Focus on Sexually Transmitted Diseases STDs Relates to

Focus on Sexually Transmitted Diseases (STDs) (Relates to Chapter 53, “Nursing Management: Sexually Transmitted Diseases, ” in the textbook) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc.

Sexually Transmitted Diseases Infectious diseases most commonly transmitted through sexual contact l Can also be transmitted by l • Blood products • Autoinoculation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 2

Sexually Transmitted Diseases Estimated 65 million Americans infected with one or more STDs l Additional 19 million newly infected each year l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

Sexually Transmitted Diseases Can be bacterial or viral l Usually start as lesions on genitals or mucous membranes and can spread to other areas l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 4

Sexually Transmitted Diseases l Latent or subclinical phase present with all STDs • Leads to long-term persistent infection • Contributes to the transmission of disease from asymptomatic (but infected) person to another person Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 5

Sexually Transmitted Diseases l All cases of gonorrhea and syphilis (and in most states chlamydia) must be reported to state or local public health authorities. • Still underreported Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 6

Sexually Transmitted Diseases l Contributing factors to STD rates • Earlier reproductive maturity • Longer sexual life span • Greater sexual freedom • Media emphasis • Lack of barrier methods during sexual activity Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Sexually Transmitted Diseases l Changes in methods of contraception • Condom is best protection against STDs but still is not used frequently in general population. • Oral contraceptive effects on acidity of vaginal/cervical secretions promote growth of certain organisms, causing STDs. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Gonorrhea Second most frequently reported STD in the United States l Since 2006, infection rate has been increasing. l • More than 700, 000 new cases each year Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Gonorrhea l Highest incidence • Adolescents • African Americans Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 10

Gonorrhea Etiology and Pathophysiology l Caused by Neisseria gonorrheae • Gram-negative bacteria • Direct physical contact with infected host • Mucosa with columnar epithelium is susceptible. • Present in genitalia, rectum, and oropharynx Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 11

Gonorrhea Etiology and Pathophysiology Easily killed by drying, heating, or washing with antiseptic l Incubation period: 3 to 8 days l Provides no immunity to subsequent reinfection l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Gonorrhea Etiology and Pathophysiology l Elicits inflammatory process that can lead to fibrous tissue and adhesions • Tubal pregnancy • Chronic pelvic pain • Infertility in women Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

Gonorrhea Clinical Manifestations l Men • Initial site infection is urethra. • Symptoms • Develop 2 to 5 days after infection • Dysuria • Profuse, purulent urethral discharge • Unusual to be asymptomatic Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Gonococcal Urethritis Fig. 53 -1. Profuse, purulent drainage in a patient with gonorrhea. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Gonorrhea Clinical Manifestations l Women • Mostly asymptomatic or have minor symptoms • Vaginal discharge • Dysuria • Frequency of urination Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 16

Gonorrhea Clinical Manifestations l Women (cont’d) • After incubation • Redness and swelling occur at site of contact. • Greenish, yellow purulent exudate often develops. • May develop abscess Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 17

Endocervical Gonorrhea Fig. 53 -2. Endocervical gonorrhea. Cervical redness and edema with discharge. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 18

Gonorrhea Clinical Manifestations l Women (cont’d) • Disease may remain local or may spread by tissue extension to uterus, fallopian tubes, and ovaries. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 19

Gonorrhea Clinical Manifestations l Anorectal gonorrhea • Usually from anal intercourse • Few symptoms • Include soreness, itching, and discharge of anus Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 20

Gonorrhea Clinical Manifestations l Orogenital • Few symptoms • Gonococcal pharyngitis can develop. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 21

Gonorrhea Complications l Men • Include prostatitis, urethral strictures, and sterility • Often seek treatment early, so less likely to develop complications Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 22

Gonorrhea Complications l Women • Include pelvic inflammatory disease (PID), Bartholin’s abscess, ectopic pregnancy, and infertility • Usually asymptomatic, so seldom seek treatment Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 23

Gonorrhea Complications l Women (cont’d) • Small percentage develop disseminated gonococcal infection (DGI). • Skin lesions, fever, arthralgia, arthritis, or endocarditis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 24

Disseminated Gonococcal Infection (DGI) Fig. 53 -3. Skin lesions with disseminated gonococcal infection. A, On the hand. B, On the fifth toe. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 25

Gonorrhea Clinical Manifestations l Eye infections in newborns • Instillations of prophylactic erythromycin (0. 5%) ophthalmic ointment or silver nitrate (0. 1%) aqueous solution • Untreated infants develop permanent blindness. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 26

Gonorrhea Diagnostic Studies History and physical examination l Laboratory tests l • Gram-stained smear to identify organism • Culture of discharge • Nucleic acid amplification test • Testing for other STDs Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 27

Gonorrhea Diagnostic Studies l Women • Smears and discharge do not establish diagnosis. • Female GU tract harbors organisms resembling N. gonorrhea. • Must have culture to confirm diagnosis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 28

Gonorrhea Collaborative Care l Drug therapy • Treatment generally instituted without culture results • Treatment in early stage is curative. • Most common • Oral dose of cefixime (Suprax) • IM dose of ceftriaxone (Rocephin) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 29

Gonorrhea Collaborative Care l Drug therapy (cont’d) • Fluoroquinolones are no longer used. • Patients with coexisting syphilis are likely to be treated with azithromycin (Zithromax) or doxycycline (Vibramycin). Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 30

Gonorrhea Collaborative Care All sexual contacts of patients must be evaluated and treated. l Patient should be counseled to abstain from sexual intercourse and alcohol during treatment. l Reexamine if symptoms persist after treatment. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 31

Syphilis About 11, 500 cases annually l Mainly due to men who have sex with men l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 32

Syphilis Etiology and Pathophysiology l Caused by Treponema pallidum • Spirochete bacterium • Enters the body through breaks in skin or mucous membranes • Facilitated by abrasions that occur during sexual intercourse Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 33

Syphilis Etiology and Pathophysiology Complex disease in which many organs and tissues can become infected l Causes production of antibodies that react with normal tissues l Not all exposures cause disease. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 34

Syphilis Etiology and Pathophysiology Destroyed by drying, heating, or washing l May also be spread through l • Contact with infectious lesions • Sharing of needles among IV drug users Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 35

Syphilis Etiology and Pathophysiology Incubation 10 to 90 days l Spread in utero after 10 th week of pregnancy l • Infected mother has a greater risk of stillbirth or of having a baby who dies shortly after birth. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 36

Syphilis Etiology and Pathophysiology Association with HIV l Syphilitic lesions on the genitals enhance HIV transmission. l Evaluation of all patients with syphilis includes testing for HIV with patient’s consent. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 37

Syphilis Clinical Manifestations Variety of signs/symptoms can mimic another disease. l Primary stage l • Chancres appear. • Painless indurated lesions • Occur 10 to 90 days after inoculation • Lasting 3 to 6 weeks Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 38

Syphilis Complications Occur most often in late syphilis l Gummas can produce irreparable damage to bone, liver, or skin. l Aneurysm may press on structures such as intercostal nerves, causing pain. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 39

Syphilis Complications l Neurosyphilis causes degeneration of brain with mental deterioration. • Neurologic deficits possible l Tabes dorsalis causes nerve involvement. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 40

Syphilis Complications Sudden attacks of pain l Loss of vision and sense of position l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 41

Syphilis Diagnostic Studies History, including sexual history l PE l • Examine lesions. • Note signs/symptoms. Dark-field microscopy l Serologic testing l Testing for other STDs l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 42

Syphilis Collaborative Care l Drug therapy • Benzathine penicillin G (Bicillin) • Aqueous procaine penicillin G • Recurring or persistent symptoms after drug therapy are re-treated. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 43

Syphilis Collaborative Care Monitor neurosyphilis with periodic serologic testing, clinical evaluation, and repeat CSF exams. l Confidential counseling and HIV testing l Surveillance l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 44

Chlamydial Infections Most commonly reported STD in the United States l Incidence is 3 times higher in women than in men. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 45

Chlamydial Infections l Major contributor to • PID • Ectopic pregnancy • Infertility in women • Nongonococcal urethritis in men Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 46

Chlamydial Infections Etiology and Pathophysiology l Caused by Chlamydia trachomatis • Gram-negative bacteria Largely underreported because infected persons are asymptomatic l Transmitted during vaginal, anal, or oral sex l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 47

Chlamydial Infections Etiology and Pathophysiology Closely associated with gonococcal infections l Incubation period: 1 to 3 weeks l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 48

Chlamydial Infections Etiology and Pathophysiology l Risk factors • Women and adolescents • New or multiple sexual partners • Sexual partners who have had multiple partners Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 49

Chlamydial Infections Etiology and Pathophysiology l Risk factors • History of STDs and cervical ectopy • Coexisting STDs • Inconsistent or incorrect use of condoms Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 50

Chlamydial Infections Clinical Manifestations l “Silent disease” l Infection often is not diagnosed until complications appear. • Symptoms may be absent or minor. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 51

Chlamydial Infections Clinical Manifestations l Men • Urethritis • Dysuria • Urethral discharge • Proctitis • Rectal discharge • Pain during defecation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 52

Chlamydial Infections Clinical Manifestations l Men (cont’d) • Epididymitis • Unilateral scrotal pain • Swelling • Tenderness • Fever • Possible infertility and reactive arthritis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 53

Chlamydial Infection Fig. 53 -7. Chlamydial epididymitis. Red, swollen scrotum. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 54

Chlamydial Infections Clinical Manifestations l Women • Cervicitis • Mucopurulent discharge • Hypertrophic ectopy • Urethritis • Dysuria • Frequent urination • Pyuria Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 55

Chlamydial Infections Clinical Manifestations l Women (cont’d) • Bartholinitis • Purulent exudate • Perihepatitis • Fever, nausea, vomiting, right upper quadrant pain Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 56

Chlamydial Infections Clinical Manifestations l Women (cont’d) • PID • Abdominal pain, nausea, vomiting, fever, malaise, abnormal vaginal bleeding, menstrual abnormalities • Can lead to chronic pain and infertility Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 57

Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 58

Chlamydial Infections Diagnostic Studies l Laboratory tests • Nucleic acid amplification test (NAAT) • Direct fluorescent antibody (DFA) • Enzyme immunoassay (EIA) • Testing for other STDs • Culture for chlamydia Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 59

Chlamydial Infections Diagnostic Studies l Cervical or urethral discharge less purulent, watery, and painful in chlamydia than in gonorrhea Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 60

Chlamydial Infections Collaborative Care l Drug therapy • Doxycycline (Vibramycin) • 100 mg bid for 7 days • Azithromycin (Zithromax) • 1 g in single dose Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 61

Chlamydial Infections Collaborative Care Abstinence from sexual intercourse for 7 days after treatment l Follow-up care for persistent symptoms l Treatment of partners l Encouraging use of condoms l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 62

Genital Herpes Not a reportable disease in most states l True incidence difficult to determine l More than 45 million infected in the United States l • 1 in 5 Americans Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 63

Genital Herpes Etiology and Pathophysiology Caused by herpes simplex virus (HSV) l Enters through mucous membranes or breaks in the skin during contact with infected persons l HSV reproduces inside cell and spreads to surrounding cells. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 64

Genital Herpes Etiology and Pathophysiology Virus enters peripheral or autonomic nerve endings. l Ascends to sensory or autonomic nerve ganglion, where it is dormant l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 65

Genital Herpes Etiology and Pathophysiology Recurrence when virus descends to initial site of infection l Persists for life l Virus sheds even in absence of lesion. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 66

Genital Herpes Etiology and Pathophysiology l Two different strains • HSV-1 • Causes infection above the waist • HSV-2 • Frequently infects genital tract and perineum l Either strain cause disease on mouth or genitals. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 67

Genital Herpes Clinical Manifestations l Primary (initial) episode • Burning or tingling at site • Small vesicular lesion appear on penis, scrotum, vulva, perineum, perianal areas, vagina, or cervix. • Vesicles contain large quantities of infectious virus particles. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 68

Unruptured Vesicles Fig. 53 -8. Unruptured vesicles of herpes simplex virus type 2 (HSV-2). A, Vulvar area. B, Perianal area. C, Penile herpes simplex, ulcerative stage. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 69

Genital Herpes Clinical Manifestations l Primary (initial) episode (cont’d) • Lesions rupture and form ulcerations. • Crusting and epithelialization occur. • Tend to be associated with local inflammation and pain with systemic manifestations • Including fever, headache, malaise, myalgia, and regional lymphadenopathy Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 70

Genital Herpes Clinical Manifestations l Primary (initial) episode (cont’d) • Urination may be painful from urine touching lesion. • Purulent vaginal discharge may develop. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 71

Genital Herpes Clinical Manifestations l Primary (initial) episode (cont’d) • Primary lesions present for 17 to 20 days • New lesions sometimes continue to develop for 6 weeks. • Lesions heal spontaneously. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 72

Genital Herpes Clinical Manifestations l Recurrent genital herpes • Occurs in 50% to 80% in following year • Triggers • Stress • Fatigue • Sunburn • Menses Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 73

Genital Herpes Clinical Manifestations Women with recurrent symptoms shed virus up to 1% of the time, even with no lesions present. l Suppressive therapy reduces but does not eradicate shredding. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 74

Genital Herpes Clinical Manifestations Condoms or abstinence l With lesions, sexual activity should be avoided. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 75

Genital Herpes Complications Aseptic meningitis l Lower neuron damage l • Atonic bladder • Impotence • Constipation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 76

Genital Herpes Complications l Autoinoculation to extragenital sites • Lips, breasts, and fingers l High risk of transmission in pregnancy with episode near delivery • Active lesion is indication for cesarean section. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 77

Autoinoculation of Herpes Simplex Virus Fig. 53 -9. Autoinoculation of herpes simplex virus (HSV) to the lips. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 78

Genital Herpes Complications l Herpes simplex virus keratitis • HSV infection of the eye • Resolves within 1 to 2 weeks • Can progress to ulcers • Most common cause of corneal ulceration and blindness in the United States • May result in scarring of the cornea and vision impairment Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 79

Genital Herpes Complications l Herpes simplex virus keratitis (cont’d) • Treatment • Topical antiviral agents • Systemic acyclovir • Ulcer may need to be debrided. • Corneal transplant may be needed. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 80

Genital Herpes Diagnostic Studies History and physical examination l Viral isolation by tissue culture l Antibody assay for specific HSV viral type l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 81

Genital Herpes Collaborative Care l Drug therapy • Inhibit viral replication • Suppress frequent recurrences • Acyclovir (Zovirax) • Valacyclovir (Valtrex) • Famciclovir (Famvir) • Not a cure, but shorten duration and healing time and reduce outbreaks Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 82

Genital Herpes Collaborative Care l Symptomatic care • Genital hygiene • Loose-fitting cotton underwear • Lesions clean and dry • Sitz baths • Barrier methods during sexual activity Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 83

Genital Warts Estimated 20 million Americans are currently infected. l Most common STD in the United States l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 84

Genital Warts Etiology and Pathophysiology l Caused by human papillomavirus (HPV) • Usually types 6 and 11 Highly contagious l Frequently seen in young, sexually active adults l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 85

Genital Warts Etiology and Pathophysiology Minor trauma causes abrasions for HPV to enter and proliferate into warts. l Epithelial cells infected undergo transformation and proliferation to form a warty growth. l Incubation period: 3 to 4 months l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 86

Genital Warts Clinical Manifestations Discrete single or multiple growths l White to gray and pink-fleshed colored l May form large cauliflower-like masses l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 87

Genital Warts Fig. 53 -10. Genital warts. A, Severe vulvular warts. B, Perineal wart. C, Multiple genital warts of the glans penis. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 88

Genital Warts Clinical Manifestations Itching may occur with anogenital warts. l Bleeding on defecation may occur with anal warts. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 89

Genital Warts Clinical Manifestations Rapid growth with pregnancy l Transmitted to newborn l Linked with cervical and vulvar cancer in women l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 90

Genital Warts Clinical Manifestations Linked with anorectal and squamous cell carcinoma of penis in men l More than 100 types identified l • Some harmless and self-limiting, while others have oncogenic potential • Two thirds of early lesions are undetectable by visual examination. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 91

Genital Warts Diagnostic Studies l Diagnosis on basis of appearance of lesions • May be confused with other diseases Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 92

Genital Warts Diagnostic Studies l Serologic and cytologic tests • HPV DNA test to determine if women with abnormal Pap test results need follow-up • Identify women who are infected with high-risk HPV strains Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 93

Genital Warts Diagnostic Studies l Primary goal: removal of symptomatic warts • Removal may or may not decrease infectivity. • Difficult to treat • Often require multiple office visits and variety of treatment modalities Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 94

Genital Warts Collaborative Care l Treatments • Chemical • Trichloroacetic acid (TCA) • Bichloroacetic acid (BCA) • Podophyllin resin • For small external genital warts Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 95

Genital Warts Collaborative Care l Treatments (cont’d) • Patient managed • Podofilox (Condylox/Condylox gel) • Imiquimod (Aldara) • Immune response modifier Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 96

Genital Warts Collaborative Care l Treatments (cont’d) • If warts do not regress with previously mentioned therapies • Cryotherapy with liquid nitrogen • Electrocautery • Laser therapy • Use of α-interferon • Surgical excision Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 97

Genital Warts Collaborative Care Recurrences and reinfection possible l Careful long-term follow-up advised l Vaccine to prevent cervical cancer, precancerous genital lesion, and genital warts due to HPV l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 98

Nursing Management Nursing Assessment l Subjective data • Past medical history, including sexual history • Medication use • IV drug use • Nausea/vomiting Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 99

Nursing Management Nursing Assessment l Subjective Data (cont’d) • Dysuria • Urethral discharge • Burning lesions • Vaginal discharge • Presence of genital or perianal lesions Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 100

Nursing Management Nursing Assessment l Objective data • Fever • Visual assessment of lesions, warts, rash • Purulent rectal discharge • Proctitis • Urethral and cervical discharge • Laboratory findings Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 101

Nursing Management Nursing Diagnoses Risk for infection l Anxiety l Ineffective health maintenance l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 102

Nursing Management Planning l Patient with STD will • Demonstrate understanding of mode of transmission and risks imposed • Complete treatment and follow-up • Notify or assist in notification of sexual contacts Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 103

Nursing Management Planning l Patient with STD will • Abstain until infection is resolved • Demonstrate knowledge of safer sex practices Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 104

Nursing Management Nursing Implementation Discuss practices with all patients. l Screen for cervical cancer. l Teach to inspect partner’s genitals. l Some protection if void immediately after intercourse; wash genitalia and adjacent areas with soap and water l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 105

Nursing Management Nursing Implementation Proper use of condoms l Avoiding sexual contact with HIV-infected persons l Establishing risk of contracting STD l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 106

Nursing Management Nursing Implementation Compassion and respect l Screening programs l Locating and examining all contacts of person with STD for testing and treatment l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 107

Nursing Management Nursing Implementation Education programs l Counseling to verbalize feelings l Explaining side effects, need for treatment adherence, and follow-ups l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 108

Nursing Management Nursing Implementation Emphasize hygiene (hand washing, bathing). l Avoid douching. l Avoid synthetic materials in undergarments. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 109

Nursing Management Nursing Implementation Abstinence during treatment period, condoms afterward l Avoid oral-genital contact. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 110

Nursing Management Evaluation l Patient with STD will • Demonstrate modes of transmission • Use appropriate hygienic measures • Experience no reinfection • Demonstrate compliance with follow-up protocol Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 111

Audience Response Question When caring for a patient with a sexually transmitted disease, it is important that the nurse teach the patient to: 1. Advise all sexual partners of the need for treatment. 2. Use a condom for sexual intercourse during treatment. 3. Engage in monogamous relationships to prevent reinfection. 4. Wash the genitalia before sexual intercourse to prevent disease transmission. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 112

Audience Response Question The nurse teaches the patient with genital herpes about the use of: 1. Acyclovir ointment. 2. Oral acyclovir (Zovirax). 3. Human papillomavirus vaccine. 4. Podofilox (Condylox) topical gel. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 113

Case Study Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 114

Case Study l 18 -year-old woman and 20 -year-old man enter a college student clinic for an STD screening. l They would like to begin to have unprotected sex but are concerned they might have an STD. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 115

Case Study The man has some pain upon urination that began 2 days ago. l The woman has no symptoms. l A blood test is performed on both, and a culture is taken from the man’s penis. l Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 116

Case Study l He is diagnosed with gonorrhea. l She is diagnosed with chlamydia. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 117

Case Study l The man is given a single intramuscular injection dose of ceftriaxone (Rocephin). l The woman is given a prescription for azithromycin (Zithromax). Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 118

Discussion Questions 1. They would like to know how long to wait before they can have protected or unprotected sex. What can you tell them? 2. What patient teaching should you do with them? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 119