Ch. 65 - STIs

Individuals at greatest risk for STI’s

• those who have more than one sexual partners currently (esp anonymous partners)

• more than one sexual partner in the past

• engaging in sexual activity w someone who has an STI

• hx of STI

• use IV drugs

• have/had a partner who uses IV drugs

• engage in anal, vaginal, or oral sex w/out a condom

• have sex while using drugs or alcohol

• women & gay men

• sexual trafficking

legal & ethical considerations for STIs

• chlamydia, gonorrhea, syphilis, chancroid, & HIV must be reported to the authorities bc must protect the public

• herpes is not reportable in KY

BOX 65.3

What are key patient teachings for managing genital herpes (GH)?

• Take prescribed oral analgesics and antiviral medications.

• Use local anesthetic sprays/ointments as directed.

• Apply ice packs or warm compresses to lesions.

• Take sitz baths 3–4 times daily.

• Increase fluid intake to compensate for fluid loss.

• Practice frequent urination; pour water over genitalia while voiding.

• Maintain genital hygiene (keep clean and dry).

• Wear gloves when applying ointments/touching lesions.

• Wash hands thoroughly after lesion contact.

• Launder towels that contact lesions.

• Avoid sexual activity during outbreaks.

• Use latex/polyurethane condoms during all sexual exposures.

• Disclose GH status to partners for treatment/prevention.

OLDER ADULT BOX
Why is STI education important for older adults, and how should it be approached?

• Risk Awareness: Older adults may not recognize their STI risk or feel comfortable discussing sexuality.

• Safe Environment: Provide a private, nonjudgmental space for education.

• Key Teaching Points:

  • STIs can affect anyone, regardless of age.

  • Safe sex practices (e.g., condom use) reduce transmission risk.

  • Regular STI screening is important if sexually active.

  • Open communication with partners and healthcare providers is essential.

Prevention of STIs

• Using a latex or polyurethane condom for genital and anal intercourse

• Using a condom or latex barrier (dental dam) over the genitals or anus during oral-genital or oral-anal sexual contact

• Wearing gloves for finger or hand contact with the vagina or rectum

• Practicing abstinence

• Practicing mutual monogamy

• Decreasing the number of sexual partners

Key features Genital herpes

• most common in the US

• HSV1 (above waist) HSV2 (below waist, but both can spread above or below)…either type can produce oral or genital lesions

• arrays of lesions and vesicles, one or more on or around genitals, rectum or mouth

• 2-10 days incubation

• self management education: teach about antivirals and side effects, sitz baths, keep towels separate

• first outbreak is the worst

ACTION ALERT

what key points should you teach a pt with GH about sexual and condom use?

• Abstain during outbreaks: Avoid sex when lesions are present (risk of pain & transmission is highest).

• Always use condoms: HSV can spread via viral shedding, even without visible lesions.

• Partner communication: Disclose HSV status to partners to support informed decisions.

• teach how to use condoms

Action Alert: Reinforce that condoms reduce but do not eliminate HSV transmission risk.

s/s genital herpes

• prodrome: itching, tingling, flare ups w stress, can have flu like s/s, outbreaks may be completely asymptomatic

• when blisters burst it is very painful and highly contagious

• several weeks to heal

Complications of genital herpes

• risk for neonatal transmission

• increased risk for HIV

Drug examples to treat genital herpes

• -clovir

  • acyclovir

  • valacyclovir

  • famciclovir

acyclovir is indicated when…

IV & hospitalization indicated for pt w severe s/s, like aseptic meningitis, encephhalitis, end-organ disease, or systematic disease

how do drugs help GH

• can prevent or shorten outbreaks

• make it less likely to pass infection on to sex partners by decreasing viral shedding, but wont prevent viral shedding

genital herpes & pregnancy

• can cause spontaneous abortion

• can lead to premature delivery & neonatal herpes (potentially deadly)

• can result in encephalitis and brain damage during childbirth

what is episodic therapy?

for GH

taking an antiviral drug at the first sign of a recurrent outbreak, is most beneficial if it is started within 1 day of the appearance of lesions or when itching or tingling occur before lesions appear

what is suppressive therapy?

for GH

taking a prescribed antiviral drug daily, can also be offered to patients. Suppression reduces recurrences in most patients, but it does not prevent viral shedding, even when symptoms are absent.

DRUG ALERT - podophyllotoxin, podophyllum resin, or trichloroacetic acid (TCA)

PTs taking these may experience pain, bleeding, or discharge from the site or sloughing of parts of warts. Teach to keep the area clean and dry and to be alert for any signs or symptoms of further infection or side effects of the treatment.

key features of primary syphilis

• appearance of chancre: painless, smooth, weeping lesions dev @ site of entry 12 days- 12wks after exposure (3w average)

• HIGHLY INFECTIOUS

key features of secondary syphilis

• systemic

• mistaken for flu

• s/s

  • malaise, low-grade fever, h/a, sore throat, hoarseness, generalized adenopathy, joint pain, skin & mucous membrane lesions or rash

• rash subsides in 2-10 wks and pt enters early latent stage

key features early latent syphilis stage

• seropositive but asymptomatic

• may last a yr or lifetime

key features tertiary syphilis

• uncommon bc of antibiotics

• can occur from 4-20 yrs

• cardiovascular lesions, gummatous lesions?

BOX

syphilis care & health equity

• Disparities: Syphilis rates disproportionately affect marginalized groups, especially non-Hispanic American Indian/Alaska Native and multiracial individuals (CDC, 2022).

• Barriers: Inequitable access to testing, treatment, and education worsens outcomes.

• Nurse’s Role:

  • Advocate for culturally competent, stigma-free care.

  • Support accessible screening (e.g., community outreach, prenatal testing).

  • Educate on early treatment (penicillin G prevents complications).

  • Address social determinants of health (e.g., poverty, healthcare access).

BOX
How can healthcare providers ensure equitable sexual health assessments for LGBTQIA2+ patients?

1. Actively ask about and document:

   • Gender identity and pronouns

   • Sexual orientation

   • Sexual practices/partners

2. Address specific needs:

   • STI screening/prevention

   • Gender-affirming care

   • Mental health support

3. Overcome barriers by:

   • Using inclusive language

   • Providing non-judgmental care

   • Continuously educating yourself

4. Advocate for systemic changes to improve health equity

diagnosing syphilis

• confirmed by veneral disease research lab test (VDRL)

• rapid plasma reagent test (RPR), more sensitive

• smear of lesions

health assessment in lgbtq pt’s

• discrimination, health equity imbalances, and lack of understanding can affect health status of this population

• they have difficulty finding HCP who ask and address their specific needs, risks, and concerns

• taking health hx where the pt can share their sexual orientation, gender equity, and sexual activity is crucial

considerations for gay men r/t syphilis

• gay men are at high risk for contracting primary and secondary syphilis

• do not assume that they have only had sex congruent w their sexual orientation bc it limits the accuracy of the nurses assessment

• collect an appropriate sexual hx for all pt’s, and design a plan of care based on that info

tx for primary, secondary, and early latent stage syphilis

• benzathine penicillin g IM, 2.4 million units, 4 mL

• will need to give dose in 2 injections

• doxycyclime amd tetracycline can be used if allergic to PCN

jarisch-haxhemier reaction

• occurs with antibiotics for syphilis - febrile reaction

• need follow up evaluations of blood work at 6, 12, and 24 months. Have to tell ALL partners.

• s/s

  • aches, rigors, vasodilation, diaphoresis, hypotension and worsening of any rash that was present

treatment for late latent syphilis

3 IM injections of long acting Benzathine penicillin G (2.4 million units administered intramuscularly) 1 x a week for 3 weeks

DRUG ALERT

benzathine pcn g

• monitor for allergic rxn signs

  • rashm edema, SOB, chest tightness, anxiety

• pcn desensitization is recommended for pcn allergic pts

• keep all pts at the facility for at least 30 mins after receiving the antibiotic so s/s can be detected

• most severe rxn is anaphylaxis

• tx should be implemented immediately if symptoms occur

congenital syphilis

• in utero, the fetus is protected from syphilis for the first 4mo of pregnancy

• then it can be passed from mother to fetus

• untreated maternal syphilis leads to fetal death 40% of the time

• c-section is the safest if active sores

• can be stillborn or die w/in 28 days

• need immediate IM or IV pcn

• S/S: Skin rash, jaundice, anemia, developmental delays, deformed bones, stillborn/death.

Key features of genital warts

• aka condylmata acuminata

• caused by HPV

• need to be checked for other STIs

• cauliflower lesions

• increased/high risk is for cervical cancer

• can disappear on their own w/out treatment

• no sex until warts are gone

• reoccurrence likely

Therapy for genital warts

• podophyllotoxin

• podophyllum resin

• traichloroacetic acid (TCA)

• OTC wart meds/ointment are not to be used on genitals

• cryotherapy/electrocardirization/surgical excision - usually repeated tx’s

genital warts vaccination?
check/test for what?

Vaccination to protect against HPV is very important especially for MSM. 

Check for other STIs. Blood test for HIV and culture for gonorrhea and chlamydia. 

DRUG ALERT

podophyllotoxin, podophyllum resin, or TCA

• may experience pain, bleeding, or discharge from the site or sloughing of parts of warts

• teach pt to keepy area clean & dry and to be alert for s/s of further infection

what can gardasil prevent

• types of cervical cancer, vaginal, anal, vulvar, oropharyngeal and other head and neck cancers cause by HPV, & some genital warts

recommendation groups for gardasil

• males & females 9-45 yrs old

what can cervarix prevent

• cervical disease

• precancerous cervical lesions

• anogenital cancers

recommendation group for ceravarix

• males & females 9-26

key features of chlamydia

• caused by parasitic bacterium

• most reported STI in the US

• frequently asymptomatic

• mucopurulent discharge

• dysuria

• pelvic pain

• irregular bleeding

• hx of STIs

• cultural disparities

• no sex during 7 day tx

• women are rescreened to detect repeat infection

Diagnosis of chlamydia

• swab cells from cervical or male urethra

• urine testing

• retesting after 3mo is advised to detect repeat infection

• often occurs as coinfection w chlamydia

Tx for chlamydia

• doxycycline*

• azithromycin

• levofloxacin

what is expedited partner therapy (EPT)

• sending pt home with drugs for partner too

• shows signs of decreased infection rates

• one of the best ways to reduce incidence

complications of chlamydia

• PID

• infertility

• ectopic pregnancy

• newborn complications

• **Gonorrhea often occurs as a coinfection with chlamydia, and treatment may be necessary. 

BOX

chlamydia rates

• higher in black individuals & MSM

BOX

urethritis in men

• ask about

  • dysuria, frequent urination, or discharge

• pt with chlamydia may report mucoid discharge that is more watery and less copious than gonorrheal discharge

• some men only have discharge in the morning

• comp: epididymitis or epididymo- orchitis and sexually acquired reactive arthritis

Key features gonorrhea

• the drip or clap

• often occurs as coinfection w chlamydia

• s/s apear w/in a week (3-10d) of exposure

• may smell like mushrooms

• pt may be asymptomatic

• all pts w gono should be tested for syphilis, chlamydia, hep b, c, and HPV

• avoid sex until 7 days after tx

s/s of gono in men

• painful urination, urethritis, pus like (profuse) discharge from penis, pain or swelling in one testicle

s/s gono in women
what can happen?

• increased vaginal discharge, yellow green or scant clear and odorous, painful urination and frequency, vaginal bleeding between periods and after intercourse, abdomen pain, pelvic pain, can ascend and cause PID

treatment for gono in pharynx, cervix, rectum, or urethra

• IM ceftriaxone 250mg

• azithromycin 1g oral and doxycycline 100mg BID for 1wk (tx for coinfection)

• EPT if refuse to come to facility

Complications of chronic gono

• PID

• ectopic pregnancy

• infertility

• chronic pelvic pain

• Patients should avoid sexual intercourse until 7 days after completion of treatment.

gono in pregnancy

• c section safest

• usually retested

• return in 14 days to ensure oral is gone. 

key features of MPOX

• not a traditional STI but most infected were gay or bisexual

• most transmission via sexual contact

s/s MPOX

• fever

• lymphadenopathy

• lesions in oropharynx and skin throughout the body

tx for MPOX

• supportive

• jynneos vaccine (18+)

Pelvic Inflammatory Disease (PID) key features

• infection of the upper genital tract usually the endometrium, fallopian tubes, and ovaries cause by BV or STIs

• some pt’s have mild discomfort or menstrual irregularity and others have no s/s

• major cause of infertility, ectopic pregnancies, can cause death

• untreated or prolonged infection can increase risk for cervical cancer and HIV

s/s PID

• lower abdominal pain

• irregular bleeding

• dysuria

• increase or change in vaginal discharge

• dysparenuria

• malaise

• fever

• chills

minimum criteria for diagnosis of PID for women with pelvic/lower abdominal pain:

• one or more of these present during pelvic exam…

  • cervical motion tenderness

  • uterine tenderness

  • adnexal tenderness

BOX 65.5

additional criteria for diagnosis of PID

• oral temp >101

• abnormal mucopurulent discharge or cervical friability

• increased WBCs on saline sample of vaginal fluid

• elevated ESR

• elevated C-reactive protein

• documentation of hx of gono or chlamydia

• Endometriosis on endometrial biopsy

• MRI demonstrating thickened fluid-filled tube with or w/out free pelvic fluid, or Doppler studies suggesting pelvic infection

• laparoscopic studies consistent w PID

BOX

psychosocial concerns of pt w STI

• may benefit from mental health professional

• can help work through feelings of embarrassment, betrayal, anger, fear, or concerns about infertility or reproduction implications

• can help pts adjust to life changes

treatment for PID

• IV antibiotics (antibiotic therapy) until pt shows signs of improvement

  • decrease pain by destroying pathogens and decreasing inflammation

• other comfort measures

comfort measures for PID
teach?

• increase fluid intake and nutritious foods

• teach to rest in sem-fowlers, encourage limited ambulation to promote gravity drainage of infection

• mild analgesics

• apply heat to lower abdomen and back

ACTION ALERT

PID

• instruct pts to avoid sex for full course of antibiotic tx, until their s/s have resolved, and until their partner has been treated for any STIs

• check temp twice a day and report changes to PCP

• see HCP w/in 72 hrs from start of antibiotic tx and 1-2 wks from time of initial diagnosis

BOX 65.6

pt & fam education oral antibiotics for PID & STIs

• take medicine as prescribed even if feeling bette r

• antibiotics can be taken on empty stomach or w food depending on which drug was prescribed

• do not take antacids containing calcium, mg, or aluminim w antibiotics, can decrease effectiveness

• your partner must be tx if you have an STI (EPT)

• do not have sex until antibiotics are completed

• wait 7 days to resume sex if tx was delivered in one dose

• drink 8-10 glasses of water a day

• return for follow up

• call if questions or concerns

s/s of trichomoniasis women

• fishy smell

• red itching and burning genitals

• frothy, thin, white or yellow green discharge

• strawberry cervix (from petechiae)

• itching

• dyspareunia

• dysuria

s/s trich in men

• often asymptomatic

• itching inside penis

• burning after urination or ejaculation

• discharge from penis

additional trich s/s

 itching, dyspareunia, and dysuria

trich in pregancy

• if untreated can have preterm baby w low birth weight

tx for trich

• metronidazole or tinidazole

  • Usually a 1x dose (2 grams for men and a 1-week regimen for women 500 mg twice daily)

• *Follow up testing is often needed due to reinfection.

  *Untreated or prolonged infections can increase the risk of cervical cancer and HIV.