Ch.7 STI & Vaginal Infections Lecture notes (Completed)

Overview of Sexually Transmitted and Reproductive Tract Infections

• Definition and Scope:

  • Reproductive tract infections (RTIs) encompass both sexually transmitted infections (STIs) and other common infections of the genital tract.

  • According to the World Health Organization (WHO, 2024), STIs are spread predominantly through unprotected sexual contact.

  • Common STIs specifically noted in women include:

    • Chlamydia (CT).

    • Gonorrhea (GC).

    • Human Papillomavirus (HPV).

    • Herpes Simplex Virus (HSV) Type 2.

    • Syphilis.

    • Human Immunodeficiency Virus (HIV).

• Organism Types:

  • Infections are caused by various types of organisms:

    • Bacteria.

    • Viruses.

    • Protozoa.

    • Parasites.

Prevention and Risk Reduction Strategies

• Prevention Levels:

  • Primary Prevention: Focused on public education to prevent the acquisition of infections.

  • Secondary Prevention: Focused on early diagnosis and prompt treatment (tx) to prevent complications and further transmission.

• Risk Reduction Framework (Table 7.1):

  • Safest Behaviors:

    • Abstinence.

    • Self-masturbation or mutual masturbation.

    • Monogamous relationships where neither partner engages in high-risk (h/r) behaviors and both have tested negative for STIs.

    • Hugging and kissing.

  • Low but Potential Risk:

    • Wet kissing.

    • Vaginal or anal intercourse with consistent use of condoms.

    • Monogamous relationships where partners do not engage in h/r behaviors but have not been tested for STIs.

    • Oral sex with a woman (using dental dams or plastic wrap).

    • Oral sex with a man using a condom.

  • High-Risk (Unsafe) Behaviors:

    • Unprotected anal or vaginal intercourse.

    • Maintaining multiple sex partners without STI testing.

    • Sharing sex toys or douching equipment.

    • Sharing needles or using illicit drugs.

• Nursing Assessment and the "5 P's":

  • When obtaining a sexual history, nurses should use open-ended questions and implement the 5 P's:

    1. Partners: Number and gender of partners.

    2. Practices: Types of sexual activities.

    3. Protection from STIs: Consistency and type of barrier methods used.

    4. Past History of STIs: Previous diagnoses and treatments.

    5. Pregnancy Intention: Plans for future children to guide care and counseling.

Sexually Transmitted Bacterial Infections

• Chlamydia (CT):

  • Causative Organism: Chlamydia trachomatis.

  • Symptoms: Usually "silent" (asymptomatic), purulent vaginal discharge, and post-coital bleeding.

  • Predisposing Factors: Risky sexual behaviors, lower socioeconomic bracket.

  • Effects/Complications: Ectopic pregnancy, infertility, cervicitis, salpingitis, pelvic inflammatory disease (PID), and ophthalmia neonatorum (in newborns).

  • Screening & Diagnosis: Recommended for sexually active women in the $20-25$ age group and all pregnant women; diagnosed via cervical cultures.

  • Management: Azithromycin or Doxycycline. Retest pregnant women $3-4$ weeks following treatment; all sex partners must be treated.

• Gonorrhea (GC):

  • Causative Organism: Neisseria gonorrhea (Gram-negative bacteria).

  • Symptoms: Often absent, but may include purulent discharge, lower abdominal pain, and painful menstruation (dysmenorrhea).

  • Transmission: Sexual contact of any mode.

  • Effects/Complications: Similar to chlamydia (PID, infertility, etc.).

  • Screening & Diagnosis: Endocervical cultures.

  • Management: Ceftriaxone (Rocephin) administered intramuscularly (IM). Includes counseling, condom education, and contacting all partners for exam, cultures, and treatment.

• Syphilis:

  • Causative Organism: Treponema pallidum (spirochete). Can cross placenta and infect fetus.

  • Stages of Infection:

    • Primary: Characterized by a lesion or chancre.

    • Secondary: Characterized by a rash on the soles of feet and palms of hands.

    • Latent Phase: Asymptomatic stage.

    • Tertiary: Results from untreated syphilis; affects multiple organs and systems.

  • Transmission: Via subcutaneous tissue through microscopic abrasions during sexual intercourse, kissing, biting, or oral-genital sex.

  • Diagnosis: Serology tests including non-treponemal tests (VDRL or RPR) and treponemal tests (FTA-ABS).

  • Management: Benzathine penicillin G and patient education.

• Pelvic Inflammatory Disease (PID):

  • Causative Organism: Multiple (often follows GC or CT infections).

  • Presentation: Pain, fever, vaginal discharge, and cervical motion tenderness.

  • Effects/Complications: Ectopic pregnancies, infertility, dyspareunia (painful intercourse), tubo-ovarian abscesses, and pelvic adhesions.

  • Management: Antibiotics, analgesia, and documentation of prior STIs.

Sexually Transmitted Viral Infections

• Human Papillomavirus (HPV):

  • Types: Many types exist; Types $16$ and $18$ specifically predispose individuals to reproductive health cancers.

  • Clinical Presentation: Soft papillary lesions on external genitalia, posterior introitus, or buttocks. Can be single or clustered (cauliflower appearance). Painless flesh-colored or dark papules may appear on the vagina or cervix.

  • Management: Oatmeal baths for comfort, cotton underwear, limiting sex partners, and yearly gynecological exams/Pap smear screenings. Prophylactic vaccination with Gardasil is recommended.

• Genital Herpes Simplex Virus (HSV):

  • Types:

    • HSV-1: Related to oral blisters (cold sores). (not sexually trasmitted)

    • HSV-2: Predominantly sexually transmitted.

  • Clinical Presentation: Fever, chills, malaise, tender genital lesions (vesicles), and lymphadenopathy.

  • Complications: Miscarriage in the first trimester of pregnancy and neonatal herpes.

  • Management: Secretion cultures for diagnosis, normal saline (NS) cleansing, analgesics, and antiviral medication (Acyclovir). Cesarean section (C/S) delivery is required if active lesions are present at the time of labor.

• Viral Hepatitis:

  • Hepatitis A: Acquired via the fecal-oral route.

  • Hepatitis B: Transmitted sexually or through blood transfusions. Symptoms include nausea/vomiting, fever, abdominal pain, and late-stage jaundice/clay-colored stools. Mandatory screening for all pregnant women and healthcare providers. Newborns of Hep B+ mothers require Hepatitis B immune globulin (HBIg) and the vaccine.

  • Hepatitis C: Transmission route is similar to Hepatitis B.

  • Management General: Bedrest and specific dietary recommendations.

• Human Immunodeficiency Virus (HIV):

  • Pathophysiology: Severe depression of the cellular immune system, leading to Acquired Immunodeficiency Syndrome (AIDS).

  • Presentation: May be asymptomatic; seroconversion occurs within $6-12$ weeks. Symptoms include flu-like illness, increased erythrocyte sedimentation rate (ESR), and decreased white blood cell (WBC) and platelet counts. CD4 counts correlate with AIDS progression and death.

  • Pregnancy Transmission: Increased risk during the perinatal period.

  • Diagnosis: Western Blot confirmed screening test.

  • Management during Pregnancy:

    • Oral Zidovudine during pregnancy.

    • ART (Antiretroviral Therapy) or HAART (Highly Active Antiretroviral Therapy) given IV during labor and prior to C/S.

    • Delivery mode depends on viral load.

    • Post-delivery: No breastfeeding; oral Zidovudine administered to the newborn 6-8 hours after birth.

• Zika Virus:

  • Transmission: Bites from the Aedes mosquito, sexual contact via semen, and from pregnant woman to fetus.

  • Complications: Associated with Guillain-Barre syndrome.

  • Diagnosis/Testing: Blood draw, prenatal ultrasound findings, and newborn assessment for microcephaly.

Vaginal and Other Infections

• Normal Vaginal Findings:

  • Leukorrhea: Clear to cloudy discharge.

  • Characteristics: Nonirritating and inoffensive odor.

  • pH: Acidic ($3.8-4.5$).

  • Composition: Contains lactobacilli and epithelial cells.

• Abnormal Vaginal Findings:

  • Heavy or offensive discharge.

  • Changes in color (e.g., yellow, green, or frothy).

  • Itching (pruritus).

• Bacterial Vaginosis (BV):

  • Causative Organism: Gardnerella vaginalis.

  • Etiology: Lack of lactobacilli and increase in anaerobic bacteria, leading to an alteration in vaginal pH.

  • Predisposing factors: New/multiple sex partners, douching, and lack of lactobacilli.

  • Presentation: Fishy odor and thin, frothy discharge.

  • Diagnosis: Normal saline wet mount and the Whiff test.

  • Management: Metronidazole.

• Trichomoniasis:

  • Causative Organism: T. Vaginalis (protozoa).

  • Presentation: Yellow to green frothy discharge, malodorous, vulval/vaginal inflammation, and petechiae on the cervix (known as "strawberry spots").

  • Diagnosis: Nucleic acid amplification test (NAAT) or saline wet mount.

  • Management: Metronidazole for both partners; no sexual intercourse (SI) until the full course of treatment is completed.

• Candidiasis (Yeast Infection):

  • Causative Organism: Candida albicans.

  • Predisposing Factors: Antibiotic therapy, Diabetes Mellitus (DM), pregnancy, and tight-fitting clothing.

  • Presentation: Pruritus (itching), dysuria, and lumpy white ("cottage cheese") discharge.

  • Management: Antifungal oral and/or topical medications such as Monistat or Clotrimazole.

• Group B Streptococcus (GBS):

  • Context: Part of normal flora in nonpregnant women; present in $25\%$ of pregnant women.

  • In-Labor Management: Prophylactic antibiotics. Loading dose of Penicillin G ($5 \text{ million units}$ IV), followed by $2.5 \text{ million units}$ every $4 \text{ hours}$ until delivery.

TORCH Infections and Global Health Concerns

• TORCH Profile (Table 7.6):

  • T: Toxoplasmosis (protozoa).

  • O: Other infections (including Hepatitis A and B).

  • R: Rubella (German Measles).

  • C: Cytomegalovirus (CMV, a herpes virus).

  • H: Herpes Genitalis (HSV I or II).

• Vaginal Health Education:

  • Emphasis on hygiene and appropriate clothing.

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

  • Importance of annual gynecological visits.

  • Adherence to medication regimens to avoid reinfection.

• U.S. STI Statistics (CDC, 2023):

  • In 2023, over $2.4 \text{ million}$ cases of syphilis, gonorrhea, and chlamydia were reported.

  • Syphilis: Over $209,000$ cases.

  • Gonorrhea: Over $600,000$ cases.

  • Chlamydia: Over $1.6 \text{ million}$ cases.

  • Congenital Syphilis: Includes $3,882$ cases, resulting in $279$ stillbirths or neonatal/infant deaths.