Module 7: STIs Flashcards
Diff Kinds of Infections
Bacterial infections
Chlamydia
Gonorrhea
Syphilis
Parasitic/protozoan
infections
Trichomoniasis
Viruses
Genital herpes
HIV
Hepatitis B and C
HPV
Molluscum
Chlamydial Infections
Etiology and Pathophysiology
Most common STI in the United States
~1.6 million new cases/year; increased incidence
Etiology and pathophysiology
Caused by Chlamydia trachomatis
Gram-negative bacterium
Intracellular pathogen
Transmitted through exposure to sexual fluids; ejaculation not necessary
1 - 3 week incubation period
Reinfection possible even after treatment
Most common site in men—urethra (urethritis)
Most common site in women—cervix (cervicitis)
Anyone can get anal and/or oropharynx infections
Serotypes: lymphogranuloma venereum (LGV) and
nongonococcal urethritis (NGU)
Often asymptomatic
Men
* Pain with urination (dysuria) or urethral discharge
* Rare: testicular pain or swelling
Women
* Mucopurulent vaginal discharge, abnormal vaginal bleeding, dysuria, pain with intercourse
Rectal
* Anorectal pain, discharge or bleeding, anal pruritus,
tenesmus, mucus-coated stools, or painful BMs
Throat
* Asymptomatic or sore throat
Chlamydial Infection
Complications
Men
Epididymitis can cause infertility
Women
Pelvic inflammatory disease (PID)
* Increased risk of ectopic pregnancy, infertility, and chronic
pelvic pain
* Risk of PID increases with repeated infections
Rare: reactive arthritis
Autoimmune response to infection with C. trachomatis
Chlamydial Infections
Diagnostic Studies
Sexual history, physical exam, lab tests
*Nucleic acid amplification testing (NAAT); used to
identify small amounts of DNA or RNA in test samples
* Endocervical or vaginal swabs (women)
* Urethral swabs (men)
* Urine (both)
* Rectal and oropharyngeal screening and diagnosis
Chlamydial Infections
Interprofessional Care
Regular screening in high-risk populations
Drug therapy
Doxycycline twice a day for 7 days
Alternates: erythromycin, ofloxacin, or levofloxacin
Patient education
All sexual contacts within 60 days should be
evaluated and treated
Abstain from sex for 7 days after treatment or until all
partners have been treated an abstained for 7 days
High rate of recurrence of infection
* Review risk reduction methods
* Return for repeat testing 3 months after treatment to
ensure cure or detect reinfection
* Teach patients to return with persistent or recurrent
symptoms
Must treat sexual partner(s) to avoid “ping-pong”
effect – treatment, re-exposure, reinfection
CDC recommends expedited partner therapy
(EPT); provide drugs or prescription without exam
* Not recommended for MSM; high risk for coinfection
* Not recommended for symptomatic women due to risk of PID
Gonococcal Infections
Etiology and Pathophysiology
Second most common reportable STI
Incidence increasing; reported 600,000 cases/year;
estimates of actual # around 1.6 million
Caused by Neisseria gonorrhoeae
Gram-negative diplococcus bacterium
Transmitted by exposure to sexual fluids; ejaculation
not necessary
Incubation period 1 to 14 days
Prior infection does not provide immunity to subsequent reinfection
Most common site
Men—urethra
* Dysuria, purulent discharge, epididymitis
Women—cervix
* Increased vaginal discharge, dysuria, frequency of urination, bleeding after sex
All persons- infection in rectum and oropharynx
Gonococcal Infections
Clinical Manifestations
Symptoms of rectal gonorrhea
Mucopurulent rectal discharge or bleeding, pain,
pruritus, tenesmus, mucus-coated stools, painful
bowel movements
Symptoms of oropharyngeal gonorrhea
Few, if any symptoms
Some have a sore throat
Gonococcal Infections
Complications
Men often seek treatment early due to symptoms;
less likely to develop serious complications
* Epididymitis can cause infertility
Women often asymptomatic; serious complications
from lack of care
* Infection in Bartholin’s or Skene’s glands
* PID can cause ectopic pregnancy infertility, chronic
pelvic pain
Neonates can develop gonococcal conjunctivitis
(ophthalmia neonatorum)
From exposure to an infected mother during delivery
Can result in permanent blindness
Almost all states require prophylactic treatment for
newborns so it is rare
STI Gender Considerations
Men
Syphilis, gonorrhea more
common, especially in MSM (men having sex with men)
More likely have symptoms of
genital infection
Genital infection results in
fewer complications
Easier to diagnose – less
complex anatomy
Less likely to seek medical
care unless symptomatic
Women
Anatomy increases risk for
STIs
Less likely to show early signs
of genital infection
Trichomoniasis and herpes
simplex type 2 more common
Screened for, thus more likely
to be diagnosed with HPV
Have more frequent and
serious complications related
to STIs
Gonococcal Infections Diagnostic Studies
History and physical exam
Lab tests
Gram stain smears
Culture
NAAT
Testing for other STIs
Treatment
Drug therapy
Often started before test results return
N. gonorrhoeae has developed resistance to many
classes of antibiotics
First-line treatment: high-dose IM ceftriaxone
* Do sensitivity testing on patients who persistently test
positive
Patient education: treat all sexual contacts within last
60 days; abstain from sexual contact for 7 days;
return for repeat testing in 3 months
Trichomoniasis (“trich”)
Caused by a protozoan parasite, Trichomonas
vaginalis
Common in United States; 2.6 million
Often overlooked; better testing methods have
improved detection
Much more common among women than men
* Particularly among women with HIV
Transmitted by exposure to sexual fluids; ejaculation
not necessary
Incubation period—1 week to 1 month or longer
Infection provides no protection to future reinfection
Most common site for infection
Men—urethra
Women—cervix
Uncommon to infect rectum
Not known to infect oropharynx
Routine screening for high risk women is
recommended
Trichomoniasis
Clinical Manifestations
Most asymptomatic
Men: burning with urination or ejaculation or urethral
discharge
Women: painful urination, vaginal itching, painful
intercourse, bleeding after sex, or yellow-green
discharge with a foul odor
* Exam: “strawberry” appearance of cervix
Trichomoniasis Complications
Inflammation and irritation in genital track if left
untreated
Makes a person more likely to acquire or
transmit another STI, particularly HIV
Associated with PID in women with HIV
Trichomoniasis Diagnostic Studies
NAAT testing of vaginal or endocervical
secretions or urine
Culture
Point-of-care testing
Direct visualization of trichomonads under a
microscope
Trichomoniasis
Interprofessional Care
Drug therapy
Metronidazole (Flagyl) or tinidazole (Tindamax)
* Abstain from sex for 7 days after treatment; and all
partners abstained
* Treat all sexual partners within past 60 days
* Return with persistent or recurrent symptoms
* Use barrier methods
* Repeat testing in 3 months
STIs
STIs characterized by genital lesions or ulcers
Genital herpes infections
Genital warts
Syphilis
Genital Herpes Infections
Life-long, incurable infection
Very common, treatable
Two strains
Herpes simplex virus type 1 (HSV-1)
Herpes simplex virus type 2 (HSV-2)
* 18.6 million in US infected
* Rate of infection twice as high among women
* Hispanic and black persons more likely infected
Most new infections transmitted by someone who
does not know they are infected
Genital Herpes Infections
Etiology and Pathophysiology
Virus
Enters through mucous membranes or breaks in skin
during contact with an infected person
Virus reproduces inside cell and spreads to
surrounding cells
Virus then enters peripheral or autonomic nerve
endings and ascends to the sensory or autonomic
nerve ganglion near infection site where it becomes
dormant
Reactivation (recurrence or outbreak) may occur
when virus descends to initial site of infection
HSV-1 and HSV-2
Transmission occurs through direct contact when an
infected individual is symptomatic
Asymptomatic viral shedding occurs without
symptoms being apparent
* Impossible to predict when this will occur or for how
long
* HSV-2 more likely to shed than HSV-1
Formerly
HSV-1 mainly associated with oral lesions (“cold
sores” or “fever blisters”)
HSV-2 associated with anogenital disease
Currently
HSV-1 or HSV-2 can cause genital, anal, or orolabial
infections
Rare to have HSV-2 infection of the mouth
HSV-1 infections
More common “above the waist”
* Gingivae, dermis, upper respiratory tract
* Rarely, the CNS
HSV-2 infections
Almost always occurs “below the waist”
* Genital tract, perineum, or anus
Having 1 type does not protect against getting the
other
Genital Herpes Infections
Clinical Manifestations
Primary episode
Incubation period: 2 to 12 days
Primarily asymptomatic; if symptoms occur, follow
stages:
* Prodromal stage
Period before lesions appear
Burning, itching, tingling may occur at site of inoculation
Primary episode—stages
Vesicular Stage
* Few to multiple small , painful vesicles appear on buttocks, inner thigh, penis, scrotum, vulva, perineum, perianal region, vagina, or cervix
* Contain large quantities of infectious particles
Ulcerative stage
* Lesions rupture and form shallow, moist ulcerations
Final stage
* Spontaneous crusting and epithelialization of erosions occur
Genital Herpes Infections
Primary Episode
Process from prodrome to healing varies and may
take up to 3 weeks
Local inflammation and pain
Regional lymphadenopathy
Systemic flu-like symptoms
Urination may be painful
Autoinoculation can occur if active lesions are
touched or scratched
Genital Herpes Infections and Recurrent Episodes
Recurrence can occur in year following primary
episode
Symptoms are less severe
Lesions usually heal more quickly
HSV-1 genital infections recur less frequently than
HSV-2 infections
* Over time, both decrease in frequency
Common triggers
Stress, fatigue, sunburn, general illness,
immunosuppression, menses, local trauma at site of
infection
* May experience prodromal symptoms
Greatest risk for transmitting infection exists when
active lesions are present
* Possible to transmit virus when no visible lesions or
symptoms are present
* Majority of HSV transmission occurs during
asymptomatic periods
Herpes Infections Complications
Rare but serious complications
Blindness, encephalitis, and aseptic meningitis
Autoinoculation may cause extragenital lesions
Genital ulcers increase risk of acquiring HIV
HSV lesions can be more severe and persistent in
HIV-infected patients
Can be transmitted from mom to baby during birth
Highest risk during primary episode
Can infect skin, eyes, mouth, CNS
Significant morbidity and mortality when disseminated
An active genital lesion is usually an indication for
cesarean delivery
Can have an impact on psychologic well-being,
relationships, and sexual lives
Teach patients how to talk to sexual partners
Refer for counseling
Help patients understand treatment options and
management of condition
* Non-life-threatening
Genital Herpes Infections
Diagnostic Studies
Diagnosis
History and physical exam
* Self-report; confirmation by visual exam
Viral isolation by tissue culture
* Cultures of lesion can differentiate between HSV-1 and
HSV-2
Antibody assay for HSV type
* Don’t show site of infection
* Usually appear by 12 weeks after exposure
Genital Herpes Infections
Interprofessional Care
No cure for HSV infection
Antiviral medications can
* Shorten duration of viral shedding
* Shorten healing time of lesions
* Reduce frequency of outbreaks by 80%
Treatment should be started before diagnostic
confirmation
* Reduces duration of ulcers
* Reduces risk of transmission
Three antiviral agents—inhibit viral replication
Acyclovir (Zovirax) – IV for very severe infections
Famciclovir (Famvir)
Valacyclovir (Valtrex)
Prescribed for primary and recurrent infections
Can be used daily as suppressive therapy for
anogenital recurrences
Reduce but not eliminate risk of transmission to
others
Patient education
Identify triggers
Active outbreak: good hygiene; loose, cotton
undergarments; abstinence until lesions healed
Keep lesions clean and dry
Pour water on perineum during urination to reduce
pain
Local anesthetics: lidocaine gel
Analgesics
Ice packs
Genital Warts
Condylomata acuminata
Caused by human papillomavirus (HPV)
About 100 types of HPV; 40% sexually transmitted
High-risk strains cause cancers of genital tract, anus,
or oropharynx
* 90% of genital and anal warts are caused by HPV types 6 and 11
* Types 16 and 18 cause 70% of cervical cancer, most anal and some throat cancers
Most sexually active people will be infected at some
point in their lives
Not reportable in most states
Genital Warts
Etiology and Pathophysiology
HPV is transmitted:
Skin-to-skin contact mostly during vaginal, anal, or
oral sex; nonpenetrative transmission possible
Incubation period ranges from weeks to months to
years
Infection with 1 type of HPV does not prevent
infection with another type
Basal epithelial cells infected with HPV undergo
transformation and proliferation to form a warty
growth
HPV is transient
Resolves spontaneously usually after 1 to 2 years
Can persist when warts or no longer visible after
treatment
Unclear if removal of warts clears, cures, or reduces
transmission of the virus
Genital Warts
Clinical Manifestations
Most asymptomatic; unaware
Genital or anal warts—single or multiple papillary
growths
May grow and coalesce to form large, cauliflower-like
masses
Most patients have few lesions
Growths may be pink, pink-flesh colored, or
hyperpigmented (depends on skin type
Men
Warts on penis and scrotum, in or around anus, or in
urethra
Women
Warts on inner thighs, vulva, vagina, cervix,
perineum, internal or external anus
Anogenital warts—itchy
Anal warts—bleeding with defecation
Characteristic lesions diagnosis
Testing should be done to rule out other conditions
(e.g., syphilis, cancer, benign growth)
Biopsy required for definitive diagnosis
Genital Warts
Complications
Few long-term complications
HPV strains that cause warts do not cause cancer
Certain high-risk strains (types 16 and 18) can lead to
cancer of cervix, vagina, vulva, penis, anus, or oropharynx
Psychosocial burden
* Cosmetic appearance and long treatment course
Pregnancy—warts grow rapidly and increase in size
Genital Warts
Interprofessional Care
May be possible to eradicate HPV types if all youths
are vaccinated
9-valent vaccine (Gardasil 9) available in US
Protects against types 6, 11, 16, 18 plus 5 other
high-risk HPV types
Given in 2-3 IM doses over a 6-month period
Few side effects
CDC recommends all 11-12 year-olds be vaccinated
Can start at age 9 up to age 26
Recently approved for ages 27-45 who are at risk
Vaccine protects against strains causing 90% of
anogenital warts and cervical cancers; also penile,
anal and throat HPV-related cancers
Does not treat active HPV infection
Ideally, vaccination should occur before the start of
sexual activity or before the potential for infection
Genital Warts Treatment
Primary goal of treatment—removal of symptomatic
warts
Chemical methods (in office)
* Trichloroacetic acid (TCA) or bichloroacetic acid (BCA)
Ablative methods
* Laser, electrocautery, or cryotherapy
Patient applied topical treatments
* Podofilox liquid and gel, imiquimod cream, or
sinecatechin ointment
Treatment may or may not decrease infectivity; does not destroy virus, just infected tissue
Modify treatment if no improvement or if can’t tolerate side effects
Local alpha-interferon injections or surgical excision may be needed
Recurrence and reinfection are possible
Long-term follow-up is advised
Syphilis
Sexually transmitted bacterial infection
Can cause serious long-term complications if not
effectively treated
In United States, over 35,000 cases reported annually
* Likely 150,000 cases due to undiagnosed infections
* Incidence increasing significantly
Prevalent population affected
* MSM with highest rates among MSM of color
Syphilis Etiology
Caused by Treponema pallidum (bacterial spirochete)
Transmission direct contact with chancre (syphilitic
ulcer) or through mucosa of infected person
Genitals, anus, lips, vagina, rectum, mouth or tongue
* Incubation period averages 21 days but can range from 10 to 90 days
Infection does not provide protection from reinfection
Syphilis can be transmitted from an infected
pregnant woman to her fetus
High risk for stillbirth or complications after birth
* Seizures
* Death
Incidence of congenital syphilis in US has risen
185% since 2014
Syphilis
Clinical Manifestations
“The Great Imitator”—mimics a number of other
diseases
More difficult to recognize; delays treatment
Progresses to specific clinical stages
Can take weeks to years to progress through all
stages
Stages of Syphilis
Primary
Highly infectious
Duration 3 to 6 weeks
Single or multiple chancres
* Unnoticed if internal
Regional lymphadenopathy
Exudate and blood from chancre are highly infectious
Secondary
Highly infectious; occurs a few weeks after primary
chancre heals
Duration 1 to 2 years
* Systemic flu-like symptoms
* Mucous patches in mouth, tongue or cervix
* Symmetric, nonpruritic, maculopapular rash on palms,
and/or soles, and trunk or extremities
Even without treatment, rash will resolve but patient still has syphilis and is infectious
May be other systemic symptoms
Final stage - tertiary or late syphilis
No obvious symptoms
Organ damage is silently occurring over many years
Gummas can lead to serious complications
* Inflammatory tumor-like response to syphilis
* Gummas cause irreparable damage to skin, bone, liver
* Cardiovascular aneurysm, aortic valve insufficiency, HF
* Neurosyphilis—invasion of CNS
Impaired vision, tabes dorsalis, dementia (all are rare)
Syphilis
Complications
Chancres on or inside genitalia or anus enhance
HIV transmission
Patients with HIV and syphilis are at greatest risk for
significant CNS involvement; need more intensive
treatment than others
Syphilis
Diagnostic Studies
Blood tests for screening and staging infection/ensuring
effective treatment
Detect antibodies to T. pallidum
FTA-Abs test – fluorescent treponemal antibody absorption test
TP-PA test – T. pallidum particle agglutination test
EIA test – syphilis qualitative enzyme-linked immunoassay
Remains positive even after treatment so cannot be used to detect reinfection
Nontreponemal tests detect antibodies not specific
for syphilis
VDRL and RPR tests
Positive 10 to 14 days after chancre
When positive or “reactive” test will read as a titer and
increase exponentially
* Continue to climb during primary and secondary stages of infection
* Fall back to negative or “non-reactive” several months
after treatment
False-negative and false-positive tests can occur
During primary syphilis if done before antibodies are
produced
If patients have other diseases
* Positive screening tests are always confirmed
* Once a person has tested positive, test may remain
positive in spite of successful treatment
