8.8 Sexually Transmitted Infections

Sexually transmitted infections affect both males and females. The terms sexually transmitted infection (STI) and sexually transmitted disease (STD) are used interchangeably. STI and STD imply the infection was acquired through sexual transmission. Examples of STIs include chlamydia, gonorrhea, human immunodeficiency virus (HIV), human papillomavirus (HPV), and herpes simplex virus. Nurses teach clients how STIs are spread, and the only way to completely avoid STIs is to not have vaginal, anal, or oral sex. If clients are sexually active, the following factors can lower their chances of getting an STI^[1]:

• Being in a long-term mutually monogamous relationship with a partner who has been tested and does not have STI
• Correctly using condoms every time you have sex

Nurses also assist providers in reporting STI occurrences to the public health department to reduce transmission of communicable diseases in the community. According to the CDC, HIV, chlamydia, gonorrhea, syphilis, and chancroid are nationally notifiable. State, local, and territorial governments collect information about communicable disease and submit it to the CDC.^[2]

The following subsections will describe chlamydia, gonorrhea, human immunodeficiency virus (HIV), human simplex virus (HSV), human papillomavirus (HPV), syphilis, and trichomoniasis.

Chlamydia

Chlamydia is the most common type of bacterial STI. It is caused by a bacteria called Chlamydia trachomatis. Many people with chlamydia do not have any symptoms and unknowingly pass the infection to their sexual partner(s). Anyone can get chlamydia during oral, vaginal, or anal sex with someone who has chlamydia. A pregnant woman can also pass chlamydia to her baby during childbirth, causing eye infections or pneumonia. These eye infections can scar the cornea and cause blindness. Chlamydia is common among young people with 1 in 20 sexually active young women aged 14-24 years having chlamydia.^[3]

Clients with chlamydia may be asymptomatic. If symptoms appear, it may be several weeks after having sex with someone who has chlamydia. Symptoms in women include abnormal vaginal discharge, which may have a strong smell, and a burning sensation when urinating. Symptoms in men include discharge from the penis and a burning sensation when urinating. If untreated, chlamydia in females can lead to pelvic inflammatory disease (PID), which can cause permanent damage to the reproductive organs and infertility.^[4]

Chlamydia is diagnosed by a health care provider by a urine sample or by using a cotton swab to obtain a specimen that is sent to a lab for analysis. Chlamydia is treated with antibiotics. All sexual partners within the past 60 days should be notified and examined by a health care provider, keeping in mind that not having symptoms does not mean there is no infection. Reinfection is common, so people diagnosed with chlamydia should be retested three months after treatment of the initial infection, regardless of whether they believe that their sexual partners were successfully treated.^[5]

Gonorrhea

Gonorrhea is a bacterial STI caused by Neisseria gonorrhoeae. Neisseria gonorrhoeae infects the mucous membranes of the reproductive tract, including the cervix, uterus, and Fallopian tubes in women, and the urethra in both women and men, causing inflammatory discharge. Neisseria gonorrhoeae can also infect the mucous membranes of the mouth, throat, eyes, and rectum. Gonorrhea is transmitted through sexual contact with the penis, vagina, mouth, or anus of an infected partner. Ejaculation does not have to occur for gonorrhea to be transmitted or acquired. Gonorrhea can also be spread perinatally from mother to baby during childbirth, which can cause blindness, joint infection, or a life-threatening blood infection in the baby if left untreated.^[6]

Many people infected with gonorrhea have no symptoms and can unknowingly pass the infection on to their sexual partner(s). Most women with gonorrhea are asymptomatic. Even when a woman has symptoms, they are often so mild and nonspecific that they are mistaken for a bladder or vaginal infection. The initial symptoms and signs in women include dysuria, increased vaginal discharge, or vaginal bleeding between periods. Women with gonorrhea are at risk of developing serious complications from the infection, such as pelvic inflammatory disease (PID).^[7]

When present, signs and symptoms of gonorrhea in men include dysuria (painful urination) or a white, yellow, or green urethral discharge that usually appears 1 to 14 days after infection. Men may also experience testicular or scrotal pain. Symptoms of rectal gonorrhea infection in both men and women may include discharge, anal itching, soreness, bleeding, or painful bowel movements. Pharyngeal gonorrhea infection may cause a sore throat, but it is usually asymptomatic.

Urogenital gonorrhea can be diagnosed by testing urine, a urethral swab (for men), or endocervical or vaginal swab (for women) using nucleic acid amplification testing (NAAT). It can also be diagnosed using a gonorrhea culture, which requires endocervical or urethral swab specimens.^[8]

Gonorrhea is treated with an intramuscular (IM) injection of antibiotics. It is important that individuals complete the treatment and abstain from unprotected sexual activity for at least seven days following treatment. All sexual partners within the past 60 days should be notified and examined, keeping in mind that having no symptoms does not mean they are infection-free. Reinfection is common, so people with gonorrhea should be retested three months after treatment of the initial infection, regardless of whether they believe that their sexual partners were successfully treated.^[9]

Human Immunodeficiency Virus (HIV)

Human immunodeficiency virus (HIV) is a virus that attacks the T-helper cells (a type of lymphocyte or white blood cell) of the immune system. If HIV is not treated, it can lead to acquired immunodeficiency syndrome (AIDS). There is currently no cure for HIV, so people who become infected with HIV have it for life. However, with proper medical care, HIV can be controlled, and people with HIV can live long, healthy lives while also preventing its spread to their partners.^[10]

Most people infected with HIV have flu-like symptoms within two to four weeks after becoming infected. Symptoms include fever, night sweats, fatigue, swollen lymph nodes, sore throat, muscle aches, and rash. If not treated, the infection becomes chronic, with or without symptoms, and can take up to ten years to develop AIDS. Without HIV treatment, people with AIDS typically only survive about three years.^[11]

HIV tests can be performed on blood or oral fluid. HIV is treated with medication called antiretroviral therapy that reduces the amount of virus in the body, helps maintain a healthy immune system, and prevents AIDS from developing.^[12]

Herpes Simplex Virus

Genital herpes is an STI caused by the herpes simplex virus (HSV) that is characterized by blisters in the genital area. There are two types of herpes simplex viruses: HSV-1 and HSV-2. HSV-1 (oral herpes) causes mouth ulcers, commonly called “cold sores.” HSV-2 causes genital herpes when a person has genital contact with someone who has a genital HSV-2 infection. Additionally, receiving oral sex from a person with an oral ulcer from an HSV-1 infection can result in getting a genital HSV-1 infection. Herpes infection can also be passed from mother to child during pregnancy or childbirth, which can result in a potentially fatal neonatal herpes infection.^[13]

Herpes lesions typically appear as one or more vesicles (i.e., small blisters) on or around the genitals, rectum, or mouth. The vesicles break and leave painful ulcers that may take two to four weeks to heal after the initial herpes infection. Once a client is infected with HSV, the virus remains in their body even after the symptoms are gone and can cause recurring outbreaks related to fever, stress, or other triggering factors. Clients can take a daily anti-herpes medication or use condoms to reduce likelihood of passing herpes on to sexual partners.^[14]

See Figure 8.27^[15] for an image of a mouth ulcer caused by HSV-1. Although this is not considered an STI, herpes lesions that occur on the genitals have a similar vesicular appearance.

HSV nucleic acid amplification tests (NAAT) are the best test for diagnosing herpes, but in some settings, a viral culture is the only test available. There is no cure for herpes. Antiviral medications can prevent or shorten outbreaks, and daily suppressive therapy (i.e., daily use of antiviral medication for herpes) can reduce the likelihood of transmission to partners.^[16]

Human Papillomavirus

Human papillomavirus (HPV) is a common STI. Almost three quarters of sexually active individuals have been exposed to HPV during their lifetime. HPV spreads through sexual activity and skin-to-skin contact in the genital area with an infected person. Because some types of HPV are asymptomatic, people don’t know they have the virus and, consequently, pass the virus to their sexual partners.^[17]

There are over 100 strains of HPV, and some strains of HPV can cause visible genital warts. Genital warts usually appear as a small bump or group of bumps in the genital area. They can be small or large, raised or flat, or shaped like a cauliflower. Some strains of HPV cause genital, anal, throat, and cervical cancers. Routine pap smears detect abnormal cervical cells from HPV which can be treated before they develop into cancer.^[18]

Treatments are available for genital warts, but there is no cure for HPV. The HPV vaccine can protect against diseases (including cancers) caused by HPV. The HPV vaccine is recommended for all preteens (including boys and girls) at age 11 or 12 years and adults through age 26 years. Adults over age 26 should discuss HPV vaccination with their health care provider.^[19]

Pubic Lice

Pubic lice, also known as “crab” lice, are parasitic insects found in the pubic or genital area that are spread by sexual contact. Signs and symptoms of pubic lice include itching in the genital area, visible nits (lice eggs), lice crawling or attached to pubic hair, or lice present in other hairy areas such as the eyelashes, eyebrows, beard, mustache, armpits, chest, or back. However, lice found on the head are typically head lice, not pubic lice. Pubic lice is treated with lotion containing 1% permethrin or a mousse containing pyrethrins and piperonyl butoxide. Sexual contact should be avoided until treatment is successful, and all sexual contacts should be notified to have a physical exam for lice. Clothing and used bedding by the infested person should be washed in hot water (at least 130°F) and dried on the high heat drying cycle. Clothing and items that are not washable should be sealed in a plastic bag for two weeks.^[20]

Syphilis

Syphilis is an STI that can cause serious health problems without treatment. Infection develops in stages called primary, secondary, latent, and tertiary. Each stage can have different signs and symptoms. Syphilis is spread by direct contact with a syphilis sore during vaginal, anal, or oral sex. Syphilis can also be spread from a mother with syphilis to her unborn baby.^[21]

During the first (primary) stage of syphilis, a single sore or multiple sores appear in the location where syphilis entered the body. See Figure 8.28^[22] for an image of a sore caused by syphilis, referred to as a chancre. Sores are typically firm, round, and painless. The sore usually lasts three to six weeks and heals regardless of whether treatment is received.

During the secondary stage, skin rashes and/or sores in the mouth, vagina, or anus appear. The rash can show up when the primary sore is healing or several weeks after the sore has healed. The rash can also be on the palms of the hands and/or the bottoms of the feet and look rough, red, or reddish-brown. Without treatment, syphilis can spread to the brain and nervous system (neurosyphilis), the eye (ocular syphilis), or the ear (otosyphilis). This can happen during any of the stages. Syphilis is treated with antibiotics, but antibiotics do not reverse any damage that occurred prior to treatment.^[23]

The latent stage of syphilis is a period of time when there are no visible signs or symptoms. Without treatment, syphilis can remain in the body for years.^[24]

Most people with untreated syphilis do not develop tertiary syphilis. However, when it does happen, it can affect many different organs such as the heart and blood vessels, the brain, and the nervous system. Tertiary syphilis is very serious and occurs 10–30 years after initial infection and can result in death.

Trichomoniasis

Trichomoniasis is a common STI caused by infection with Trichomonas vaginalis, a protozoan (tiny, single-celled) parasite. Although symptoms vary, most people who have trichomoniasis cannot tell they have it. Men with trichomoniasis may notice itching or irritation inside the penis, burning after urinating or ejaculating, or discharge from the penis. Women with trichomoniasis may notice itching; burning; redness or soreness of the genitals; dysuria; or a clear, white, yellowish, or greenish vaginal discharge with a fishy smell. Trichomoniasis is diagnosed with a swab specimen evaluated in a laboratory. It is treated with antibiotics taken by mouth.^[25]