NURS 420 Final Exam Ch. 5 Sexually Transmitted Infections

Sexually Transmitted Infections

Infections of the reproductive tract by microorganisms that enter the body via genital, rectal, or oral routes.

Microorganisms include bacteria, viruses, and sometimes fungi, although fungal STIs are less common.

Ongoing global health work is being done to adequately address STIs, although funding fluctuates with political and international priorities.

Infection rates continue to increase worldwide.

> 1 million STIs acquired every day worldwide in people age 15-49 (WHO).

-"Acquired" does not mean diagnosed; many infections are never formally diagnosed.

STIs are very common; many, if not most, people will be exposed to or contract an STI at some point in their life.

Stigma can prevent people from seeking care even when they have insurance and access.

Teens and High‑Risk Factors

Female anatomy predisposes them to STIs (columnar epithelial cells sensitive to invasion).

Columnar epithelial cells of the cervix are particularly susceptible and are "not great" at preventing microbial invasion.

Teenagers' feelings of invincibility.

Unprotected intercourse and shorter partnerships, leading to a larger number of sexual partners over time.

Obstacles to using the health care system (transportation, cost, insurance, fear parents will find out via insurance statements).

Some adolescents deliberately seek care outside their usual health system (e.g., Planned Parenthood) to avoid parental notification.

Common STIs

Chlamydia

Gonorrhea

Herpes Simplex Virus (HSV)

Syphilis

Human Papilloma Virus (HPV)

Hepatitis A, B, and C

HIV

Trichomoniasis

General Nursing Assessment and Interventions for STIs

Obtain thorough history

-Establish rapport.

-Use therapeutic communication to minimize stigma.

-Provide unbiased, non‑judgmental care to build trust so patients feel safe disclosing sensitive sexual histories.

Testing: obtain/run or send specimens

Education

Support for coping with non-curable STIs

Refer for counseling other resources PRN

General STI Patient Education

Medication teaching.

-Explain what the medication is for, how to take it, when to take it, how long to take it, and how to know if it worked.

Safer sex practices.

-Clarify which STIs condoms help protect against and which they do not; oral contraceptives do not protect against STIs.

Contraceptive counseling as needed.

Public health education.

-Sexual health education varies widely by region and state (e.g., abstinence‑only vs comprehensive sex ed, inclusion or exclusion of abortion and LGBTQ+ care).

Dietary changes (depending on infection).

-Possible advice in some cases: consider probiotics to help reestablish normal flora, and reduce sugar, alcohol, and caffeine, especially with fungal infections.

Chlamydia

Most common bacterial STI in U.S. (~1.6 million cases/year).

Majority of infections are asymptomatic.

Curable with appropriate antibiotics.

Highly contagious and reportable to the Department of Public Health.

Bacterium: obligate intracellular parasite.

Is Chlamydia Curable?

Yes, with antibiotics

Chlamydia Risk Factors

Adolescence/young adult (14-24).

Multiple sex partners.

New sex partner.

Sex without condom.

Oral contraceptive use (correlates with risk but is not a direct cause).

Pregnancy (often due to lack of barrier contraception).

History of other STI (history of one STI increases risk of others).

Chlamydia Screening

Nucleic‑acid amplification test (NAAT).

Genital swab or urine test. Urine should not be clean catch for STI testing.

Can mimic UTI: When UTI is also suspected, a midstream clean‑catch urine may be sent for UTI plus a separate non‑clean‑catch urine or swab for STI NAAT.

Specimens are sent to the lab for culture or NAAT; results may take a couple of days.

Chlamydia Treatment

Antibiotics such as doxycycline or azithromycin.

If gonorrhea is also present, combination therapy is used.

Partners should also be treated to prevent reinfection, especially because they may be asymptomatic.

Chlamydia Symptoms

tends to ascend the reproductive tract, causing inflammation, scarring, and potential infertility, even if the infection self‑limits and was never diagnosed.

If Present:

Dysuria / urinary frequency.

Dyspareunia (painful vaginal intercourse).

Cervical discharge.

Endocervicitis.

Inflammation of rectum, throat, or conjunctiva.

Mucopurulent vaginal discharge.

Urethritis.

Bartholinitis - inflammation of the Bartholin glands at the vaginal introitus.

Endometritis.

Salpingitis - inflammation of the fallopian tubes.

Abnormal uterine bleeding (AUB).

May progress to pelvic inflammatory disease (PID).

Gonorrhea

Second most common bacterial STI in U.S. (>600,000 cases/year).

Curable with appropriate antibiotics, but increasing antibiotic resistance is a concern.

Many infections are asymptomatic or have nonspecific symptoms that resemble other gynecologic conditions (e.g., endometriosis, AUB).

Highly contagious and reportable to the Department of Public Health.

Bacterium: aerobic, gram‑negative intracellular diplococcus.

Is Gonorrhea Curable?

Yes, with antibiotics

Gonorrhea Site of Infection

Columnar epithelium of the endocervix; the infection can ascend to the uterus and fallopian tubes and contribute to PID and scarring.

Gonorrhea Risk Factors

Under age 25.

Sex without condom.

History of previous STI infection.

Substance misuse (associated risk, not cause‑and‑effect).

New partner.

History of multiple partners.

Gonorrhea Screening

NAAT via genital swab or non‑clean‑catch urine.

Often a single GC/chlamydia swab is sent to evaluate for both infections.

Gonorrhea Treatment

Combination therapy with a cephalosporin plus doxycycline or azithromycin, due to antibiotic resistance.

If chlamydia is also present, combination therapy covers both.

Gonorrhea Symptoms

Mucopurulent vaginal discharge.

Dysuria.

Dyspareunia.

Abnormal uterine bleeding.

Bartholin abscess.

Pelvic/abdominal pain.

May be self‑limiting, but may also progress to PID.

Symptom overlap with chlamydia is common, so diagnosis relies on testing rather than symptoms alone; coinfection is frequent.

Chlamydia & Gonorrhea – Additional Nursing Interventions

Emphasize importance of completing the full course of antibiotics, even if symptoms improve.

Ensure all sexual partners are referred for treatment to prevent reinfection.

Educate about neonatal eye prophylaxis to prevent GC/chlamydial eye infections in newborns (routine prophylaxis after birth).

Arrange for follow‑up testing (test of cure, TOC) to confirm eradication; documentation often shows a positive test earlier in pregnancy followed by a negative TOC later.

Maintain confidentiality if a patient has more than one partner; do not disclose additional partners to a primary partner.

Herpes Simplex Virus (HSV)

Most common lesion‑causing STI (~572,000 new cases/year in the U.S.).

Treatable but not curable: recurrent lifelong infection (belongs in the "uncurable but treatable" category).

Virus family: Herpesviridae.

Types:

-HSV‑1 - mainly oral; often acquired in childhood (cold sores).

-HSV‑2 - mainly genital; usually acquired through sexual transmission.

Can be transmitted at birth if active genital lesions are present; cesarean birth is recommended when lesions are present at delivery.

Is Herpes Simplex Virus (HSV) Curable?

No, it is treatable.

Recurrent and Lifelong

Herpes Simplex Virus (HSV): Site of Infection

Mucous membranes via vaginal, rectal, or oral routes; can also appear on the breast, which temporarily contraindicates breastfeeding if an active lesion is present.

Herpes Simplex Virus (HSV) Risk Factors

Approximately twice as common in female patients.

Inconsistent or no condom use.

Herpes Simplex Virus (HSV) Screening

Diagnosis by culture or PCR from vesicle fluid.

Herpes Simplex Virus (HSV) Treatment

Oral antiviral medications, taken 2-3 times/day for limited courses or daily for suppression.

Common medications include acyclovir, valacyclovir (Valtrex), and similar antivirals.

Pregnant patients with known genital HSV are often given prophylactic antivirals late in pregnancy to reduce risk of an outbreak at delivery.

Herpes Simplex Virus (HSV) Symptoms

Primary episode:

Most severe and prolonged.

Fever, chills, malaise, lymphadenopathy.

Multiple painful vesicular lesions.

Dysuria.

Healing period up to 2 weeks.

Recurrent episodes:

More localized.

Resolve more quickly.

Tingling, itching, pain before lesions appear.

Lesions may be unilateral.

Textbook states 5-8 outbreaks per year on average, but actual frequency varies widely (some have none for years; some have outbreaks with each menstrual cycle).

Typical lesion progression: small red tingling area → vesicle → rupture with highly contagious fluid.

Syphilis

Highly contagious and reportable to public health; >200,000 diagnoses/year.

Second most common lesion‑causing STI.

Usually curable with appropriate antibiotics, but spirochetes can “hide” in the body, which can make established infections harder to treat.

Bacterium: spirochete Treponema pallidum.

Serious systemic disease; if untreated, can affect cardiovascular, neurologic, and other systems and cause psychosis‑like illness.

Has 5 stages of Manifestation if Untreated

Can cross placenta or be transmitted at birth; gross fetal anomalies may be seen on prenatal anatomy ultrasound if infection is present during pregnancy.

Historical note: syphilis rates dropped when penicillin became widely used, but have risen again over the last few decades.

Is Syphilis Curable?

Yes, with antibiotics

Syphilis Site of Infection

Mucous membranes (vaginal, rectal, oral).

Syphilis Risk Factors

Having a diagnosis of another STI.

Inconsistent or no condom use.

Being young and sexually active.

Syphilis Screening

Serologic testing:

-Nontreponemal: RPR/VDRL.

-Treponemal tests.

Syphilis Treatment

Benzathine penicillin G IM (often more than one large, painful injection; need repeat visit).

Doxycycline if allergic to penicillin.

Follow‑up serologic testing to confirm treatment effectiveness.

Syphilis Symptoms: Primary Stage 1

Chancre at site of bacterial entry.

Painless, often unnoticed.

Appears ~3-6 weeks after infection and then disappears, which can cause the infection to be missed.

Syphilis Symptoms: Secondary Stage 2

Maculopapular rash.

Sore throat.

Lymphadenopathy.

Flu‑like symptoms.

Occurs about 2-6 months after infection.

Patients may think they "just have the flu."

Syphilis Symptoms: Early and Late Latent Stages 3 and 4

Typically asymptomatic.

Latent period may last up to 20 years.

Syphilis Symptoms: Tertiary Stage 5

Life‑threatening cardiovascular and CNS effects.

Liver tumors; multi‑system involvement, including neuropsychiatric illness.

May affect skin, eyes, scalp, and other organs.

Generally not treatable once advanced.

Syphilis and HSV – Additional Nursing Interventions

Education:

-Abstain from intercourse if lesions are present because transmission risk is high.

-Avoid extremes of hot/cold (no hot packs or ice packs on lesions).

-Wear cotton underwear and loose‑fitting clothing if lesions are present.

-Take medications as ordered.

-Track HSV symptoms to identify individual triggers (e.g., stress, menses).

Pregnancy counseling:

-Review potential irreversible fetal anomalies and congenital infection outcomes, depending on timing of maternal infection.

Human Papilloma Virus (HPV)

Most common STI in the U.S.; ~80% of sexually active people will acquire at least one strain in their lifetime.

Virus family: Papillomaviridae.

>150 strains carried by humans; ~40 affect genital tract.

Strains 6 and 11 cause genital warts (condylomata).

At least 14 high‑risk strains are associated with increased cervical cancer risk; number may now be higher as more are identified.

Wart‑causing strains and cancer‑associated strains are different “families” of HPV.

Spread via genital and/or anal contact; oral contact may also transmit certain strains and is associated with some oral cancers.

Condoms are recommended and may lower risk, but they do not fully prevent HPV transmission due to skin‑to‑skin spread.

Is Human Papilloma Virus (HPV) Curable?

No, it is treatable

The body may permanently clear some strains, but HPV is categorized as "not curable but treatable."

Human Papilloma Virus (HPV) Risk Factors

Multiple sex partners.

Young, sexually active individuals, especially ages 15-25.

Human Papilloma Virus (HPV) Screening

Pap smear every 3-5 years for low‑risk females ≥21 years to detect cervical cell changes.

HPV testing via vaginal or cervical swab.

Biopsy of visible lesions when present.

Human Papilloma Virus (HPV) Treatment

Prevention with Gardasil vaccine:

-Recommended for people of all genders and sexual orientations, typically ages 11-26 per the lecture/testing emphasis.

No cure; topical medications and procedures can remove warts but lesions may recur.

Human Papilloma Virus (HPV) Symptoms

Warts/condylomata:

-Lumps or sores on genital/anal area, vaginal walls, or cervix.

-Can be flat or raised, painful or painless.

-May cause pain with lesions, post‑coital bleeding, or abnormal discharge.

Non‑wart high‑risk strains are often clinically silent; patients may not know they are infected without screening.

Human Papilloma Virus (HPV) Additional Nursing Interventions

Education:

Abstinence is the only way to completely avoid STI risk.

HPV vaccines provide primary prevention and are about 90% effective at preventing disease from targeted strains, but not 100%.

Stress importance of recommended cervical cancer screening.

Teach medication/procedure expectations for symptom relief.

Explain the connection between HPV and cervical (and some other) cancers.

Human Immunodeficiency Virus (HIV)

Approximately 1.2 million people in the U.S. are living with HIV.

Retrovirus; treatable but not curable. With modern ART, HIV is often managed as a chronic disease state.

Human Immunodeficiency Virus (HIV) Modes of Transmission

Sexual contact.

Exposure to infected blood.

Perinatal transmission (pregnancy, birth, breastfeeding).

Human Immunodeficiency Virus (HIV) Perinatal Care History

Previously, IV AZT during labor was routinely given to reduce vertical transmission; with current ART and viral suppression, this is rarely needed.

Effective ART that keeps viral load undetectable greatly reduces perinatal transmission risk.

Human Immunodeficiency Virus (HIV) Risk Factors

Having another STI.

Not using or inconsistently using condoms.

Multiple sexual partners.

Sharing contaminated needles for IV drug use.

Engaging in sex work.

Human Immunodeficiency Virus (HIV) Screening

Nucleic acid tests.

Antibody tests.

Antibody/antigen tests.

Viral load testing.

Human Immunodeficiency Virus (HIV) Treatment

Antiretroviral therapy (ART) - daily pills or long‑acting injections given monthly or every 2 months.

Many key ART advances were developed in San Francisco, which has a major historical role in HIV care.

Human Immunodeficiency Virus (HIV) Manifestations: Phase 1: Acute primary infection

Onset 2-6 weeks after exposure.

Flu‑like symptoms and/or rash may or may not occur.

Symptoms usually last about 3 weeks.

Seroconversion detectable by blood tests around 3-12 months after infection; viral load is often relatively low early on.

Human Immunodeficiency Virus (HIV) Manifestations: Phase 2: Chronic HIV

Virus continues to replicate.

Often asymptomatic or mild, nonspecific symptoms.

Human Immunodeficiency Virus (HIV) Manifestations: Phase 3: AIDS

CD4 T‑cell count <200.

Severe immune compromise with increased risk of opportunistic infections and cancers.

Human Immunodeficiency Virus (HIV) Additional Nursing Interventions

Education:

-Safer sex practices for prevention.

-Importance of adhering to ART regimen.

-Strategies to prevent perinatal transmission tailored to viral load and treatment adherence.

-PrEP for HIV‑negative partners to prevent acquisition.

Support:

-Provide or coordinate referrals for counseling, peer support, and substance use treatment if needed.

-Educate about diagnosis, transmission, and long‑term outlook; many patients still equate HIV with a terminal diagnosis despite dramatically improved outcomes.

-Help patients navigate insurance and access barriers to obtain medication and follow‑up.

Hepatitis A, B, and C

Vaccines available for Hepatitis A and B (primary prevention).

Major chronic concern is liver damage.

Nursing management: screening and vaccination (for A and B).

Hepatitis A

Spread via GI tract; usually fecal‑oral route (often foodborne), less commonly sexual.

Hepatitis B

Spread via saliva, blood, semen, menstrual blood, and vaginal secretions; bloodborne pathogen.

Hepatitis C

May spread through sexual contact but less commonly; often bloodborne (e.g., IV drug use).

Body may clear infection; chronic infection is common.

Direct‑acting antivirals (DAAs) can be curative.

Trichomoniasis

Single‑celled protozoan parasite.

Sexually transmitted and also found in damp environments like hot tubs, drains, wet bathing suits, and towels.

Consider trichomoniasis if empiric GC/chlamydia treatment fails and cultures are negative.

Trichomoniasis Treatment

Metronidazole or tinidazole for 5-7 days; treat partner as well to prevent reinfection.

Trichomoniasis Symptoms

May be asymptomatic or may cause dysuria, urinary frequency, vaginal discharge, dyspareunia, and genital irritation.

Chancroid

Bacterium: Haemophilus ducreyi.

Painful lesions, dyspareunia, dysuria, etc.

Treat with antibiotics.

Ectoparasitic Infections

Scabies.

Pubic lice (crabs).

Pelvic Inflammatory Disease (PID)

STI Complications

Result of ascending polymicrobial infection of the upper female reproductive tract.

Often due to untreated chlamydia or gonorrhea.

Complications: pain, scarring, infertility.

Pelvic Inflammatory Disease (PID) Therapeutic Management

Empiric broad‑spectrum antibiotics.

Oral fluids.

Bed rest.

Pain management.

Pelvic Inflammatory Disease (PID) Nursing Assessment

Risk factors:

Existing STI infection.

IUD use.

Not using safer sex practices.

Pelvic Inflammatory Disease (PID) Manifestations

Lower abdominal tenderness.

Adnexal tenderness.

Cervical motion tenderness on pelvic exam.

Fever.

Dysmenorrhea.

Dysuria.

Dyspareunia.

Pelvic Inflammatory Disease (PID) Diagnosis

Endometrial biopsy.

Transvaginal ultrasound.

Laparoscopic examination when diagnosis is unclear.

Pelvic Inflammatory Disease (PID) Nursing Management

Hydration and analgesics.

Education to prevent recurrence (see Teaching Guidelines 5.4).

Risk assessment and helping the patient identify factors that increase risk (e.g., STI exposure, condom use).

Vulvovaginal Candidiasis

Non STI Infection

Fungal/yeast infection (overgrowth of normal vaginal yeast).

Vulvovaginal Candidiasis Risk Factors

Antibiotic use (removes protective bacteria).

Diabetes, especially if blood sugar is poorly controlled.

Obesity.

Estrogen‑containing oral contraceptives.

Immunosuppression.

Tight clothing that does not breathe.

Vulvovaginal Candidiasis Symptoms

Pain.

Dyspareunia.

Intense itching.

Thick, white "cottage cheese" vaginal discharge.

Vulvovaginal Candidiasis Treatments

Oral antifungal (e.g., fluconazole/Diflucan).

Vaginal antifungal (e.g., miconazole), often OTC.

Patients with prior documented yeast infection may be advised to self‑treat future similar episodes with OTC vaginal antifungals.

Vulvovaginal Candidiasis Nursing Management

Cotton underwear.

Avoid douches and irritating products.

Good perineal hygiene.

Bacterial Vaginosis (BV)

Overgrowth of bacteria in the vaginal microbiome (often thought of as the “opposite” of yeast infection).

Most prevalent cause of abnormal vaginal discharge; 50–75% of cases are asymptomatic.

The textbook and NCLEX generally classify BV as non‑STI, but the instructor noted emerging data that partner‑related transmission may occur (keep an asterisk in mind for the future).

Many patients feel embarrassed by odor and delay care; reassure them that GYN clinicians are familiar with BV and will not judge them.

Bacterial Vaginosis (BV) Symptoms

(if present):

Gray/white discharge.

Pain, burning.

Fishy odor.

Bacterial Vaginosis (BV) Treatment

Metronidazole (Flagyl) or clindamycin.

Bacterial Vaginosis (BV) Risk Factors

Multiple sex partners.

Douching (alters vaginal pH and microbiome).

Lack of vaginal lactobacilli.

Gonorrhea Maternal Effects

Chorioamnionitis, spontaneous abortion, preterm birth, PROM, IUGR, and postpartum sepsis

Gonorrhea Fetal Effects

Pharyngeal and eye infection (gonococcal ophthalmia), which can cause blindness

Candidiasis Maternal Effects

Resistant to treatment during pregnancy; uncomfortable localized genital itching and discharge

Candidiasis Fetal Effects

Can acquire thrush in the mouth during birthing process if birthing parent infected

Trichomoniasis Maternal Effects

Has been implicated in causing PROM and preterm births

Trichomoniasis Fetal Effects

Risk of prematurity and low birth weight

Bacterial vaginosis Maternal Effects

Increases risk for spontaneous abortion, PROM, chorioamnionitis, postpartum endometritis, and preterm labor

Bacterial vaginosis Fetal Effects

Risk of low birth weight and neonatal sepsis

Chlamydia Maternal Effects

Postpartum endometritis, PROM, and preterm birth

Chlamydia Fetal Effects

Conjunctivitis, which can lead to blindness, low birth weight, neonatal sepsis, and pneumonitis

Genital herpes Maternal Effects

Spontaneous abortion, intrauterine infection, preterm labor, PROM, and IUGR

Genital herpes Fetal Effects

Contamination during birth, newborn can develop skin or mouth sores, birth anomalies, neurologic impairment, and transplacental infection

Syphilis Maternal Effects

Spontaneous abortion, preterm birth, and stillbirth

Syphilis Fetal Effects

Congenital syphilis, leading to multisystem organ failure and structural damage as well as intellectual disability

Human papillomavirus Maternal Effects

May cause dystocia if large wartlike genital lesions

Human papillomavirus Fetal Effects

May develop warts in throat, uncommon but life-threatening

Hepatitis B Maternal Effects

May cause preterm birth; can be transmitted to fetus if active in last trimester

Hepatitis B Fetal Effects

Can become chronic carrier of hepatitis B, which may lead to liver cancer or cirrhosis

Human immunodeficiency virus Maternal Effects

Fatigue, nausea, and weight loss

Human immunodeficiency virus Fetal Effects

Transmission can occur transplacentally, during childbirth or through breast milk.