Sexually Transmitted Infections

1. SEXUALLY TRANSMITTED
INFECTIONS

2. • Sexually transmitted infections (STIs) are
infectious diseases that are spread through
sexual contact with the penis, vagina, anus,
mouth, or sexual fluids of an infected
person.

3. • Mucosal tissues in the urethra in men, vagina in women,
rectum, and mouth are susceptible to the bacteria and
viruses that cause STIs.
• Common STIs are
– Genital human papillomavirus (HPV), can spread from direct
skin-to-skin contact with an infected person.
– human immunodeficiency virus (HIV), may be contracted via
blood or blood products or be transmitted from mother to
baby during pregnancy or labor and delivery.
– Some STIs can spread through autoinoculation (spread of
infection by touching or scratching an infected area and
transferring it to another part of the body).
– STIs cannot typically be transmitted from casual contact or
inanimate objects.

4. SI Diseases Causes
I Bacterial Infections
Chlamydial Chlamydia trachomatis
Gonorrhea Neisseria gonorrhoeae
Syphilis Treponema pallidum
II Viral Infections
Genital herpes Herpes simplex virus (HSV 1 or 2)
Genital warts (condylomata
acuminata)
Human papillomavirus (HPV)
Human immunodeficiency
virus infection (HIV)
Human immunodeficiency virus (HIV)
Hepatitis B and C Hepatitis B and C viruses
Molluscum Molluscum contagiosum
III
Parasitic/Protozoan
Infection
Tricomoniasis Tricomonas vaginalis

5. Risk Factors for STIs
High-Risk Behaviors
• Alcohol or drug use (inhibits judgment)
• Having new or multiple sexual partners
• Having more than 1 sexual partner
• Having sexual partners who have/have
had multiple partners
• Inconsistent or incorrect use of condoms
or other barrier methods
• Sharing needles used to inject drugs
High-Risk Medical History
• Having 1 STI is a risk factor for getting
another
• Not being vaccinated for STIs or other
infections that may be transmitted through
some forms sexual activity (HPV, hepatitis
A and B)
• Receiving multiple courses of non
occupational poste xposure prophylaxis
for HIV infection
High-Risk Populations
• Adolescents and young
adults (age <25)
• Ethnicity
• Men who have sex with
men
• Persons in correctional
facilities
• Transgender persons
• Victims of sexual
assault
• Women

6. Chlamydial Infections

7. Etiology and Pathophysiology
• Chlamydial infections are caused by Chlamydia trachomatis, a
gram-negative bacterium and intracellular pathogen.
• Chlamydia is transmitted through exposure to sexual fluids
during vaginal, anal, or oral sex.
• Ejaculation does not have to occur for it to be transmitted.
• The incubation period for chlamydia is 1 to 3 weeks.
• The common site for infection in men is the urethra. Infections
in the male urethra are called urethritis.
• The common site for infection for women is the cervix.
Infections in the female cervix are called cervicitis.
• Both men and women can get chlamydia of the rectum from
receptive anal sex or the oropharynx from giving oral sex.
Because the vagina acts as a natural reservoir for infectious
secretions, STI transmission is often more efficient from men to
women than it is from women to men.

8. Clinical manifestations
• No symptoms
• Pain with urination
• Urethral discharge.
• Pain or swelling of the
testicles
• Mucopurulent discharge
(mucus with pus),
• Bleeding
• Dysuria
• Pain with intercourse.
Symptoms of rectal
chlamydia
• Anorectal pain
• Discharge
• Bleeding
• Pruritus
• Tenesmus
• Mucus-coated stools
• Painful bowel
movements.

9. Diagnostic Studies
• Accurate sexual history
• A physical examination
• Laboratory tests specific to each infection.
• Nucleic acid amplification test (NAAT):- is
used to identify small amounts of DNA or
RNA in test samples.

10. Treatment
• The preferred treatment is a single dose of
azithromycin (Zithromax) or doxycycline
(Vibramycin) twice a day for 7 days

11. Role of nurse in Treatment (Drug
alert)
• Patients should avoid prolonged or
excessive exposure to sunlight.
• Take doses on an empty stomach either 1
hour before eating or 2 hours after eating.
• Avoid taking with antacids, iron products, or
dairy products.
• Pregnant women should not take
doxycycline

12. Gonococcal Infections

13. Etiology
• Gonorrhea is caused by Neisseria
gonorrhoeae, a gram-negative, diplococcus
bacterium.

14. Pathophysiology
• Gonorrhea can be transmitted by exposure to
sexual fluids during vaginal, anal, or oral sex.
• Ejaculation does not have to occur for it to be
transmitted. The incubation period ranges
from 1 to 14 days.
• The most common site for infection for men is
the urethra and for women, the cervix. Both
men and women can get gonorrhea of the
rectum from anal sex or of the oropharynx
from oral sex.

15. Clinical manifestations
Male
• Dysuria
• Purulent urethral discharge
• Epididymitis
In female
• Increased vaginal discharge
• Dysuria
• Frequency of urination
• Bleeding after sex
• Redness and swelling can
occur at the cervix or urethra
along with a purulent
exudate
Symptoms of rectal infection
include
• Mucopurulent rectal
discharge
• Bleeding
• Anorectal pain
• Pruritus
• Tenesmus
• Mucus-coated stools,
• Painful bowel movements.
Patients with gonorrhea in
the throat
• A sore throat within days of
performing oral sex.

16. Diagnostic Studies
• History and physical examination
• Gram-stained smears of urethral or
endocervical exudate
• Culture for Neisseria gonorrhoeae
• Nucleic acid amplification test (NAAT) to
detect N. gonorrhoeae
• Testing for other STIs (syphilis, HIV,
chlamydial infection)

17. Treatment
• The first-line treatment is dual therapy with
IM ceftriaxone with oral azithromycin as a
single dose.

18. Trichomoniasis

19. Trichomoniasis
• Trichomonas can be transmitted by
exposure to sexual fluids during vaginal,
anal, or oral sex, even if ejaculation does not
occur.
• The incubation period is usually 1 week to 1
month but can be much longer.
• The most common site for infection in men
is the urethra and in women is the cervix.

20. Clinical Manifestations
Men
• Burning with urination and ejaculation,
• Urethral discharge.
Women
• Painful urination
• Vaginal itching
• Painful intercourse
• Bleeding after sex
• A yellow-green discharge with a foul odor.
• The cervix can have a “strawberry” appearance.

21. Diagnostic Evaluations
• NAAT testing of vaginal or endocervical
secretions or urine.
• Culture, point-of-care testing,
• Direct visualization of trichomonads under the
microscope.
• Identification of motile trichomonads in the
vaginal secretions confirms infection.
• Tests can be done on liquid-based cervical Pap
samples.

22. Role of nurse in Treatment (Drug
alert)
• Patients and their partners should be treated with either
metronidazole or tinidazole.
• Teach patients to abstain from sexual contact for 7 days
after treatment or until all sexual partners have
completed a full course of treatment and abstained from
sexual contact for 7 days.
• Tell patients to return if symptoms persist or recur. A
• ny sexual partner within the preceding 60 days should
be treated.
• Teach patients to use condoms or other barrier methods
with every sexual contact.
• Because of a high rate of recurrence, repeat testing 3
months after treatment is recommended.

23. Genital Herpes Infections

24. • Genital herpes is a common, lifelong,
incurable infection.
• There are 2 strains of herpes:
– Herpes Simplex Virus Type 1 (HSV-1):- HSV-1 is
associated with oral lesions.
– Herpes Simplex Virus Type 2 (HSV-2):- HSV-2 is
more common in the genitals or anus.

25. Pathophysiology
Viral reactivation occurs when the virus descends to that initial site of
infection, either the mucous membranes or skin.
Then the virus enters the peripheral or autonomic nerve endings and
ascends to the sensory or autonomic nerve ganglion near the infection site
Reproduces inside the cell and spreads to the surrounding cells.
The virus enters through the mucous membranes or breaks in the
skin during contact with an infected person.

26. Clinical Manifestations
A primary episode
• A primary (initial) episode of genital herpes has an incubation of 2 to
12 days. Most people do not have any recognizable symptoms of
primary HSV genital infection.
• Symptoms do occur, they follow a series of stages.
– Prodromal stage:- the period before lesions appear, the patient
may have burning, itching, or tingling at the site of inoculation.
– Vesicular stage:- few to multiple small, often painful vesicles
(blisters) may appear on the buttock, inner thigh, penis, scrotum,
vulva, perineum, perianal region, vagina, or cervix. The vesicles
have large quantities of infectious viral particles.
– Ulcerative stage:- the lesions rupture and form shallow, moist
ulcerations. In the final stage, spontaneous crusting and
epithelialization of the erosions occur
• Regional (inguinal node) lymphadenopathy and systemic flu-like
symptoms, including fever, headache, malaise, and myalgia.

27. Recurrent Episodes
• It occurs in many people during the year after the
primary episode.
• The symptoms of recurrent episodes are less severe, and
the lesions usually heal more quickly. HSV-1 genital
infections recur less often than HSV-2 genital infections.
Over time, both decrease in frequency.
• Common triggers of recurrence include stress, fatigue,
sunburn, general illness, immunosuppression, and
menses. Many patients can predict a recurrence by
noticing the prodromal symptoms of tingling, burning,
and itching at the site where the lesions will recur.

28. Diagnostic Assessment
• History and physical examination
• Antibody assay for HSV type
• Viral isolation by tissue culture

29. Treatment
• Primary (Initial) Infection
– Acyclovir (Zovirax), valacyclovir (Valtrex) or
famciclovir (Famvir)
• Recurrent Episodic Infection
– Acyclovir, valacyclovir, or famciclovir for shorter
duration

30. Genital Warts

31. • Genital warts (condylomata acuminata) are caused
by the HPV.
• There are around 100 types of papillomavirus, of
which at least 40 strains are sexually transmitted.
• “Low-risk” strains of the virus can cause warts on
the skin.
• “High-risk” strains can lead to cancers of the genital
tract, anus, or oropharynx in some patients.
• HPV types 6 and 11 cause about 90% of genital and
anal wart cases.

32. Etiology and Pathophysiology
• HPV is transmitted by skin-to-skin contact,
most often during vaginal, anal, or oral sex.
• It can be transmitted during nonpenetrating
sexual activity.
• The basal epithelial cells infected with HPV
undergo transformation and proliferation to
form a warty growth
– The incubation period can range from weeks to
months to years.

33. Clinical Manifestations
• Asymptomatic.
• Genital or anal warts are discrete single or multiple papillary
growths that are white to gray, are pink-flesh colored, or can be
hyperpigmented depending on the skin type.
• They may grow and coalesce to form large, cauliflower-like masses.
• In men, warts occur on the penis and scrotum, inside or around the
anus, or in the urethra.
• In women, warts occur on the inner thighs, vulva, vagina, or cervix,
in the perianal area, including in the internal anal canal
• Itching may occur with anogenital warts.
• Bleeding on defecation may occur with anal warts.

34. Diagnostic Evaluations
• Visual examination
• Biopsy
• Pap smear test
• Viral markers

35. Treatment
• Trichloroacetic acid (TCA)
• Bichloroacetic acid (BCA)
• Podofilox liquid and gel
• Petroleum jelly applied with a cotton swab to
the surrounding normal skin can minimize
irritation.
• If the warts do not resolve with topical
therapies, treatments such as cryotherapy with
liquid nitrogen, electrocautery, laser therapy,
local α-interferon injections, or surgical
excision may be needed

36. Syphilis

37. • Syphilis is caused by Treponema pallidum, a bacterial
spirochete.
• It is transmitted by direct contact with a syphilitic ulcer called a
chancre.
• A chancre can occur externally on the genitals, anus, or lips or
internally in the vagina, rectum, or mouth or tongue or through
the mucosal membranes of an infected person.
• Transmission can occur during vaginal, anal, or oral sex. The
incubation period can range from 10 to 90 days (average 21
days).
• An infected pregnant woman can transmit syphilis to her fetus
during her pregnancy. There is a high risk for stillbirth or having
babies who develop complications after birth, including seizures
and death.

38. Stages of syphilis
Primary
• Infectivity: Highly infectious
• Duration of stage: 3–6 wk
• Single or multiple chancres (painless indurated
lesions) of penis, vulva, lips, mouth, vagina, and
rectum) Occurs 10–90 days after inoculation
• Regional lymphadenopathy (microorganisms
drain into the lymph nodes)
• Exudate and blood from chancre are highly
infectious

39. Secondary
• Infectivity: Highly infectious
• Duration of stage: Occurs a few weeks after primary
chancre heals, lasts 1–2 yr
• Flu-like symptoms: malaise, fever, sore throat,
headaches, fatigue, arthralgia, generalized adenopathy
• Mucous patches in mouth, tongue, or cervix
• Symmetric, nonpruritic rash bilaterally that appears on
trunk, palms, and/or soles
• Condylomata lata (moist, weeping papules) in the
anogenital area
• Weight loss, alopecia

40. Latent
• Infectivity: Early (<1 yr)—infectious; late (≥1
yr)—noninfectious
• Duration of stage: Throughout life or
progression to late stage
• Absence of signs or symptoms
• Diagnosis based on positive specific
treponemal antibody test together with normal
CSF and absence of clinical manifestations

41. Late
• Infectivity: Noninfectious
• Duration of stage: Chronic (without treatment), occurs 1–20
years after initial infection
• Gummas (chronic, destructive lesions affecting any organ of
body, especially skin, bone, liver, mucous membranes)
• Cardiovascular: Aneurysms, heart valve insufficiency, heart
failure, aortitis
• Neurosyphilis: Can occur at any stage of syphilis
• General paresis: Personality changes from minor to psychotic,
tremors, physical and mental deterioration
• Tabes dorsalis (ataxia, areflexia, paresthesias, lightning pains,
damaged joints)

42. Diagnostic Assessment
• History and physical examination
• Dark-field microscopy
• Nontreponemal and/or treponemal
serologic testing
• Testing for other STIs (HIV, gonorrhea,
chlamydial infection)

43. Management
• Antibiotic therapy:
• Penicillin G benzathine (Bicillin LA)
• Doxycycline or tetracycline (if penicillin
contraindicated)
• Confidential counseling and testing for HIV infection
• Surveillance
• Repeat of nontreponemal tests at 6 and 12 mo
• Examination of cerebrospinal fluid at 1 yr if
treatment involves alternative antibiotics or
treatment failure has occurred.

44. Nursing Management: STIs
Nursing Diagnoses
• Impaired sexual functioning
• Risk for infection
• Lack of knowledge

45. Health education
• Explain precautions to take, such as
– Using condoms and other barrier methods with every sexual encounter
– Being monogamous, defining what monogamy means with your partner
– Asking potential partners about their sexual history
– Asking potential partners if they have been tested for STIs
– Avoiding sex with partners who have visible oral, inguinal, genital, perineal, or
anal lesions or those who use IV drugs
– Voiding and washing genitalia and surrounding area after sex to flush
out/wash away organisms to reduce potential for transmitting infection
• Explain the importance of taking all antibiotics or antiviral agents as
prescribed. Symptoms will improve after 1–2 days of treatment, but
organisms may still be present.
• Teach patients diagnosed with gonorrhea, chlamydia, syphilis, or
trichomoniasis that all sexual partners need to be treated to prevent
transmission and reinfection.

46. • Teach patients to abstain from sexual contact during and for
7 days after treatment and to use condoms or other barrier
methods when sexual activity is resumed to prevent spread of
infection and reinfection.
• Explain the importance of follow-up examination and retesting
at least once after treatment (if appropriate) to confirm
complete cure and prevent relapse.
• Allow patients and partners to voice their concerns and clarify
areas that need explanation.
• Teach patients about the signs and symptoms of complications
and need to report problems to their HCP to ensure proper
follow-up and early treatment of reinfection.
• Tell patients of the infectious nature of these infections to avoid
a false sense of security, which may result in careless sexual
practices or poor personal hygiene.
• Tell patients about health department requirements for
anonymously reporting certain STIs.

47. Preventing Sexually Transmitted
Infections
• Follow “safer” sex practices every time you have
sexual contact and be responsible for your own
protection.
• Have sexual activity only in an established,
monogamous relationship.
• Obtain vaccinations to help prevent some types of
HPV.
• Know your sex partners. Be comfortable saying “no”
to sexual activity.
• Limit alcohol use to moderate levels.
• If you are at risk, obtain testing regularly and
encourage partners to do the same.

48. THANK YOU