Chapter 76: Care of Patients with Sexually Transmitted Disease

Question 1

Chancre

Answer 1

The ulcer that is the first sign of syphilis. It develops at the site of entry of the organism, usually three weeks after exposure. It may be found on any area of the skin or mucous membranes but occurs most often on the genitalia, lips, nipples, and hands and in the oral cavity, anus, and rectum

Question 2

Chancroid

Answer 2

A sexually transmitted disease characterized by painful genital ulcerations and caused ny infection with Haemophilus ducreyi. Infections develop as a result of sexual exposure or self contamination from a lesion elsewhere on the body. Incubation period varies from 3 to 10 days. A tender papule appears at the site of the innoculation and rapidly breaks down to form an irregularly shaped, deep ulcer that has purulent discharge and bleeds easily

Complications include ovarian infection or penile infection, urethral fistulas. They differ from syphilis in that they are soft and painful. Transmission is by contact with the ulcer or discharge during sexual activity. Uncircumcised men are greater risk, and men get it more than women.

Treated with Zithromax, Rocephin, Cipro, or erythromycin.

Question 3

Expedited partner therapy

Answer 3

Therapy used to treat chlamydia in which patients are given a drug or prescription with specific instructions for administration to their partners without direct evaluation by a healthcare provider; also called patient delivered partner therapy

Question 4

Genital herpes

Answer 4

An acute, reoccurring, incurable viral disease of the genitalia caused by the herpes simplex virus and transmitted by contact with an infected person. An outbreak typically is preceded by tingling sensation of the skin followed by the appearance of vesicles on the penis, scrotum, vulva, perineum, vagina, cervix, or perianal region. The blisters rupture spontaneously, leaving painful erosions. After the lesions heal, the virus remains dormant, periodically reactivating with a recurrence of symptoms. Lesions usually last 2-6 weeks. May also have headache, fever, malaise, lymph nodes, painful urination

Most common STD in US.
HSV-1 cold sores, non genital
HSV-2 most of genital lesions

Incubation 2-20 days, Symptoms usually severs during first infection. Recurrences are not as severe. Recurrence may be triggered by stress, fever, sunburn, poor nutrition, menses, sex,

Neonatal transmission, Increased risk for HIV

Question 5

granuloma inguinale

Answer 5

And ulcerative disease at the genital area that appears as a painless nodule

Question 6

Pelvic inflammatory disease

Answer 6

Any infection of the pelvis involving the upper genital tract beyond the cervix in women. It occurs when organisms from the lower genital tract migrate from the endocervix upward through the uterine cavity into the fallopian tubes. Infections include endometritis, salpingitis, oophoritis, parametritis, peritonitis, tubal or ovarian abscess. Infections spread during intercourse, childbirth, or abortions. Sepsis and death can occur.

Causes infertility, ectopic pregnancies,

Manifestations include a low dull abdominal pain, mild discomfort, menstrual irregularity, irreversible scarring, abnormal vaginal bleeding, dysuria, change in discharge, dyspareunia (pain sex), malaise, fever, chills. Diagnosis is difficult because of the lack of manifestations.

Question 7

salpingitis

Answer 7

Infection of the fallopian tubes

Question 8

Syphilis

Answer 8

A complex sexually-transmitted disease that can become systemic and cause serious complications and even death. It is caused by the spirochete treponema pallidum which is found in the mouth, intestinal tract, and genital areas of people and animals. The infection is usually transmitted by sexual contact, but can occur through close body contact and kissing.

Increasing in the Black and hispanic population.

Question 9

Stages of syphilis

Answer 9

Primary: appearance of a chancre (usually about 3 wks after exposure). It starts as a small papule and breaks down into a painless, indurated, smooth, weeping lesion. Regional lymph nodes enlarge, firm, but not painful. Will disappear in about 6 wks without treatment, but has spread through the body and is still infectious.

Secondary: From six weeks to six months. Systemic disease with manifestations such as malaise, low-grade fever, headache, muscular aches and pains, sore throat, generalized rash. They are often mistaken for the flu. The rash involves the hands and feet. The rash is highly contagious, should not be touched without gloves, and usually goes away in 4 to 12 weeks without treatment.

Latent: Early latent occurs during the first year and lesions can recur. Late latent is over a year. This stage is not infectious except to the fetus of a pregnant woman. There serologic test may or may not be reactive.

Tertiary: From 4 to 20 years. Can mimic any pathologic condition because any organ can be infected. Manifestations include the benign lesions of the skin, mucous membranes, and bones. Cardiovascular syphilis in the form of a aorta valvular disease and aortic aneurysms. Neurosyphilis causing CNS problems such as meningitis, hearing loss, generalized paresis.

Question 10

Treatment of Syphilis

Answer 10

Specimen of chancre for darkfield microscope. Repeat in 3 days if negative
Blood tests: VDLR, RPR that test antibodies which are reactive 2-6 weeks after. Not specific. HIV test. If blood is positive, order more specific tests.

Drug therapy
Benzathine penicillin G, IM, single 2.4 million U dose for primary, secondary, and early latent. Every 7 days for 3 weeks for late latent.

Keep pt in office of 30 minutes to assess for allergy (rash, edema, SOB, chest tightness, anxiety). If pt has never had PCN, perform a skin test first.

Follow up at 6,12, and 24 months and repeat pcn if needed.

Partner notification and prophylactic treatment.

Question 11

Jarisch-Herxheimer reactiion

Answer 11

Reaction to antibiotic therapy from syphilis when the release of products from the disruption of the cells. Generalized aches, pains at the injection, vasodilation, hypotension, and fever. Begin within two hours and peaks around 4 to 8 hours. Treat with analgesic and antipyretics.

Question 12

Nursing diagnosis for patients with sexually transmitted disease

Answer 12

Risk for injury. Ineffective coping. Noncompliance. Sexual dysfunction. Impaired skin integrity. Ineffective health maintenance. Impaired social interaction. Acute pain. Anxiety. Chronic low self-esteem.

Question 13

Treatment of genital herpes

Answer 13

Viral culture within 48 hours of first lesion. Obtain fluid from inside the blister.
PCR or CSF if central nervous system involvment
POCkit rapid test

Antivirals: do not cure, bur reduce the severity. Take them 7-10 days for primary, and 5 days for recurrence.

Analgesics, topical anesthetic, sitz bath, increase fluids;

If more that 6 occurences in 1 year, may need suppressive therapy

Severe with encephalitis may need IV acyclovir

Always condom, no sex when lesions present

Neonatal infection.

Question 14

Condylomata Acuminata (genital warts)

Answer 14

Caused by HPV, type 6 or 11, which rarely cause cancer
Types 16, 18, 31,33, and 35 are high risk and can cause cancer. May have several types. HPV infection is thought to be the primary risk factor for development of cervical cancer. Sites commonly infected include the urinary meatus, labia, vagina, cervix, penis, scrotum, anus, and Perenial area. Incubation is 2 to 3 months.

Small papillary growths that grow into large cauliflower like masses. Bleeding may occur if the wart is disturbed. They may heal on their own without treatment.

Pap test and HPV DNA probe
VDLR, HIV, cultures for chlamydia and gonorrhea are done to rule out other STDs

Question 15

Treatments for condylomata acuminata (genital warts)

Answer 15

Patient applied: podofilox (condylox) .5% bid for 3 days. Rest for 4 days, repeat for four cycles.
imiquimod (aldara) 5% cream at bedtime 3xweek for 16 wks

Provider applied:
Cryotherapy using liquid nitrogen every 1-2 wks
Podophyllin resin in benzoin, wash off 1-4 hours after
TCA-BCA acid weekly. With any of the above, they may have discomfort, bleeding, discharge, sloughing. Keep clean and dry. Watch for infection.
CO2 laser, intra-lesion interferon injections, surgical removal.

Recurrence is likely in first 3 months. Avoid sex if warts present. Condoms if not present. Annual pap. Test both pt and partner

Vaccine for females 9-26

Question 16

Gonorrhea

Answer 16

Bacterial infection, neisseria gonorrhoeae, transmitted by direct sexual contact with mucosal surfaces (vaginal, orogenital, anogenital) 3- 10 days, may be asymptomatic (more often in women).

Can cause: PID, endometritis, salpingitis, pelvic peritonitis, ectopic pregnancy, infertility, pelvic pain. Rare includes: arthrits, meningitis, hepatitis, disseminated infection.

Highest 15-24 years; 6x higher MSM

Men: dysuria, penile discharge (profuse yellowish green or scant clear), urethra infected but can go to prostate, seminal vesicles, and epididymis. Usually seek trtmnt earlier than women

Women: change in discharge (yellow green, profuse, odor), urinary frequency, dysuria. Cervix and urethra most common

Anal: itching and irritation, bleeding, diarrhea, painful defecation,
Mouth: red throat, ulcerated lips, tender gums, blisters on throat

Systemic (called DGI disseminated gonococcal infection: fever, chills, skin lesion on distal extremities, joint pain with possible swelling, heat and redness.

Resembles chlamydia

Question 17

Treatment of Gonorrhea

Answer 17

Molecular testing NAATs is sensitive and specific. Uses urine or vaginal swabs. Discharge for men with gram stain.

If positive, test for HPV, syphillis, chlamydia, Hep B and C, HIV
Test partners

Antibiotics (usually ones that treat chlamydia also)
Ceftriaxone(rocephin) 125 mg IM or
cefixime (suprax) 400 mg orally single
plus azithromycin (zithromax) 1 g orally single dose or
Doxycycline 100 mg orally bid for 1 week if chlamydia not ruled out.

Quinlones such as Ciprofloxacin and levofloxacin are no longer recommend

No need to test after, advise to return if symptoms reccur.

DGI hospitalization IV or IM ceftriaxone 1g q 24hrs followed by oral antibiotics for a week at home. Also for meningitis or endocarditis, but given more often and for longer

Question 18

Chlamydia Infection

Answer 18

Intracellular bacteria, invades epithelial tissues in the reproductive tract. 1-3 wks incubation. 16-24 years old, african, increasing in men,
Women: usually asymptomatic, Vaginal or urethral discharge (usually becomes yellow and opaque), dysuria, pelvic pain, irregular bleeding, urinary frequency, abdominal discomfort. Complications: salpingitis, PID, ectopic pregnancy, infertility.
Men: urethritis, mucoid watery discharge, dysuria, frequent urination. Complications: epididymitis, prosatitis, infertility, Reiters syndrome (CT disease).

Question 19

Treatment for Chlamydia

Answer 19

Culture of cells gold standard, NAAT, LCR, PCR, testing of urine is becoming more accepted.
Screen all women above 25, and under 25 if sex active.

Zithromax 1g orally single or
doxycycline 100mg bid for 7 days
If allergic to the above, use erythromycin, Ofloxacin, or levofloxacin.

partner therapy recommended. Abstain for 7 days from start of treatment, no test of cure, rescreen women 3-12 months later

Question 20

Risk factors for PID

Answer 20

younger than 26
multiple partners
IUD in place
smoking
history of PID 
chlamydia or gonorrhea
bacterial vaginosis
history of STDs

Question 21

Criteria for PID

Answer 21

Must be sexually active woman at risk for sexually transmitted diseases, must have pelvic or lower abdominal pain. Must not be able to find another cause such as appendicitis. They must also have uterine, adnexal, or cervical motion tenderness.

Additional: Fever about 101, abnormal discharge, presence of white blood cells on vaginal secretions, elevated ESR, elevated C reactive protein, documentation of chlamydia or gonorrhea.

Definitive Criteria:
endometritis, sonography that shows thickened tubes, laparoscopic abnormalities

Question 22

Treatment for PID

Answer 22

Test for gonorrhea and chlamydia. Test WBC, ESR, C-reactive protein.
Ultrasound to rule out appendicitis and ovarian abscesses. Endometrial biopsy.

Oral and-or parenteral antibiotics for 14 days. Hospitilization if does not respond to oral therapy. See pg 1750

Abstain from intercourse, check temperature twice a day, report an increase, check up 72 hours after antibiotic and 1 to 2 weeks after diagnosis.

Laporascope. Bed rest in semi fowlers position to encourage drainage.

Treat partner for gonorrhea and chlamydia.

Question 23

Nursing diagnosis for PID

Answer 23

Acute pain. Anxiety. Additional include ineffective health maintenance. Chronic pain. Sexual dysfunction, Low self esteem.

Outcomes include no pain, no fever, no infection

Question 24

Vaginal infection

Answer 24

Trichomonas vaginalis: must also treat partner

Candida: Only treat partner if he as it, can be from antibiotic use.

Bacterial vaginosis: upper genital tract infections.

Question 25

Lymphogranuloma venerum

Answer 25

The result of Chlamydia which friend systemically until localizes in the gentle or rectal lymph nodes. Primary lesion of the point of entry is transient, painless, and not noticed. Blisters, ulcers, or papules appear within 1-2 wks after primary. Lymphadenopath is more often in men than women. Swelling forms a characteristic groove sign. Manifestations include headache, malaise, arthralgia, and anorexia. It may cause fistulas, rectal strictures, enlarged lymph nodes, proctitis. Systemically : carditis, arthritis, pneumonia

Doxycycline 100mg po bid or
Erythromycin 500 mg po qid for 21 days.

May drain lymph nodes to prevent abcess.
Treat partner if sex contact within 60 days.

Question 26

Granuloma inguinale

Answer 26

klebsiella granulomatis. Nodule at site after inoculation for 1-2 weeks. Ulcerates and forms more. Painless, grow together, spread, can be mutilating. NO lymphadenopathy. The lesions are very vascular and bleed easily on contact. They appear necrotic, hypertrophic, and sclerotic. The open areas can become infected. This treated with doxycycline, Zithromax, ciprofloxacin, erythromycin. Treat for a minimum of three weeks until lesions are healed. Relapse may occur in 6 to 18 months.