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Chapter 49
Sexually Transmitted
Infections
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
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Learning Objectives
• List infectious diseases classified as sexually transmitted
infections.
• Explain the importance of the nurse’s approach when
dealing with patients who have sexually transmitted
infections.
• Describe tests used to diagnose sexually transmitted infections
and the nursing considerations associated with each.
• Explain why specific sexually transmitted infections must
be reported to the health department.
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Learning Objectives
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Describe the pathophysiology, signs and symptoms,
complications, and medical treatment for selected sexually
transmitted infections.
Design a teaching plan on the prevention of sexually
transmitted infections.
List nursing considerations when a patient is on drug
therapy for a sexually transmitted infection.
Identify data to be collected when assessing a patient
with a sexually transmitted infection.
Assist in developing a nursing care plan for a patient with
a sexually transmitted infection.
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Sexually Transmitted Infections (STIs)
• Serious public health problem in the United States
despite medical advances
• Spread primarily through sexual contact and may have
serious and permanent consequences
• Some people resist taking preventive measures
• Infected people do not always inform sexual partners;
disease continues to be passed on
• Nurses must be aware of their feelings about working
with people who have STIs
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Diagnostic Tests and Procedures
• Serologic tests
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Hepatitis A, B, C, D, and E
Syphilis
Human immunodeficiency virus (HIV)
Herpes simplex
Cytomegalovirus
• Smears and cultures
• Discharge and exudate from lesions can be collected and
studied to determine the exact infecting organism
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Reporting STIs
• Confirmed cases of HIV, AIDS, gonorrhea, syphilis,
chlamydia, chancroid, and viral hepatitis must be
reported to the local health department
• Investigator asks patient to name sexual contacts
• Those individuals contacted and advised that they
have been exposed to the disease and encouraged to
seek medical evaluation
• Process is to identify and treat infected people so
transmission of disease can be slowed
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Chlamydial Infection
• Most common bacterial STI in the United
States
• Estimated 2.8 million diagnosed each year
• Organism virus-like bacterium Chlamydia
trachomatis; infects men and women
• Transmitted by contact with the mucous
membranes in the mouth, eyes, urethra, vagina,
or rectum
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Chlamydial Infection
• Signs and symptoms
• Most people have no symptoms
• Males: penile discharge; painful or frequent
urination
• Females: vaginal discharge, painful urination,
nausea, fever, painful intercourse, bleeding between
menstrual periods, and lower abdominal pain
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Chlamydial Infection
• Complications
• Sterility
• Risk of ectopic pregnancy is increased
• Women with chlamydia are approximately 5 times
more like to become infected with HIV if exposed to
it
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Chlamydial Infection
• Medical diagnosis and treatment
• Laboratory studies
• Chlamydia antigen test
• Cell tissue culture
• Treated with a single dose of azithromycin (Zithromax) or 7day course of doxycycline (Vibramycin)
• Repeat culture in 4-7 days; confirms successful treatment
• Patient to avoid all sexual contact (genital, oral, anal) until
cured
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Gonorrhea
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Commonly reported STI in the United States
Most often through direct sexual contact
Caused by Neisseria gonorrhoeae
Affects pharynx, rectum, urethra, prostate,
epididymis, uterus, and fallopian tubes
• With systemic (disseminated) infection: heart,
joints, skin, and meninges
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Gonorrhea
• Signs and symptoms
• Many people have no symptoms
• Males: whitish or greenish discharge from penis; often a
burning sensation during urination
• Females: vaginal discharge, redness and swelling of the
external genitalia, a burning sensation during urination,
abdominal pain, or abnormal menstruation
• Rectal infection: discharge, anal itching, soreness, bleeding, or
painful bowel movements
• Throat infections: usually no symptoms, but sore throat
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Gonorrhea
• Complications
• Sterility in both sexes and infections may lead to damage to
heart tissue and joints
• Males may develop epididymitis and prostatitis
• Females may develop pelvic inflammatory disease (infection of
the ovaries, fallopian tubes, pelvic area)
• Medical diagnosis
• Health history and physical examination findings as well as
laboratory analysis of exudate from infected body parts or
urinalysis
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Gonorrhea
• Medical treatment
• Single dose of IM ceftriaxone (Rocephin), oral
cefixime (Suprax), ciprofloxacin (Cipro), ofloxacin
(Floxin)
• If concurrent chlamydial infection, initial drug
followed with 7 days of oral doxycycline
(Vibramycin)
• Erythromycin ophthalmic ointment for the newborn
to prevent eye infection caused by exposure to
gonococci during delivery
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Syphilis
• Caused by microscopic organism, a spirochete
(coiled bacterium) called Treponema pallidum
• Organism transmitted by sexual contact; also
spread through breaks in skin
• Also passed through the placenta, thus
causing an infant to be born with the disease
(congenital syphilis)
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Syphilis
• Signs and symptoms
• Primary stage
• Chancre: first sign of syphilis
• Reddish papule appears where the organism entered the
body, usually on genitals, anus, or mouth
• Within a week, papule becomes a painless red ulcer
• Lymph nodes near chancre enlarged but not tender
• Chancre may last from 1 to 5 weeks
• When it disappears, patients assume they are cured, but in
fact organism has moved into the blood
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Figure 49-1
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Syphilis
• Signs and symptoms
• Secondary stage
• Occurs 1 to 6 months after contact
• Rash on extremities, chest or back, palms, soles
• Pustules containing highly contagious material often
develop
• Fever, sore throat, and generalized aching
• Patient contagious during first and second stages
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Syphilis
• Signs and symptoms
• Latent stage
• There are no symptoms
• Organisms are invading major organs
• Disease is not spread by sexual contact during the latent
stage but may be transmitted by blood exposure
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Syphilis
• Signs and symptoms
• Late stage
• Generally 3 years after contact before late syphilis
develops, although it may be decades
• Arthritis, numbness of the extremities, ulcers of the skin
and internal organs, and pain due to damage to the heart,
blood vessels (especially the aorta), spinal cord, or brain
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Syphilis
• Complications
• Blindness, mental illness, paralysis, heart disease
• Easier for a person to contract HIV
• Medical diagnosis
• Physical examination findings
• Venereal Disease Research Laboratory (VDRL) test and rapid
plasma reagin (RPR) test
• Fluorescent treponemal antibody absorption test (FTA-ABS)
and the microhemagglutination test
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Syphilis
• Medical treatment
• Parenteral penicillin G, unless contraindicated
• Advise follow-up appointment with physician to see
whether treatment was effective
• Advise not to engage in sexual activity until 1 month
after completing treatment for primary or secondary
syphilis
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Herpes Simplex
• Cold sores
• Caused by herpes febrilis or herpes simplex virus 1
(HSV-1)
• Transmitted through contact with open lesions,
usually on the lips or inside the mouth
• Genital herpes
• Caused by herpes simplex virus 2 (HSV-2)
• Vaginal or anal intercourse and oral-genital contact
but also can be by hand contact
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Herpes Simplex
• Signs and symptoms
• Painful, itching sores on or around the genitals approximately
2 to 20 days after infection
• Symptoms last about 2 to 3 weeks
• Rash appears first, then small blisters that ulcerate
• Complaints of flulike symptoms and a burning sensation during
urination
• Active symptoms may recur; frequently precipitated by anxiety
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Figure 49-2
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Herpes Simplex
• Complications
• Increased risk of cervical cancer
• Obstetricians recommend cesarean sections for
infected women who have active lesions to
decrease risk of transmission to the baby
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Herpes Simplex
• Medical diagnosis and treatment
• Diagnosed by
• Appearance of genital lesions
• Exudate from lesions examined under a microscope and
cultured
• Herp-Check
• No cure for HSV infection, but oral antivirals
acyclovir (Zovirax), valacyclovir (Valtrex), or
famciclovir (Famvir) partially control signs and
symptoms
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Trichomoniasis
• Caused by the protozoan parasite
Trichomonas vaginalis
• Usually sexually transmitted
• Parasite can survive for hours on damp cloths
and clothing
• CDC estimates 7 million new cases per year
• Affects vagina in women, urethra in men
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Trichomoniasis
• Signs and symptoms
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Frothy, yellowish discharge that has a foul odor
Vaginal irritation and itching
Urinary frequency/burning: infection in urethra
Chronic infection: bladder and anal involvement
• Men
• Usually no symptoms; a mild discharge or slight burning
after urination or ejaculation
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Figure 49-3
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Trichomoniasis
• Medical diagnosis and treatment
• Detected by microscopic study of vaginal discharge
or urine (in males)
• Discharge can be cultured to reveal organism
• Metronidazole (Flagyl) is drug of choice
• Important that patient and sexual partners be
treated at the same time to avoid reinfection
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Condylomata Acuminata
(Genital Warts)
• Caused by the human papillomavirus
• Affect genital, anal regions of men and women
• Transmission by vaginal, anal, or genital
contact
• Incidents of transmission from people who had
no visible signs of infection
• Incubation period: 3 weeks to 8 months
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Condylomata Acuminata
(Genital Warts)
• Signs and symptoms
• Males
• Glans, foreskin, urethral opening, penile shaft, or scrotum
• Females
• In/around vulva, vagina, cervix, perineum, anal canal, urethra
• Also on labia, deep within the vaginal canal and endocervix
• Homosexual and bisexual men and women who engage in
anal intercourse, common in anal area
• Oral, pharyngeal, and laryngeal lesions as well
• Warts are generally pink or red and soft, with a cauliflower-like
appearance
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Figure 49-4
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Condylomata Acuminata
(Genital Warts)
• Medical diagnosis
• Observation of the warts
• Biopsy necessary to make a definitive diagnosis
• Medical treatment
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No cure
Removal provides symptomatic relief
Application of podofilox or imiquimod by the patient
Cryotherapy, topical trichloroacetic acid or podophyllin resin,
surgical removal, and injection of interferon into the lesions
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Bacterial Vaginosis
• Caused by Gardnerella vaginalis and other anaerobic
bacteria
• Infectious bacteria emerge when normal bacteria in
vagina are suppressed
• Associated with having multiple sex partners and
douching; unclear if actually transmitted sexually
• Signs and symptoms
• Genital irritation and itching, thin gray discharge, and a fishy
odor, but some women report no symptoms
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Bacterial Vaginosis
• Diagnosed by microscopic examination of the
discharge fluid and by culture
• Treated with metronidazole (Flagyl)
administered orally or vaginally or clindamycin
vaginal cream
• Combination of alcohol and metronidazole may
trigger a disulfiram-like reaction, with vomiting,
tachycardia, and hypotension
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Human Immunodeficiency Virus
Infection
• HIV gradually destroys T4 lymphocytes, which are
essential for resisting pathogens
• As lymphocytes decline, patient increasingly
susceptible to opportunistic infections
• Opportunistic infection thrives when immune system is
impaired
• When immune system ceases to function, patient has
acquired immunodeficiency syndrome (AIDS)
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Care of the Patient with a
Sexually Transmitted Infection
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Assessment
• History of present illness
• Patient’s reason for seeking medical care. With an STI,
common reasons: pain, fever, lesions, or genital discharge.
Obtain a thorough description of the signs and symptoms,
including onset, duration, and severity
• Past medical history
• Serious conditions or chronic illnesses; obstetric history may
be significant
• If childbearing age, date of last menstrual period
• Recent/current medications and drug allergies
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Assessment
• Review of systems
• Elicits potentially significant signs and symptoms,
including weight change; fever; weakness; fatigue;
skin rashes or lesions; oral lesions; dysuria; whether
the patient is sexually active; pain, lesions, or lumps
in the genitals; vaginal or penile discharge; and
altered sexual functioning
• A history of blood transfusions is important
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Assessment
• Functional assessment
• Frequency and variety of sexual behaviors, IV drug use, past
infections with STIs, and sexual contact with a person known
to have an STI
• Determine if classified as at risk because age, sexual
preference, or habits place patient at a higher risk for acquiring
STI
• Victims of sexual abuse (of all ages) may have been exposed
to STIs
• Occupation significant if contact with infected body fluids
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Physical Examination
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Skin for rashes and lesions
Mouth is inspected for lesions
Neck palpated for enlarged lymph nodes
Abdomen is inspected for distention and
palpated for tenderness
• Depending on your specialized education, you
may examine the genitals or assist the
physician/nurse practitioner with examination
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Physical Examination
• In cases of sexual assault, it is especially
important that the examiner be specially
trained
• If discharge present, its color, amount, and
consistency are recorded. Specimens may be
collected for laboratory study
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Interventions
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Impaired Skin Integrity
Pain
Risk for Injury
Anxiety
Situational Low Self-Esteem
Impaired Social Interaction
Sexual Dysfunction
Ineffective Coping
Ineffective Therapeutic Regimen Management
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Condom Use
• Condoms do not provide 100% protection
against disease transmission
• Latex preferred because some pathogens can
pass through natural membrane condoms
• Protect from heat and sunlight to keep them
from deteriorating
• Do not use condoms that are brittle, discolored,
or in damaged packages
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Condom Use
• Use only water-based lubricants; others can
cause condom to break; spermicides may be
used
• To put a condom on, hold it by the tip and
unroll it onto the penis. Leave a space of about
1 inch at the tip for semen
• Withdraw penis carefully after ejaculation to
keep condom from slipping off and spilling the
contents and to avoid unprotected contact
• Always discard used condoms
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