in most states
• True incidence difficult to determine
• Caused by herpes simplex virus (HSV)
53. Genital Herpes
Etiology and Pathophysiology
• Enters through mucous membranes or breaks in
the skin during contact with infected persons
• HSV reproduces inside cell and spreads to
surrounding cells
54. Genital Herpes
Etiology and Pathophysiology
• Two different strains
• HSV-1
• Causes infection above the waist
• HSV-2
• Frequently infects genital tract and perineum
• Either strain can cause disease on mouth or
genitals
55. Genital Herpes
Clinical Manifestations
• Primary (initial) episode
• Burning or tingling at site
• Small vesicular lesion appear on penis, scrotum,
vulva, perineum, perianal areas, vagina, or cervix
56. Genital Herpes
Clinical Manifestations
• Primary (initial) episode (cont’d)
• Primary lesions present for 17 to 20 days
• New lesions sometimes continue to develop for
6 weeks
• Lesions heal spontaneously
58. Genital Herpes
Clinical Manifestations
• Recurrent genital herpes (cont’d)
• Prodromal symptoms of tingling, burning, itching
at lesion site
• Lesions heal within 8 to 12 days
• With time, lesions will occur less frequently
59. Genital Herpes
Complications
• Aseptic meningitis
• Lower neuron damage
• Autoinoculation to extragenital sites
• High risk of transmission in pregnancy with
episode near delivery
• Herpes simplex virus keratitis
61. Genital Herpes
Diagnostic Studies
• History and physical examination
• Viral isolation by tissue culture
• Antibody assay for specific HSV viral type
62. Genital Herpes
Treatment & Nursing Care
• Drug therapy
• Inhibit viral replication
• Suppress frequent recurrences
• Acyclovir (Zovirax)
• Valacyclovir (Valtrex)
• Famciclovir (Famvir)
• Not a cure but shorten duration, healing time and
reduce outbreaks
63. Genital Herpes
Treatment & Nursing Care cont’d
• Symptomatic care
•
•
•
•
•
•
•
Genital hygiene
Loose-fitting cotton underwear
Lesions clean and dry
Sitz baths
Barrier methods during sexual activity
Drying agents
Pain: dilute urine with water, local anesthetic
64. Genital Herpes
• Treatment: use Betadine on lesions to dry &
prevent secondary infections, however,
Acyclovir (Zovirax) eases symptoms &
lessens reoccurrence but is not a cure
• If Untreated: in fetus/newborns there is a risk
of spontaneous abortion; neonatal herpes;
mental retardation, death
• Prevention: limit number of sexual partners
and using condoms & spermicidal foam may
reduce transmission
Nursing Implications?
65. Genital Warts
• Most common STD in the US
• Often asymtomatic so patient maybe unaware of
infection
• Caused by human papillomavirus (HPV)
• Usually types 6 and 11
• Highly contagious
• Frequently seen in young, sexually active adults
66. Genital Warts
Etiology and Pathophysiology
• Minor trauma causes abrasions for HPV to enter
and proliferate into warts
• Epithelial cells infected undergo transformation and
proliferation to form a warty growth
• Incubation period 3 to 4 months
67. Genital Warts
Clinical Manifestations
• Discrete single or multiple growths
• White to gray and pink-fleshed colored
• May form large cauliflower-like masses
68. Genital Warts
Clinical Manifestations
• Warts in men: penis, scrotum, around anus, in
urethra
• Warts in women: vulva, vagina, cervix
• Can have itching with anogenital warts & bleeding
on defecation with anal warts
69. Genital Warts
Diagnostic Studies
• Serologic and cytologic tests
• HPV DNA test to determine if women with
abnormal Pap test results need follow-up
• Identify women who are infected with high-risk
HPV strains
70. Genital Warts
Diagnostic Studies
• Primary goal: Removal of symptomatic warts
• Removal may or may not decrease infectivity
• Difficult to treat
• Often require multiple office visits and variety of
treatment modalities
71. Genital Warts
Treatment & Nursing Care
• Chemical
• Trichloroacetic acid (TCA)
• Bichloroacetic acid (BCA)
• Podophyllin resin
• For small external genital warts
• Patient managed
• Podofilox (Condylox.Condylox gel0
• Imiquimod (Aldara)
• Immune response modifier
72. Genital Warts
Treatment & Nursing cont’d
• If warts do not regress with previously mentioned
therapies
• Cryotherapy with liquid nitrogen
• Electrocautery
• Laser therapy
• Use of α-interferon
• Surgical excision
73. Genital Warts
Treatment & Nursing Care cont’d
• Recurrences and reinfection possible
• Careful long-term follow-up advised
• Vaccine to prevent cervical cancer, precancerous
genital lesion, and genital warts due to HPV
74. CMV - Cytomegalovirus
• Found is saliva, urine, semen, and vaginal
secretions
• symptoms include pharyngitis, malaise,
fever and lymphadenopathy, heterophil
antibody negative, blood smears may
show atypical lymphocytes
• may be fatal to those patients with AIDS
76. Trichomoniasis
• Symptoms:
• Most men with
trichomoniasis do
not have signs or
symptoms;
• some men may
temporarily have an
irritation inside the
penis, mild
discharge, or slight
burning after
urination or
ejaculation.
77. Trichomoniasis
• Symptoms
• frothy, yellow-green vaginal
discharge with a strong odor
• discomfort during intercourse and
urination,
• irritation and itching of the female
genital area.
• lower abdominal pain
• Incubation: 4 to 10 days
79. Trichomoniasis
• Infectivity: The vagina is the most
common site of infection in women, and
the urethra (urine canal) is the most
common site of infection in men.
• The parasite is sexually transmitted
through penis-to-vagina intercourse or
vulva-to-vulva (the genital area outside
the vagina) contact with an infected
partner.
• Women can acquire the disease from
infected men or women, but men
usually contract it only from infected
women.
80. Trichomoniasis
• Treatment: Trichomoniasis can usually be cured with
the prescription drug, metronidazole, given by mouth
in a single dose.
• If Untreated: increases a woman's susceptibility to
HIV infection if she is exposed to the virus.
• Pregnant women with trichomoniasis may have babies who
are born early or with low birth weight (less than five
pounds).
• Prevention: limit number of sexual partners and
using condoms & spermicidal foam may reduce
transmission
Nursing Implications?
81. Nursing Care : STD
Nursing Diagnoses
• Risk for infection RT ?
• Anxiety RT ?
• Ineffective health maintenance
RT ?
82. Ethical/Legal Implications
• In your opinion, what is the best way to
balance the needs of an individual patient
with STD with those of the general public?
84. Means of transmission
• Of the 10,514 HIV positive cases reported from 1984 to
2013, 92% (9,637) were infected through sexual contact,
4% (420) through needle sharing among injecting drug
users, 1% (59) through mother-to-child transmission,
<1% (20) through blood transfusion and needle prick
injury <1% (3). No data is available for 4% (375) of the
cases.
85. • Cumulative data shows 33% (3,147) were infected
through heterosexual contact, 41% (3,956) through
homosexual contact, and 26% (2,534) through bisexual
contact.
• From 2007 there has been a shift in the predominant
trend of sexual transmission from heterosexual contact
(20%) to males having sex with other males (80%)
86. • Overseas workers from the Philippines (e.g., seafarers,
domestic helpers, etc.) account for about 20 percent of
all HIV/AIDS cases in the country.
87. HIV (Human Immunodeficiency Virus)
AIDS (Acquired Immunity Deficiency Syndrome)
• HIV is NOT the same as having AIDS, it is
only the virus that causes AIDS.
• Currently there is NO cure but drug therapies
"show great promise in managing HIV
infection".
• "HIV infected people are healthy and do not
realize they have been infected. HIV
primarily infects certain white blood cells that
manage the operation of the immune system.
88. HIV (Human Immunodeficiency Virus)
AIDS (Acquired Immunity Deficiency Syndrome)
• Eventually, the virus can disable the immune
system, leaving the person with HIV infection
vulnerable to a number of life-threatening
illnesses.
• People who have HIV infection may not have
symptoms for many years, especially if they
receive good medical care and effective
therapies" (American College Health
Association [ACHA] , 2001).
89. HIV (Human Immunodeficiency Virus)
AIDS (Acquired Immunity Deficiency Syndrome)
• "When symptoms do develop, they are usually similar
at first to those of common minor illnesses, such as
the "flu", except that they last longer and are more
severe.
• Persistent tiredness, unexplained fevers, recurring
night sweats, prolonged enlargement of the lymph
nodes, and weight loss are all common.
90. HIV (Human Immunodeficiency Virus)
AIDS (Acquired Immunity Deficiency Syndrome)
• People with HIV infection can transmit the
virus to others - even if they have no
symptoms and even if they do not know they
have been infected.
• HIV can be transmitted (1) by sexual contact
(anal, vaginal, & oral); (2) by direct exposure
to infected blood; and (3) from an HIVinfected woman to her fetus during pregnancy
or childbirth, or to her infant during
breastfeeding" (ACHA, 2001).
91. HIV (Human Immunodeficiency Virus)
AIDS (Acquired Immunity Deficiency Syndrome)
• Prevention:
• "make careful choices about sexual activity,
• communicate assertively with your sexual partner
and negotiate for safer sexual practices,
• remove alcohol and drugs from sexual activity,"
and
• "use latex condoms for intercourse" (ACHA,
2001).
Notes de l'éditeur
Autoinoculation is the spread of an infection from one site to another
Women more likely then men d/t environment in vagina – microscopic tears
Any child with an STD should be considered a victim of sexual abuse.
McKinney: adolescents at greater risk d/t:
Frequent unprotected intercourse – lack knowledge of methods of preventing
Biologically more susceptible to infection?
Face multiple obstacles to access to health care
Use of drugs & ETOH increases risk for unsafe & unprotected sex.
Advocate: AAP stance “educating adolescents about sex does not increase sexual activity.”
STIs can be transmitted by any sexual activity between opposite-sex or same-sex partners
Having 1 STI does not confer immunity against that one or any others
Sexual partners need to be assessed for treatment
Youths and Geriatric patients may not be suspected/believed to be sexually active/promiscuous so health care provider may not screen them.
Lower soc/economic peoples have less education concerning risk to exposures to diseases/access to medical care/Ins/money for perscriptions/other risky behaviors etoh/drugs lower good judgement ability and inhibitions
From Black et al, pg. 973
High-risk sexual activity:
Use of prostitutes
Mult. Or casual partners, esp. w/IV drug abuse
Unprotected sex
Poverty: affects all socio-economic groups, cultures, ethnicities, & age groups, but poverty often prevents access to healthcare.
“Half of all new HIV infections in the US occur among young people between the ages of 13 and 24” (AAP, 2001)
Male homosexuals, sexually active heterosexuals, younger adolescents who are sexually active, IV drug users (McKinney et al pl 1034)
Sterility
Neurologic damage
Ophthalmic infection
Gonorrhea (newborn innoculation, self-innoculation
Cancer
Death
Assess: risky behaviors leading to unwanted/planned pregnancy? Aware of STI’s? Consequences of pregnancy/single parent/care giver burden/finances/family supports?
Abortion: neither “side” wants it used as a contraception
You do not believe in abortion: can you be forced to care for someone who has just had one?
Mucosa with columnar epithelium is susceptible to G.
Present in genitalia, rectum, and oropharynx
Characterized by redness and edema of cervix with discharge
FOR NEWBORNS:
Prophylactic instillations of erythromycin (.5%) or silver nitrate to newborn’s eyes are usually implemented
Men
Presumed to be infected if urethral discharge follows a sexual contact with an infected partner.
Gram-stained discharge from penis provides certain diagnosis
Culture of discharge from men whose smears are negative but with symptoms
Women
Smears and discharge do not establish diagnosis
Female GU tract harbors organisms resembling N. gonorrhea
Must have culture to confirm diagnosis
Other tests:
Nucleic acid amplification test like culture
Testing for other STDs
Others
Cefixime (Suprax)
Levofloxacin (Levaquin)
Ciprofloxacin (Cipro)
Patients with coexisting syphilis are likely to be cured by same drugs
Gummas
Destructive skin, bone, soft tissue nodular lesions
Cardiovascular system
Aneurysms, heart valve insufficiency, and heart failure
Neurosyphilis
General paresis, speech disturbances, tabes dorsalis
Scarring of aortic valve results in insufficiency and eventually failure
Neurosyphilis causes degeneration of brain with mental deterioration. Neurologic deficits possible.
Tabes dorsalis cause nerve involvement
Serological testing:
Nonspecific antitreponemal tests – VDRL, RPR
Specific treponemal tests – FTAaAbs, T. pallidum
Recurring or persistent symptoms after drug therapy are re-treated
Monitor neurosyphilis with periodic serologic testing, clinical evaluation, and repeat CSF exams for 3 years
Still underreported because infected persons are asymptomatic
THESE are the most common tests done:
Nucleic acid amplification test (NAAT)
Direct fluorescent antibody (DFA)
Enzyme immunoassay (EIA)
The cervical discharge tend to be be less purulent and painful in chlamydia than in gonorrhrea.
Chlamydial infections can be easily treated once diagnosed.
See Table 32-1, p. 868
Virus enters peripheral or autonomic nerve endings
Ascends to sensory or autonomic nerve ganglion where it is dormant
Genetal herpes infections tend to be benign but some complications may be present
Lower motor damage can lead to :
Atonic bladder
Impotence
Constipation
Autoinoculation to extragenital sites
Lips, breasts, and fingers
High risk of transmission in pregnancy with episode near delivery
Active lesion is indication for cesarean section
Herpes simplex virus keratitis - HSV infection of the eye
Resolves within 1 to 2 weeks
Can progress to ulcers
p 869
A member of the herpes virus family, it is mainly aquired as an infection in childhood and carried for life in a latent form. The infection typically remains quiet until the T-lymphocyte-mediated immunity is compromised. CMV is transmitted through blood to blood and intimate contacts and organ transplants and is found in saliva, breast milk, urine and semen.
Trichomoniasis can usually be cured with the prescription drug, metronidazole, given by mouth in a single dose. The symptoms of trichomoniasis in infected men may disappear within a few weeks without treatment. However, an infected man, even a man who has never had symptoms or whose symptoms have stopped, can continue to infect or re-infect a female partner until he has been treated. Therefore, both partners should be treated at the same time to eliminate the parasite. Persons being treated for trichomoniasis should avoid sex until they and their sex partners complete treatment and have no symptoms. Metronidazole can be used by pregnant women.
Having trichomoniasis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection.
The genital inflammation caused by trichomoniasis can increase a woman's susceptibility to HIV infection if she is exposed to the virus. Having trichomoniasis may increase the chance that an HIV-infected woman passes HIV to her sex partner(s).
The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.
Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of trichomoniasis.
Any genital symptom such as discharge or burning during urination or an unusual sore or rash should be a signal to stop having sex and to consult a health care provider immediately. A person diagnosed with trichomoniasis (or any other STD) should receive treatment and should notify all recent sex partners so that they can see a health care provider and be treated. This reduces the risk that the sex partners will develop complications from trichomoniasis and reduces the risk that the person with trichomoniasis will become re-infected. Sex should be stopped until the person with trichomoniasis and all of his or her recent partners complete treatment for trichomoniasis and have no symptoms.
p 869
Risk for infection RT lack of knowledge re mode of disease transmission, inadequate personal and genital hygiene,
Anxiety RT impact of disease outcome and lack of knowledge of disease
Ineffective health maintenance RT lack of knowledge re disease process, appropriate follow up measures
HCW have an obligation to maintain confidentiality unless there is a risk to the health or life of a third party.
