57
Sexually Transmitted Infections
Daniel P. Worrall
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Infection Reproduction
Pain Sexuality
LEARNING OUTCOMES
1. Identify factors contributing to sexually transmitted 4. Explain the interprofessional care and treatment of
infections (STIs) in the United States. chlamydia, gonorrhea, trichomoniasis, genital herpes,
2. Describe the etiology, clinical manifestations, genital warts, and syphilis.
complications, and diagnostic studies for chlamydia, 5. Discuss the assessment for patients who have an STI.
gonorrhea, trichomoniasis, genital herpes, genital warts, 6. Describe the nursing management of patients with STIs.
and syphilis. 7. Summarize the nursing role in the prevention and control
3. Compare and contrast primary genital herpes with of STIs.
recurrent genital herpes.
KEY TERMS
chlamydial infections sexually transmitted infections (STIs)
genital herpes syphilis
genital warts trichomoniasis
gonorrhea
Sexually transmitted infections (STIs) are infectious diseases scratching an infected area and transferring it to another part
that spread through sexual contact with the penis, vagina, anus, of the body). STIs cannot typically be transmitted from casual
mouth, or sexual fluids of an infected person. Many do not view contact or inanimate objects.
STIs as a serious health threat because most are easily treated.
However, complications of STIs are serious. They can include
infertility and cancer. Having an STI can affect a person’s
FACTORS AFFECTING INCIDENCE OF STIs
well-being, their relationships, and their sexual lives. Patient Rates of STIs in the United States are at an all-time high.
education, counseling, and referrals are essential nursing roles According to recent data, 26 million new infections are diag-
for promoting health and optimal sexual well-being. nosed in the United States each year. STIs affect 1 in 5 adults
Mucosal tissues in the genitals (urethra in men, vagina in and result in $16 billion in health care costs.1 Although all sex-
women), rectum, and mouth are especially susceptible to the ually active persons are at risk, some populations have a greater
bacteria and viruses that cause STIs. A list of common STIs is burden of infection. Socioeconomic factors, decreased condom
shown in Table 57.1. Some STIs, such as human papillomavi- use, and cuts to STD programs across the country are contribu-
rus (HPV), can spread from direct skin-to-skin contact with an tors.2 Having one STI can increase the risk for getting another. It
infected person. Other STIs, such as human immunodeficiency is also possible for a person to have more than one STI at a time.
virus (HIV), may be contracted via blood products, semen, All STIs have an incubation period. It is the time from initial
or vaginal secretions or be transmitted from mother to baby infection to the time when symptoms first appear or screen-
during pregnancy or labor and delivery. Some STIs can spread ing tests for the infection are positive. This can lead to the
through autoinoculation (spread of infection by touching or transmission of disease from an asymptomatic (but infected)
1395
,1396 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
TABLE 57.1 Causes of STIs TABLE 57.2 Risk Factors for STIs
STI Cause High-Risk Behaviors
Bacterial Infections • Alcohol or substance use (inhibits judgment)
Chlamydial Chlamydia trachomatis • Having new sexual partners
Gonorrhea Neisseria gonorrhoeae • Having more than 1 sexual partner
Syphilis Treponema pallidum • Having sexual partners who have/have had multiple partners
• Inconsistent or incorrect use of condoms or other barrier methods
Viral Infections • Exchanging sex for money, shelter, or other needs
Genital herpes Herpes simplex virus (HSV 1 or 2)
Genital warts (condylomata Human papillomavirus (HPV) High-Risk Medical History
acuminata) • Having 1 STI is a risk factor for getting another
Human immunodeficiency virus Human immunodeficiency virus (HIV) (see • Not being vaccinated for STIs or other infections that may be transmitted
infection (HIV) Chapter 15) through some forms of sexual activity (HPV, hepatitis A and B)
Hepatitis B and C Hepatitis B and C viruses (see Chapter 48) • Receiving multiple courses of non-occupational postexposure prophylaxis
Molluscum Molluscum contagiosum to prevent HIV infection
Parasitic/Protozoan Infection High-Risk Populations
Trichomoniasis Trichomonas vaginalis • Adolescents and young adults (under age 25)
• Ethnicity/race (e.g., Black, American Indian/Alaskan Native, Native
Hawaiian/Other Pacific Islander, Hispanic)
• MSM
person to another person, even before any signs or symptoms
• Persons in correctional facilities
begin.
• Transgender women
In the United States, all cases of gonorrhea, chlamydia, and • Victims of sexual assault
syphilis must be reported to public health authorities for sur- • Women
veillance purposes for federally funded control programs and
partner notification. Surveillance and partner notification are
a major part of the effort to prevent and control the spread of
STIs. Nurses and other HCPs play a vital role. They are man-
dated to report STIs to public health authorities. Despite this BOX 57.1 PROMOTING HEALTH
requirement, only a small number of infections are reported. EQUITY
This means that the cases of gonorrhea, chlamydia, and syphi- STIs
lis reported in the United States annually do not represent the
actual number of infections. Incidence of STIs
Many factors contribute to the high rate of STIs.2 Earlier • Depending on their age and gender, Black persons have
reproductive maturity and increased longevity make for a • The highest number of chlamydial infections
• More than 50% of cases of gonorrhea
longer sexual life span. Other factors include greater sexual
• Nearly 35% of cases of syphilis
freedom, individual sexual behaviors, the media’s increasing • More than 40.4% of congenital syphilis cases
emphasis on sexuality without mentioning safer sex, and sexual • A higher seroprevalence of herpes simplex type 2
network characteristics. Alcohol and substance use can further • Hispanic persons
contribute to unsafe sexual practices by impairing judgment. • Infected with chlamydia and gonorrhea at a higher rate than Whites
Risk factors for STIs are outlined in Table 57.2. • 23% of all syphilis cases
STIs affect certain groups of people disproportionately (Box • 32.6% of all congenital syphilis cases
57.1). This includes youth and young adults under age 25, men • Men who have sex with men (MSM)
having sex with men (MSM), transgender women, and those • Have the largest proportion of gonorrhea infections
who are socially and economically disadvantaged.3 Many • Are more likely to test positive for antimicrobial resistant strains of gon-
minority groups have rates of STIs greater than that of Whites, orrhea
• 64% of all syphilis cases
including Asians, Native American Indian/Alaskan Native, and
• Are at increased risk for HIV, hepatitisC, and HSV-2
Native Hawaiian/Other Pacific Islanders.4
Trends in methods of contraceptive use affect the rate of Factors Influencing Disparities
STIs. The male condom is the best form of protection (other • Social and economic disadvantages can make it hard for people to care for
than abstinence) against STIs. While condom use has increased their overall health, including their sexual health.
in the United States, many people do not use condoms. Most • People who cannot afford basic necessities may have trouble accessing
women use hormonal (e.g., oral contraceptive pills, patch, inject- and affording quality sexual health services.
ables) or long-acting reversible contraceptives (e.g., intrauterine • Fear and distrust of HCPs and institutions can negatively affect racial and
devices). These do not provide barrier protection against STIs. ethnic minorities from seeking health care.
• In communities where is a higher prevalence of STIs, it may be hard to
This chapter covers the most common STIs. HIV infection
reduce the risk for infection because a person faces a higher chance of hav-
is covered in Chapter 15. Anyone who contracts an STI may ing an infected partner than in those communities with a lower prevalence.
also be at risk for HIV infection. HIV pre-exposure prophylaxis
, CHAPTER 57 Sexually Transmitted Infections 1397
(PrEP) or non-occupational postexposure prophylaxis (nPEP)
may be appropriate for these persons. See Chapter 15 for more
about PrEP and nPEP.
STIs CHARACTERIZED BY DISCHARGE,
CERVICITIS, OR URETHRITIS
CHLAMYDIAL INFECTIONS
Chlamydia is the most common reportable STI in the United
States. Nearly 2 million cases are reported annually. Incidence
is on the rise.2 As many infections are asymptomatic, we
believe the actual number of cases is significantly higher,
around 4 million.1
Etiology and Pathophysiology
Chlamydial infections are caused by Chlamydia trachoma- Fig. 57.1 Unilateral testicular swelling from chlamydial epididymitis.
(From Jordan S, Geisler W: Infectious diseases, St. Louis, 2017, Else-
tis, a gram-negative bacterium and intracellular pathogen.
vier.)
Chlamydia is transmitted through vaginal, anal, or oral sex.
Ejaculation does not have to occur for transmission. The incu-
bation period for chlamydia is 1 to 3 weeks. Prior infection with TABLE 57.3 Interprofessional Care
Chlamydia does not provide protection from reinfection. This Chlamydial Infections
means that people who were treated for chlamydia can always
Diagnostic Assessment
be reinfected. • History and physical assessment
The most common site for infection in men is the urethra. • Nucleic acid amplification test (NAAT)
Infection in the male urethra is called urethritis. The most com- • Testing for other STIs (gonorrhea, HIV, syphilis)
mon site for infection for women is the cervix. Infection of the
female cervix is called cervicitis. Men and women can get chla- Management
mydia of the rectum from receptive anal sex or the oropharynx • Doxycycline
from giving oral sex. Because the vagina acts as a natural reser- • Alternative regimen: azithromycin or levofloxacin
• Teach to abstain from sexual contact for 7 days after completing treat-
voir for infectious secretions, STI transmission is more efficient
ment
from men to women than it is from women to men.
• Treat all sexual partners, who must also wait 7 days before resuming
There are many serotypes of C. trachomatis. The more com- sexual contact
mon are the cause of nongonococcal urethritis (NGU) in men
or cervicitis in women. There is a small subset of serotypes that
can cause another STI, lymphogranuloma venereum (LGV), a woman’s reproductive tract, resulting in pelvic inflammatory
when spread to the rectum. Although rare, this is more com- disease (PID).5 PID can damage fallopian tubes and increase a
mon in MSM. woman’s risk for an ectopic pregnancy, infertility, and chronic
pelvic pain. The risk for developing PID increases with repeated
Clinical Manifestations infection. The more episodes of PID, the more likely a woman
Patients with chlamydia often have no symptoms. If symptoms will experience infertility. Although rare, patients can develop
develop in men, they may have pain with urination (dysuria) reactive arthritis, an autoimmune response to infection with C.
or urethral discharge. Rarely, men have testicular pain or swell- trachomatis.
ing caused by infection of the epididymis (Fig. 57.1). In women,
symptoms include mucopurulent vaginal discharge (mucus Diagnostic Studies
with pus), abnormal vaginal bleeding, dysuria, and pain with Diagnosis of an STI requires an accurate sexual history, a phys-
intercourse. Symptoms of rectal chlamydia include anorectal ical assessment, and laboratory tests specific to each infection.
pain, discharge or bleeding, anal pruritus, tenesmus, mucus- The preferred method for diagnosing chlamydia is a nucleic
coated stools, or painful bowel movements. Most patients with acid amplification test (NAAT) (Table 57.3). NAAT is used to
chlamydia in the throat will have no symptoms. A few may have identify small amounts of DNA or RNA in test samples. NAAT
a sore throat. can be done on urine, rectal, and oropharyngeal swabs; endo-
cervical or vaginal swabs from women; and urethral swabs from
Complications men.
Complications often develop from poorly managed, inaccu-
rately diagnosed, or undiagnosed chlamydia. Although men Interprofessional Care
rarely have long-term complications from infection, epididymi- The preferred treatment is doxycycline (Vibramycin) twice a
tis can result in male infertility. More often, chlamydia can affect day for 7 days (Table 57.3).6 All sexual contacts within 60 days
Sexually Transmitted Infections
Daniel P. Worrall
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Infection Reproduction
Pain Sexuality
LEARNING OUTCOMES
1. Identify factors contributing to sexually transmitted 4. Explain the interprofessional care and treatment of
infections (STIs) in the United States. chlamydia, gonorrhea, trichomoniasis, genital herpes,
2. Describe the etiology, clinical manifestations, genital warts, and syphilis.
complications, and diagnostic studies for chlamydia, 5. Discuss the assessment for patients who have an STI.
gonorrhea, trichomoniasis, genital herpes, genital warts, 6. Describe the nursing management of patients with STIs.
and syphilis. 7. Summarize the nursing role in the prevention and control
3. Compare and contrast primary genital herpes with of STIs.
recurrent genital herpes.
KEY TERMS
chlamydial infections sexually transmitted infections (STIs)
genital herpes syphilis
genital warts trichomoniasis
gonorrhea
Sexually transmitted infections (STIs) are infectious diseases scratching an infected area and transferring it to another part
that spread through sexual contact with the penis, vagina, anus, of the body). STIs cannot typically be transmitted from casual
mouth, or sexual fluids of an infected person. Many do not view contact or inanimate objects.
STIs as a serious health threat because most are easily treated.
However, complications of STIs are serious. They can include
infertility and cancer. Having an STI can affect a person’s
FACTORS AFFECTING INCIDENCE OF STIs
well-being, their relationships, and their sexual lives. Patient Rates of STIs in the United States are at an all-time high.
education, counseling, and referrals are essential nursing roles According to recent data, 26 million new infections are diag-
for promoting health and optimal sexual well-being. nosed in the United States each year. STIs affect 1 in 5 adults
Mucosal tissues in the genitals (urethra in men, vagina in and result in $16 billion in health care costs.1 Although all sex-
women), rectum, and mouth are especially susceptible to the ually active persons are at risk, some populations have a greater
bacteria and viruses that cause STIs. A list of common STIs is burden of infection. Socioeconomic factors, decreased condom
shown in Table 57.1. Some STIs, such as human papillomavi- use, and cuts to STD programs across the country are contribu-
rus (HPV), can spread from direct skin-to-skin contact with an tors.2 Having one STI can increase the risk for getting another. It
infected person. Other STIs, such as human immunodeficiency is also possible for a person to have more than one STI at a time.
virus (HIV), may be contracted via blood products, semen, All STIs have an incubation period. It is the time from initial
or vaginal secretions or be transmitted from mother to baby infection to the time when symptoms first appear or screen-
during pregnancy or labor and delivery. Some STIs can spread ing tests for the infection are positive. This can lead to the
through autoinoculation (spread of infection by touching or transmission of disease from an asymptomatic (but infected)
1395
,1396 SECTION 11 Problems Related to Regulatory and Reproductive Mechanisms
TABLE 57.1 Causes of STIs TABLE 57.2 Risk Factors for STIs
STI Cause High-Risk Behaviors
Bacterial Infections • Alcohol or substance use (inhibits judgment)
Chlamydial Chlamydia trachomatis • Having new sexual partners
Gonorrhea Neisseria gonorrhoeae • Having more than 1 sexual partner
Syphilis Treponema pallidum • Having sexual partners who have/have had multiple partners
• Inconsistent or incorrect use of condoms or other barrier methods
Viral Infections • Exchanging sex for money, shelter, or other needs
Genital herpes Herpes simplex virus (HSV 1 or 2)
Genital warts (condylomata Human papillomavirus (HPV) High-Risk Medical History
acuminata) • Having 1 STI is a risk factor for getting another
Human immunodeficiency virus Human immunodeficiency virus (HIV) (see • Not being vaccinated for STIs or other infections that may be transmitted
infection (HIV) Chapter 15) through some forms of sexual activity (HPV, hepatitis A and B)
Hepatitis B and C Hepatitis B and C viruses (see Chapter 48) • Receiving multiple courses of non-occupational postexposure prophylaxis
Molluscum Molluscum contagiosum to prevent HIV infection
Parasitic/Protozoan Infection High-Risk Populations
Trichomoniasis Trichomonas vaginalis • Adolescents and young adults (under age 25)
• Ethnicity/race (e.g., Black, American Indian/Alaskan Native, Native
Hawaiian/Other Pacific Islander, Hispanic)
• MSM
person to another person, even before any signs or symptoms
• Persons in correctional facilities
begin.
• Transgender women
In the United States, all cases of gonorrhea, chlamydia, and • Victims of sexual assault
syphilis must be reported to public health authorities for sur- • Women
veillance purposes for federally funded control programs and
partner notification. Surveillance and partner notification are
a major part of the effort to prevent and control the spread of
STIs. Nurses and other HCPs play a vital role. They are man-
dated to report STIs to public health authorities. Despite this BOX 57.1 PROMOTING HEALTH
requirement, only a small number of infections are reported. EQUITY
This means that the cases of gonorrhea, chlamydia, and syphi- STIs
lis reported in the United States annually do not represent the
actual number of infections. Incidence of STIs
Many factors contribute to the high rate of STIs.2 Earlier • Depending on their age and gender, Black persons have
reproductive maturity and increased longevity make for a • The highest number of chlamydial infections
• More than 50% of cases of gonorrhea
longer sexual life span. Other factors include greater sexual
• Nearly 35% of cases of syphilis
freedom, individual sexual behaviors, the media’s increasing • More than 40.4% of congenital syphilis cases
emphasis on sexuality without mentioning safer sex, and sexual • A higher seroprevalence of herpes simplex type 2
network characteristics. Alcohol and substance use can further • Hispanic persons
contribute to unsafe sexual practices by impairing judgment. • Infected with chlamydia and gonorrhea at a higher rate than Whites
Risk factors for STIs are outlined in Table 57.2. • 23% of all syphilis cases
STIs affect certain groups of people disproportionately (Box • 32.6% of all congenital syphilis cases
57.1). This includes youth and young adults under age 25, men • Men who have sex with men (MSM)
having sex with men (MSM), transgender women, and those • Have the largest proportion of gonorrhea infections
who are socially and economically disadvantaged.3 Many • Are more likely to test positive for antimicrobial resistant strains of gon-
minority groups have rates of STIs greater than that of Whites, orrhea
• 64% of all syphilis cases
including Asians, Native American Indian/Alaskan Native, and
• Are at increased risk for HIV, hepatitisC, and HSV-2
Native Hawaiian/Other Pacific Islanders.4
Trends in methods of contraceptive use affect the rate of Factors Influencing Disparities
STIs. The male condom is the best form of protection (other • Social and economic disadvantages can make it hard for people to care for
than abstinence) against STIs. While condom use has increased their overall health, including their sexual health.
in the United States, many people do not use condoms. Most • People who cannot afford basic necessities may have trouble accessing
women use hormonal (e.g., oral contraceptive pills, patch, inject- and affording quality sexual health services.
ables) or long-acting reversible contraceptives (e.g., intrauterine • Fear and distrust of HCPs and institutions can negatively affect racial and
devices). These do not provide barrier protection against STIs. ethnic minorities from seeking health care.
• In communities where is a higher prevalence of STIs, it may be hard to
This chapter covers the most common STIs. HIV infection
reduce the risk for infection because a person faces a higher chance of hav-
is covered in Chapter 15. Anyone who contracts an STI may ing an infected partner than in those communities with a lower prevalence.
also be at risk for HIV infection. HIV pre-exposure prophylaxis
, CHAPTER 57 Sexually Transmitted Infections 1397
(PrEP) or non-occupational postexposure prophylaxis (nPEP)
may be appropriate for these persons. See Chapter 15 for more
about PrEP and nPEP.
STIs CHARACTERIZED BY DISCHARGE,
CERVICITIS, OR URETHRITIS
CHLAMYDIAL INFECTIONS
Chlamydia is the most common reportable STI in the United
States. Nearly 2 million cases are reported annually. Incidence
is on the rise.2 As many infections are asymptomatic, we
believe the actual number of cases is significantly higher,
around 4 million.1
Etiology and Pathophysiology
Chlamydial infections are caused by Chlamydia trachoma- Fig. 57.1 Unilateral testicular swelling from chlamydial epididymitis.
(From Jordan S, Geisler W: Infectious diseases, St. Louis, 2017, Else-
tis, a gram-negative bacterium and intracellular pathogen.
vier.)
Chlamydia is transmitted through vaginal, anal, or oral sex.
Ejaculation does not have to occur for transmission. The incu-
bation period for chlamydia is 1 to 3 weeks. Prior infection with TABLE 57.3 Interprofessional Care
Chlamydia does not provide protection from reinfection. This Chlamydial Infections
means that people who were treated for chlamydia can always
Diagnostic Assessment
be reinfected. • History and physical assessment
The most common site for infection in men is the urethra. • Nucleic acid amplification test (NAAT)
Infection in the male urethra is called urethritis. The most com- • Testing for other STIs (gonorrhea, HIV, syphilis)
mon site for infection for women is the cervix. Infection of the
female cervix is called cervicitis. Men and women can get chla- Management
mydia of the rectum from receptive anal sex or the oropharynx • Doxycycline
from giving oral sex. Because the vagina acts as a natural reser- • Alternative regimen: azithromycin or levofloxacin
• Teach to abstain from sexual contact for 7 days after completing treat-
voir for infectious secretions, STI transmission is more efficient
ment
from men to women than it is from women to men.
• Treat all sexual partners, who must also wait 7 days before resuming
There are many serotypes of C. trachomatis. The more com- sexual contact
mon are the cause of nongonococcal urethritis (NGU) in men
or cervicitis in women. There is a small subset of serotypes that
can cause another STI, lymphogranuloma venereum (LGV), a woman’s reproductive tract, resulting in pelvic inflammatory
when spread to the rectum. Although rare, this is more com- disease (PID).5 PID can damage fallopian tubes and increase a
mon in MSM. woman’s risk for an ectopic pregnancy, infertility, and chronic
pelvic pain. The risk for developing PID increases with repeated
Clinical Manifestations infection. The more episodes of PID, the more likely a woman
Patients with chlamydia often have no symptoms. If symptoms will experience infertility. Although rare, patients can develop
develop in men, they may have pain with urination (dysuria) reactive arthritis, an autoimmune response to infection with C.
or urethral discharge. Rarely, men have testicular pain or swell- trachomatis.
ing caused by infection of the epididymis (Fig. 57.1). In women,
symptoms include mucopurulent vaginal discharge (mucus Diagnostic Studies
with pus), abnormal vaginal bleeding, dysuria, and pain with Diagnosis of an STI requires an accurate sexual history, a phys-
intercourse. Symptoms of rectal chlamydia include anorectal ical assessment, and laboratory tests specific to each infection.
pain, discharge or bleeding, anal pruritus, tenesmus, mucus- The preferred method for diagnosing chlamydia is a nucleic
coated stools, or painful bowel movements. Most patients with acid amplification test (NAAT) (Table 57.3). NAAT is used to
chlamydia in the throat will have no symptoms. A few may have identify small amounts of DNA or RNA in test samples. NAAT
a sore throat. can be done on urine, rectal, and oropharyngeal swabs; endo-
cervical or vaginal swabs from women; and urethral swabs from
Complications men.
Complications often develop from poorly managed, inaccu-
rately diagnosed, or undiagnosed chlamydia. Although men Interprofessional Care
rarely have long-term complications from infection, epididymi- The preferred treatment is doxycycline (Vibramycin) twice a
tis can result in male infertility. More often, chlamydia can affect day for 7 days (Table 57.3).6 All sexual contacts within 60 days
