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Sexually Transmitted Infections
NURS 541: Women
Healthcare –
Diagnosis and
Management
Sexually Transmitted Infections
 Interesting facts:
 At least 50% of Americans will contract an STI in their
lifetime
 Women are biologically more likely to get an STI than men
 Most STIs are asymptomatic
 Key factors for clinicians:
 Prevention, screening, detection, and treatment
Sexually Transmitted Infections
 2010 CDC STD guidelines
 http://www.cdc.gov/std/treatment/2010/
 Look for updated 2014/2015 guidelines soon! In process….
Sexually Transmitted Infections
 Comprehensive sexual health history
 Sexual practices
 sex with men, sex with women, etc.
 penetrative, receptive, vaginal, anal, oral, etc.
 Single partner, multiple partners
 Pay/get paid for sex
 IV drug use/partner with IV drug use hx
 Prevention practices
 Barrier use (male/female condoms, dental dams, gloves)
 Past history of STI
Sexually Transmitted Infections
 Screening recommendations
 Yearly screening for all individuals under the age of 26
 Chlamydia and gonorrhea specifically, others if indicated
 Prior to initiating a new sexual relationship
 Anyone with high risk sexual practices
 Anyone with concerns about STI exposure
 Anyone with concerning symptoms
Sexually Transmitted Infections
 Chlamydia
 Gonorrhea
 Pelvic Inflammatory
Disease (PID)
 Human Immunodeficiency
Virus (HIV)
 Herpes Simplex Virus (HSV)
 Condyloma Accuminata
 Syphilis
 Pediculosis pubis
 Hepatitis B Virus (HBV)
 Molluscum contagiosum
Chlamydia
Chlamydia
 Bacterial etiology – chlamydia trachomatis
 Most common STI in the U.S.
 Most commonly seen in younger persons (14-24 years of
age), persons of black race, and those with high risk sexual
practices
 For men, often culprit for nongonococcal urethritis (NGU)
Chlamydia
 Signs/symptoms
 Often asymptomatic
 Occasional spotting after intercourse, burning with urination
(onset of stream), dyspareunia, mucopurulent discharge
 Exam may show inflammation of the cervix (cervicitis)
 Lab testing
 Urine or cervical/vaginal NAAT
Chlamydia
 Management
 Primary treatment options
 Azithromycin 1gm orally x 1 dose
 Doxycycline 100mg orally BID x 7 days
 Treat patient AND partner(s)
 Screen for other STIs
 No intercourse x 7 days
 Retest in 3 weeks if indicated, and rescreen in 3 months for
recurrence
Gonorrhea
Gonorrhea
 Bacterial etiology – Neisseria gonorrhoeae
 Second most common STI in the U.S.
 Signs/Symptoms
 Often asymptomatic
 Occasionally mucopurulent/green/yellow discharge,
dyspareunia, labial irritation/swelling, vaginal/rectal pain.
May present as dysmenorrhea.
 May manifest in mouth or anus if exposure is that route
 Lab testing
 Urine, vaginal, or cervical NAAT
Gonorrhea
 Management
 Primary treatment options
 Ceftriaxone 250mg IM x 1 dose
 Cefixime 400mg orally x 1 dose
 PLUS chlamydia treatment
 Treat patient AND partner(s)
 No intercourse x 7 days
 Retest in 3 weeks not necessary, BUT plan to rescreen
in 3 months for recurrence
Pelvic Inflammatory Disease (PID)
Pelvic Inflammatory Disease
 Upper genital tract infection
 Potentially serious complication of chlamydia and
gonorrhea, but may be caused by other anaerobic
bacteria (BV)
Pelvic Inflammatory Disease
 History
 Risk factors for STIs (sexual health history)
 Any intrauterine procedure within last month (IUD
insertion, termination, dilation of cervix, etc)
 Review of symptoms
 Fever, chills, abdominal pain, pelvic pain, sx vaginal
infection
 Physical exam
 Abdominal tenderness
 Cervical motion tenderness, uterine/adnexal
tenderness
Pelvic Inflammatory Disease
 Lab testing
 Wet mount or DNA probe for vaginal infections
 Chlamydia/gonorrhea testing (CT/NG)
 Other testing if systemic symptoms – CBC, differential,
sed rate
 Differential
 Any other potential cause for symptoms?
 Ovarian torsion, endometriosis, pregnancy,
inflammatory bowel disease, acute appendicitis
Pelvic Inflammatory Disease
 Need to determine if candidate for out-patient therapy!
 Primary Management
 Ceftriaxone 250mg IM x 1
 PLUS doxycycline 100mg BID x 7 days
 WITH OR WITHOUT metronidazole 500mg BID x 7 days
 Pelvic rest
 Rescreen for CT/NG/BV in 3-6 months
Syphilis
Syphilis
 Bacterial infection – Treponema pallidum
 Three distinct stages
 Primary (3-90 days after exposure)
 Chancre with positive lymphadenopathy
 Secondary (4-10 weeks after exposure)
 Papular rash/skin lesions (hands/feet)
 Systemic illness symptoms (fever, malaise, myalgias)
 Tertiary (years after exposure)
 Cardiovascular complications
 Skin lesions
 Neurosyphilis (can occur at any stage)
Syphilis
 If untreated in primary/secondary phases:
 Latent phase
 Early (≤1 year)
 Late (> 1 year)
 May be sexually transmissible through the first year
(through early latent phase)
Syphilis
 History
 Sexual health history, risky behaviors, exposures
 Exam
 Look for lymphadenopathy, presence of chancre or skin
lesions on genitalia
 Lab testing
 Screening: Nontreponemal antibody tests (VDRL, RPR)
 Confirmatory: Treponemal tests (FTA-ABS, TP-PA)
Syphilis
 Management
 Primary, secondary, early latent
 Benzathine penicillin G 2.4 million units IM x 1 dose
 Late latent or tertiary
 Benzathine penicillin G 7.2 million units, given as 3 individual
doses of 2.4 million units IM q 1-2 weeks
 Treat patient AND partner(s)
 Test for other STIs
 Retesting at 6, 12, 24 month intervals
Hepatitis B Virus (HBV)
Hepatitis B Virus (HBV)
 Infection etiology – DNA virus
 Blood, bodily fluids, vertical transmission routes
 Signs/Symptoms
 Largely asymptomatic (> 50%)
 Fever, arthralgias, nausea/vomiting, fatigue, anorexia,
abdominal pain, jaundice, clay-colored stool, dark urine
 Present on average 90 days after exposure
Hepatitis B Virus (HBV)
 Lab testing
 HBsAg (Hep B Surface Antigen)
 detects active infection
 Anti-HBs (Hep B Surface Antibody)
 detects immunity from vaccination or previous infection
 Anti-HBc (Total Hep B Core Antibody)
 Detects previous or ongoing (chronic) infection
 IgM anti-HBc (IgM antibody to Hep B Core Antigen)
 Indicates acute infection within past 6 months
Hepatitis B virus (HBV)
CDC, 2010
Hepatitis B virus (HBV)
 Management/Prevention
 Hepatitis B vaccination
 Anyone at risk for STI or treated for an STI
 All children < 19 years of age
 Medically-at-risk individuals
 Those with definite exposure to Hepatitis B may receive
HBIG (Hepatitis B immunoglobulin) within first 24 hours
after exposure to reduce transmission
 Referral to liver or infectious disease specialist
appropriate
Human Immunodeficiency Virus (HIV)
Human Immunodeficiency Virus (HIV)
 Incurable viral infection – RNA retrovirus
 Blood, bodily fluids, vertical transmission routes
 Signs/Symptoms
 Largely asymptomatic in early phases
 Late signs of immunocompromise
 Lab testing
 Screening: HIV ELISA/EIA tests (enzyme immunoassay tests)
 Confirmatory: Western blot or IFA (immunofluorescence
assay)
Human Immunodeficiency Virus (HIV)
 Screening
 CDC recommends:
 Pre-test counseling
 Testing
 Post-test counseling
 Screen/offer testing for HIV whenever performing other
STI tests
 Treatment
 Referral to an infectious disease specialist warranted
for anti-retroviral (ARV) treatment
Herpes Simplex Virus (HSV)
Herpes Simplex Virus (HSV)
 Recurrent, incurable viral infection
 HSV-1 usually transmitted non-sexually
 Most often cold sores/fever blisters
 Potentially up to 80% of people carry HSV-1 virus
 HSV-2 usually transmitted through sexual contact
 Most often genital sores
 Approximately 15-30% of people carry HSV-2 virus
 Approximately 50% of those infected with HSV-1 or HSV-2
have never had symptoms
Herpes Simplex Virus (HSV)
 Signs/Symptoms
 Primary outbreak: painful vesicular-like lesions, sometimes
with flu-like symptoms, inguinal lymphadenopathy, vulvar
edema, vaginal discharge, dysuria, cervicitis
 New lesions may present over a period of 10 days
 Lesions take 4-15 days to crust over and heal
 Recurrent outbreaks: lesions that are less painful in same
area as primary outbreak, localized symptoms
 Lesions usually last 7-10 days
 Prodromal symptoms are common: tingling, burning,
sensitivity in area of lesion activity
Herpes Simplex Virus (HSV)
 Physical exam
 Temperature/vital signs
 Lymph node assessment
 Careful inspection of external genitalia, vagina, cervix,
perineum
 NOTE: speculum exams are very difficult!
Herpes Simplex Virus (HSV)
 Lab testing
 Specimen collection at site of lesion
 HSV viral culture
 HSV PCR
 Serology testing
 Type-specific HSV serology (IgG)
 Culture/PCR positive, yet type-specific serology negative:
primary infection
 Culture/PCR positive, and type-specific serology positive:
recurrent infection
Herpes Simplex Virus (HSV)
 Treatment options
 Primary infection
 Acyclovir 400mg orally TID x 7-10 days (or 200mg 5x/day)
 Famcyclovir 250mg orally TID x 7-10 days
 Valacyclovir 1gm orally BID x 7-10 days
 Recurrent infection
 Acyclovir 400mg orally TID x 5 days (or 800mg BID x 5 days)
 Famcyclovir 125mg BID x 5 days (or 1000mg BID x 1 day)
 Valacyclovir 500mg orally BID x 3 days (or 1gm QD x 5 days)
 Suppressive therapy
 Acyclovir 400mg orally BID, Famcyclovir 250mg orally BID
 Valacyclovir 500mg or 1gm orally QD
Condyloma Accuminata
Condyloma Accuminata
 Caused by human papillomavirus (HPV)
 Most genital warts are caused by low risk strains (6, 11)
 As many as 75% of people exposed to genital warts will
develop them
 Signs/Symptoms
 Flat, flesh colored, wart-like bumps in genital area
 May have itching, vaginal discharge, irritation
Condyloma Accuminata
 Physical Assessment
 Thorough inspection of genital area, including vulva, vagina,
cervix, perineum, anus
 Diagnosis is by visual identification
Condyloma Accuminata
 Treatment options
 Expectant management – most resolve within 1 year
 Patient-applied modalities
 Podofilox 0.5% solution or gel, Imiquimod 5% cream (Aldara),
or Sinecatechins 15% cream (Veregen)
 Provider-applied modalities
 Cryotherapy applied q 1-2 weeks until gone
 Podophyllin resin 10-25%
 Trichloroacetic acid (TCA) or bichloracetic acid (BCA)
 Surgical excision
 Prevention
 Quadrivalent HPV vaccine protects against strains 6 & 11
Pediculosis Pubis
Pediculosis Pubis
 A parasitic infection caused by Pediculosis pubis, or pubic
lice (“crabs”)
 The pubic variation of lice most often inhabits the pubis,
but may be found in other hair-growing areas of the body
 Signs/Symptoms/History
 Pruritis, especially in genital area
 Seeing lice on skin or clothes
 Report of family member or partner with lice
Pediculosis Pubis
 Physical exam
 Thorough assessment of hair-growing areas of body
 Rule out other causes of pruritis: eczema, seborrheic
dermatitis, folliculitis, tinea cruris, scabies
 Treatment options
 Permethrin 1% cream rinse, applied to affected areas and
washed off after 10 minutes
 Wash all bed linens, clothing, toys, towels in hot water and
dry on hot cycle
Molluscum Contagiosum
 Viral infection common in children;
in adults usually sexually
transmitted
 Small painless bumps in genital
region, often with induration
 Treatment options
 Expectant management
 Cryotherapy, scraping, laser
therapy options
Prevention is Paramount!
 Keys to patient counseling on STIs
 Provide facts
 Don’t assume
 Encourage testing if any concerns
present
 Encourage protection, safer sex