SEXUAL HEALTH - STI's

• STI's

  • Curable: Syphilis (B), Gonorrhea (B), Chlamydia (B), Trichomoniasis (P)
  • Incurable: Hepatitis B (V), Herpes simplex virus (HSV), Human Immunodeficiency virus (HIV), Human papillomavirus (HPV)
• Epidemiology

  • Adolescents and Young Adults: Individuals aged 15-24 = 1/2 of all STI cases, 2 in 5 females have STI that can cause infertility or death, Adolescent males 80% of HIV dx in 13-19 y/o's
  • Some racial or ethnic minorities higher risk
  • Females more susceptible d/t anatomy: Columnar epithelial sensitive to invasion d/t lack of cervical mucus
  • Adolescents and young adults feel invincible -> engage in riskier behaviors, Tend to have unprotected intercourse, Have short-term relationships, Obstacles to health care
• Nursing Management

  Assess sexual behavior and STI risks, Recommend and perform screening, Discuss risk reduction, Convey willingness to discuss sexual health in a direct and non-judgmental way, Promote sexual health and wellness, Safe sex practices, STI screening, Completing treatment for any/all infections, Advocate for abstinence but educate for reality
• Vaginitis

  Inflammation and infection of the vagina
• Causes of Vaginitis

  • Candida – vaginal yeast, Gardnerella – bacterial vaginosis (BV), Trichomonas – protozoa (sexually transmitted)
• Bacterial Vaginosis (BV) and Yeast

  NOT STI but increases risk for STI's d/t inflammation
• Trichomonas


  Is sexually transmitted
• Vaginal Candidiasis


  One of the most common causes of vaginal discharge
• Symptoms of Vaginal Candidiasis

  • Pruritus, Thick, white, curd-like vaginal discharge, Vaginal soreness, vulvar burning, erythema in the vulvovaginal area, Dyspareunia (painful intercourse), External dysuria
• Treatment for Vaginal Candidiasis

  Fluconazole - is available OTC or prescription, OTC treatment is vaginal cream/suppository; 1,3-,and 7-day options, Prescription is single dose oral treatment
• Bacterial Vaginosis (BV)


  Most prevalent cause of vaginal discharge and odor, 50-75% are asymptomatic, Caused by change in vaginal pH, Lack of lactobacilli, High amounts anaerobic bacteria
• Increased risk for Bacterial Vaginosis

  • Preterm labor, PROM, Chorioamnionitis, Postpartum endometritis, PID – pelvic inflammatory disease
• Symptoms of Bacterial Vaginosis


  Not typically a/w redness, swelling, pain or other signs of inflammation, Increased watery discharge, Malodorous vaginal discharge; "fishy" odor, Sometimes irritation or discomfort
• Treatment for Bacterial Vaginosis

  With oral metronidazole, vaginal Metro-gel, or vaginal Clindamycin, Of male partners is not recommended
• Trichomoniasis


  Classified as vaginitis but is primarily sexually transmitted, Ovoid, single-cell protozoan parasite, Most prevalent NON-viral STI in the US, Can survive 15-20 minutes on surfaces and in poorly maintained hot tubs/drains
• Increased risk with Trichomoniasis

  • HIV in both men and women, Concomitant BV infection in women, Preterm birth and postpartum endometritis
• Symptoms of Trichomoniasis

  • May be asymptomatic, Increased, sometimes copious, thin yellow/green or gray, frothy discharge, Vaginal odor described as foul or fishy smell, Vaginal pruritus, Vulvar irritation and erythema, Dyspareunia, Cervix may be friable (bleed on contact), Cervical petechiae (strawberry cervix), Dysuria, Men are typically asymptomatic carriers
• Treatment for Trichomoniasis

  Metronidazole 2 grams in single oral dose, Expedited Partner Treatment (EPT) is recommended, Avoid intercourse for 7 days of treatment, Test of Cure (TOC): testing in 3-4 weeks after treatment to ensure infection cleared - NOT recommended, Follow up testing in 3-4 months to assess re-infection is recommended, especially in pregnancy
• Diagnosis of Candidiasis

  Diagnosis confirmed by: Microscopy (wet mount) – Gold-standard, Thick white clumpy discharge in vaginal vault and adhering to vaginal walls, Yeast hyphae and spores on wet mount
• Diagnosis of Bacterial Vaginosis and Trichomoniasis

  Bacterial Vaginosis requires 3 of 4 criteria (Amsel Criteria): Thin, white homogenous vaginal discharge, Vaginal pH of 4.5 or more, Positive "whiff test" – vaginal secretions mixed with 10% potassium hydroxide on a slide produces characteristic fishy odor, Presence of clue cells on wet-mount, Trichomoniasis: Motile flagellated trichomonad visualized on wet mount, Vaginal pH of 4.5 or more typical finding, FDA approved tests on vaginal swabs or urine
• Nursing Management for Candidiasis and Bacterial Vaginosis

  Primary prevention and education to limit recurrence, Assess lifestyle and sexual behaviors, Disrupt the vaginal pH, Reassure these are NOT STI's, No need to treat partners, Recurrence is common! Need to re-establish lactobacilli
• Cervicitis


  Implies inflammation or infection of the cervix, Symptomless erosions, Inflamed, friable cervix (bleeds with contact), Production of purulent discharge containing organisms not typically found in vagina, Treatment based on offending organism
• Chlamydia

  Most common bacterial STI, 3 million cases in the United States annually, Estimated 127 million cases globally, State reportable infection, Bacterial infection caused by chlamydia trachomatis, Often asymptomatic = untreated, Long-term consequences: Increased/prolonged opportunity for spread
• Symptoms of Chlamydia

  • Asymptomatic infection common in men and women, Men may develop urethritis, Women may have mucopurulent vaginal discharge, urethritis, endometritis, salpingitis, DUB, cervicitis, pelvic pain
• Consequences of untreated Chlamydia

  • Chronic pelvic pain, Ectopic pregnancy, Pelvic Inflammatory Disease (PID), Infertility, Ophthalmia neonatorum: mucopurulent conjunctivitis in newborns
• Management of Chlamydia

  Yearly screening of sexually active women 25 years and younger OR older high-risk women, All pregnant women, Doxycycline or azithromycin orally, Pregnant women need azithromycin, Partner should be treated, No intercourse for 7 days after treatment completed, TOC not recommended except in pregnancy, Unsure compliance w/ treatment, Symptoms persist, Suspected reinfection, Diagnosed with urine, vaginal or cervical swabs
• Gonorrhea


  Second most common STI in US, Becoming resistant to multiple treatments, 820 million new infections every year in the US, Neisseria gonorrhoeae, Aerobic gram-negative diplococcus, Infects mucosal surfaces, Sexually transmitted; passed to neonate during vaginal delivery, Ophthalmia neonatorum; erythromycin eye ointment at delivery, Diagnosed via urine or vaginal/endocervical swab
• Symptoms of Gonorrhea in women

  • 50-90% asymptomatic, Abnormal vaginal discharge; abnormal vaginal bleeding, Dysuria, Cervicitis, Enlarged lymph nodes locally, PID, Mild sore throat (for pharyngeal gonorrhea), Rectal infection (itching, soreness, bleeding, discharge), Perihepatitis
• Symptoms of Gonorrhea in men

  • Dysuria, Asymptomatic, White/yellow/green penile discharge, Painful/swollen testicles (less common)
• Consequences of untreated Gonorrhea

  • Neonatal conjunctivitis in newborns, Chronic pelvic pain, Pelvic inflammatory disease, In pregnancy: chorioamnionitis, premature labor, PROM, PP endometriosis
• Untreated Gonorrhea

  Enters bloodstream -> disseminated infection invades: Joints -> arthritis, Heart -> endocarditis, Brain -> meningitis, Liver -> toxic hepatitis
• Management of Gonorrhea


  Ceftriaxone IM injection, Zoliflodacin under development, Screening yearly if 25 or younger, 25 and older if new sex partner or mult sex partners, All pregnancies, TOC not recommended but retest in 2-3 months for re-infection
• Risk Factors for Gonorrhea and Chlamydia

  • Age 15-19 regardless of demographics or location, Having multiple sex partners, Having a new sex partner, Engaging in sex without a barrier (condom), History of another STI, Using oral contraceptives, Being pregnant
• Nursing Management for Gonorrhea and Chlamydia

  Assess lifestyle and sexual behaviors, Prevention, Stress importance of partner treatment, Educate no intercourse until patient and partner have COMPLETED treatment, Reinforce provider education
• Pelvic Inflammatory Disease (PID)

  Ascending infection-induced inflammation: Uterine lining – endometritis, Connective tissue adjacent to uterus – perametritis, Fallopian tubes – salpingitis, Serous membrane of abdominal cavity – peritonitis, Tubo-ovarian abscess, Over 1 million episodes of PID yearly, 100,000 become infertile, 1 in 8 difficulty conceiving, Significant cause of Infertility, Ectopic pregnancy, Chronic pelvic pain, Pelvic abscesses
• Diagnosis criteria for PID

  • Lower abdominal pain/tenderness, Adnexal tenderness, Cervical motion tenderness – this is usually severe, Abnormal cervical or vaginal mucopurulent discharge, Oral temperature above 101° F, N. gonorrhoeae or C. trachomatis infection, Abnormal menstrual bleeding, Dysmenorrhea, Dyspareunia (Painful sexual intercourse), Nausea/Vomiting
• Treatment for PID

  Outpatient: Ceftriaxone IM, Doxycycline PO (or azithromycin if pregnant or otherwise c/i), Metronidazole PO, Inpatient: IV antibiotics, Increased hydration – IV if necessary, Bed rest, Pain management, Possibly surgery (tubo-ovarian cyst)
• Genital Ulcers

  Typically caused by herpes, syphilis, or chancroid, Herpes most common, Increased risk for HIV, Some genital ulcers may not be STI's
• Genital Herpes Simplex

  Recurrent, lifelong virus, Affects 1 in 6 people aged 14-49, More common in women, Type 1: oral herpes – fever blisters, cold sores, Type 2 genital herpes – clustered blisters in genital area, Transmitted via direct contact of mucous membranes to virus, Kissing, sexual contact, vaginal birth, Replicates at site of contact, travels to dorsal root ganglia, Remains latent until triggered: Emotional stress, menses, sex, trauma to skin, or
• Symptoms of Primary Herpes Outbreak

  • Most severe – systemic disease; up to 2 weeks to resolve, Prolonged period of viral shedding, Clustered, open, weeping painful vesicular lesions, Mucopurulent discharge, Common to have superinfection with candida, Fever, Chills, Malaise, Headache, Dysuria, Genital pain and burning; Inguinal tenderness; Lymphadenopathy