Description

Chlamydia, the most commonly reported notifiable disease in the United States, causes urethritis in men and urethritis and cervicitis in women.

Symptoms and Signs

Chlamydia sometimes is called the silent STD because it often has no symptoms and thus it is sexually transmitted unknowingly. A high percentage of women have no symptoms before dangerous complications start. Conversely, 75% of men have symptoms 1 to 3 weeks after exposure. Chlamydia is a major cause of female sterility and a leading cause of pelvic inflammatory disease (PID).

Early female symptoms include dysuria, an odorless, yellow vaginal discharge with a burning sensation, itching, abdominal pain, and dyspareunia. Infected men experience a thin, watery discharge from the penis, with a burning sensation and itching, and a burning sensation when urinating, the latter caused by urethritis. The scrotum may be swollen and the patient may be feverish. The inguinal lymph nodes often are enlarged in either sex. A small transient lesion and skin irritation may be noticed. Newborns can acquire chlamydia from the infected mother during birth, resulting in conjunctivitis, blindness, arthritis, or overwhelming infection.

Patient Screening

Symptoms usually start 1 or 2 weeks after exposure; they are likely to be mild, such as burning with urination and a genital discharge in both men and women. Schedule an early appointment to confirm diagnosis and begin treatment.

Etiology

Chlamydia trachomatis, an intracellular bacterium, is the cause of chlamydia and usually is transmitted by sexual contact. The site of primary infection is usually around the genitals, but it can be oral or anal, depending on sexual practice. The organism can be found in the cervix, the throat, or rectum and can be transmitted unknowingly.

Diagnosis

Testing for chlamydia is most often done using a DNA-probe test, a test based on DNA detection.

Treatment

Antibiotic therapy is given to both partners, beginning with a single injection, and/or followed with a course of oral antibiotics, such as azithromycin, erythromycin, or a 7-day regimen of doxycycline. More severe cases may require hospitalization and treatment with IV antibiotics. Prompt treatment can cure the infection and prevent complications, such as PID and problematic pregnancy. Follow-up testing is recommended.

Prognosis

Chlamydial infection can be cured with a complete course of antibiotics, taken as directed, even after symptoms subside. Long-term consequences of untreated chlamydia are more serious for women who are prone to PID, which can result in infertility; they are also more likely to become infected with HIV, if exposed. Chlamydia left untreated in men can cause epididymitis, which may lead to infertility in men.

Prevention

Use standard precautions when caring for a patient with chlamydial infection. Infected patients should inform sexual contacts of their infection. See the risk factors for sexually transmitted disease. States require reporting cases of chlamydia to the public health department. The CDC recommends annual chlamydia screening for sexually active women under age 26 and for older women with multiple sex partners. Urine tests for chlamydia in men can help reduce the transmission of disease to women. Use of a protective barrier during sexual activity can help prevent transmission of chlamydial infection.

Patient Teaching

Emphasize the importance of taking the complete course of antibiotic therapy as prescribed. Recommend that patients abstain from intercourse until both partners are cured. Inform patients that meticulous personal hygiene and frequent hand washing are necessary to prevent spreading the infection to the eyes.

Description

Gonorrhea, the second most commonly reported notifiable disease in the United States, is a sexually transmitted infection of the genitourinary tract.

Symptoms and Signs

Gonorrhea, also a common infection of the genitourinary tract, causes symptoms and complications similar to those of chlamydia in male and female patients. A purulent discharge from the male or female genitourinary tract and dysuria are often present but can vary in severity. Up to 50% of men and women are asymptomatic in the early stages of infection, so they may unknowingly continue to spread the infection, making transmission difficult to control. The disease also can infect the eyes and throat or become systemic.

Patient Screening

Males develop symptoms, if any, after an incubation period of 3 to 6 days. Symptoms in females vary. Early treatment is indicated because untreated gonorrhea can spread.

Etiology

Infection with the common bacterium Neisseria gonorrhoeae usually results from sexual transmission. Although recent statistics indicate a decline in the disease rate, drug resistance is on the rise. Because transmission is also possible during birth, newborns must be protected from eye infections that can lead to blindness (Figure 12-4). Therefore prophylactic erythromycin salve is administered routinely at birth.

Diagnosis

Laboratory cultures from the infected site (cervix, rectum, or throat) of infectious body secretions and microscopic examination of exudate with a Gram stain are performed to identify the N. gonorrhoeae organism. A DNA-probe technique called PCR identifies the genetic material of the bacterium.

Treatment

Curative treatment is recommended for the infected individual and any sexual partners as well. Ciprofloxacin, ceftriaxone, or doxycycline administration is started as soon as the diagnosis is made. Many strains of N. gonorrhoeae have become resistant to tetracycline, penicillin, sulfa, and quinolones. After the antibiotic therapy, follow-up culture studies are ordered to ensure a complete cure because some strains are increasingly antibiotic resistant. Neglecting treatment of a gonococcal infection can lead to complications, including PID, septicemia, infertility, and septic arthritis. Salpingitis (inflammation or infection of the fallopian tube) is the most common complication of gonorrhea.

Prognosis

With early and complete treatment, the prognosis is excellent, even when there are complications. The presence of gonorrhea infection makes an individual more likely to acquire HIV, if exposed.

Prevention

Standard precautions are used when caring for a patient with gonorrhea. Report all cases to the local public health department. Routine instillation of erythromycin or 1% silver nitrate drops into the eyes of newborns is practiced. Abstinence from sexual contact is maintained until treatment is complete and follow-up cultures prove negative.

Patient Teaching

Emphasize the importance of complying with a complete treatment plan and follow-up testing to ensure a cure. Inform the patient of the risk factors (see Alert box: Risk Factors for Sexually Transmitted Diseases). Common bacterium Neisseria gonorrhoeae requires specific conditions for growth and reproduction. It is not transmitted from toilet seats or door handles. The organism can exist in the back of the throat from oral sex, in the genitals, and in the rectum.

Description

Trichomoniasis is a protozoal infection of the lower genitourinary tract; the infection is usually vaginal in the woman and urethral in the man.

Symptoms and Signs

About 15% of people who are sexually active have trichomoniasis. Most infected men and women, however, are asymptomatic. This contributes to spreading of the unrecognized infection and delays in treatment.

The initial symptoms for male and female patients may include urethritis with dysuria and itching. In addition, women may notice a profuse greenish yellow odorous discharge from the vagina. A thin whitish discharge from the penis may be noted by the man. In either case the discharge may subside without treatment, but the infection remains, and it can become chronic.

Patient Screening

Discomfort associated with the irritating discharge usually prompts a request for an appointment for an examination.

Etiology

Trichomoniasis is a protozoal infection caused by Trichomonas vaginalis and usually is transmitted through sexual contact. The incubation period is 5 to 28 days. E12-4

Diagnosis

A wet preparation of vaginal secretions or discharge from the male urethra is studied for the microorganism T. vaginalis. Urinalysis also may reveal the organism. The cervix is examined for the presence of small hemorrhages with a strawberrylike appearance.

Treatment

If the laboratory culture is positive, antiprotozoal drugs are given. Metronidazole or tinidazole may be given as a single dose or as a multiday treatment. Patients are cautioned never to consume products containing alcohol while taking these medications.

Prognosis

The prognosis is good if both partners receive medical treatment, including a follow-up examination that ensures that the infection is cured completely. Failure to treat both partners causes reinfection, called a “ping-pong” vaginitis. An increased risk for HIV transmission has been noted. Pregnant women with trichomoniasis can experience complications.

Prevention

Because this disease is transmitted primarily by sexual contact, prevention requires avoiding sex with someone whose sexual history one does not know. Latex condoms may help prevent the spread of trichomoniasis.

Patient Teaching

Advise the patient that consumption of alcohol is contraindicated while taking metronidazole or tinidazole.

See remarks under Prevention and Prognosis.

Description

Genital herpes is an incurable, recurrent infection of the skin of the genital area, with ulcerations spread by direct skin-to-skin contact, causing painful genital sores similar to cold sores (Figure 12-5).

Symptoms and Signs

Genital herpes is caused by herpes simplex virus type 2 (HSV-2), and less frequently by HSV-1, and is a recurrent, incurable viral disease. A large percentage of infections are subclinical, so the initial episode may go unnoticed. More often, one or more blisterlike lesions are noted somewhere on the genitals or around the anus. The painful ulcers and blisters usually occur 2 to 30 days after sexual contact with an infected person. Systemic influenza symptoms, swollen glands, fever, headache, and painful urination also may be present. The condition is infectious when sores are present, but some people, called “shedders,” can transmit the virus without symptoms. Herpetic lesions occur more often in women than in men and the infection tends to be more severe in women. Subsequent outbreaks (“breakouts”) can occur for months or years because the virus hides in the nervous system and lies dormant between flare-ups.

Patient Screening

Systemic symptoms may be present during the acute stage. When fever, headache, muscle aches, and swollen glands are present, the individual is scheduled for investigative medical evaluation.

Etiology

One in six adults between the ages of 14 and 49 are infected with the highly contagious HSV-2; it usually is transmitted sexually by viral infected body fluids during skin-to-skin contact. Cross-infection may result from oral-genital or anal sex and the infection is permanent. Studies find women and blacks are most likely to be infected. Genital herpes can also be caused by HSV-1, especially in the younger population.

The presence of open lesions increases the risk of contracting acquired immunodeficiency syndrome (AIDS) during sexual acts between persons infected with HSV-2 and those who are positive for human immunodeficiency virus (HIV).

Diagnosis

The presence of the characteristic lesions on the male or female genitalia is noted during physical examination. An antigen test or tissue culture laboratory techniques can identify the HSV-2 virus. Polymerase chain reaction (PCR) and a rapid fluorescent test are also used to identify HSV-2.

Treatment

There is no cure, but prescription drugs currently are available to reduce the duration and frequency of outbreaks. These drugs include acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex). In some cases, the body’s own immunity makes the episodes less severe. The presence of sores in the genital area and the fear of transmitting or acquiring herpes contribute to emotional stress and social embarrassment. In addition, women with genital herpes must be watched more carefully for cervical cancer. A Pap (Papanicolaou) smear every 6 months is recommended. Finally, a cesarean section may be indicated because the virus is dangerous to the newborn.

Prognosis

Recurrent herpes usually has prodromal symptoms, such as tingling, itching, or burning 1 to 5 days before the lesion(s) appear. Recurrent episodes are common but tend to be milder and often are triggered by fatigue and stress. Generally the infection poses no serious problems for healthy adults.

Prevention

Sexual abstinence and mutual monogamy are the only absolute prevention. Kissing during an outbreak should be avoided. Condoms do not necessarily provide a complete barrier against skin-to-skin contact. After years of research, attempts to develop a vaccine have been disappointing. However, clinical trials of a new vaccine for women called Herpevac have been shown to significantly reduce the incidence of genital herpes in women.

Note: Unprotected exposure of health care workers to oral and genital secretions when caring for HSV infected patients can result in an intensely painful infection of their fingers called herpetic whitlow. This is usually caused by autoinoculation or other direct contact between the HSV and a break in the skin such as a torn cuticle.

Patient Teaching

Counsel the patient about the preventive measures and prognosis mentioned previously. Recommend frequent and thorough hand washing; the infection possibly can spread into the eyes or other areas of the skin. Provide the patient with educational material on how to cope with the disease. Address any concerns about how the disease affects personal relationships. Advise the patient to inform anyone they have sex with about their genital herpes.

Description

Condyloma acuminatum is a genital infection that causes raised cauliflower-like growths in or near the vagina or rectum or along the penis (Figure 12-6). It has become one of the most common sexually transmitted infections in the world.

Symptoms and Signs

These genital warts are usually painless, and many women have no obvious symptoms. Sometimes the lesions may itch or burn. These contagious lesions appear several weeks to several months after direct skin-to-skin contact during sexual intercourse with an infected person. The discomfort experienced varies with the size, number, and location of the warts.

Patient Screening

Schedule the male or female patient for a pelvic examination.

Etiology

A highly contagious virus called the human papillomavirus (HPV) is the cause of genital warts and usually is transmitted sexually. It has a prolonged incubation period of 1 to 6 months. The HPV virus infects epithelial cells. Risk factors for acquiring persistent infection with HPV are early age for initiation of sexual activity and having multiple sexual partners. Coinfection with HIV causes a further increase in HPV-related cancer risk. Many types of HPV have been identified by scientists. Some are low-risk while high risk types can cause several cancers, including head and neck cancer which is becoming more prevalent.

Diagnosis

Genital warts can be identified by their appearance, but a biopsy sometimes is suggested to rule out carcinoma. The wart must be differentiated from a syphilitic lesion. Identification of the genetic material (DNA) of the virus confirms HPV infection.

Treatment

Up to 30% of genital warts go away without treatment, but the underlying virus is never completely eliminated. The treatment is chemical or surgical removal of the warts, but recurrence is common. Topical drug therapy to remove the warts includes a keratolytic agent, such as podofilox and trichloroacetic acid. Imiquimod, an antiviral cream, also is widely used to stop new genital warts from forming. Surgical procedures for wart removal include cryosurgery, which involves the freezing and removal of affected tissue. Electrodesiccation is a process that uses lasers to remove larger warts and is also very effective. Some genital warts go away without treatment.

Studies show that women with genital HPV infection are at greater risk for cervical cancer. Because the warts spread more rapidly during pregnancy, a cesarean section may be necessary if the warts occlude the birth canal.

Prognosis

Genital warts have no complications, but the disease tends to recur. Recurrence of symptoms is possible even after treatment. Pregnancy promotes the growth and spread of the lesions.

Prevention

Avoid sexual contact with an infected individual, and do not have sexual contact with someone whose sexual history you do not know. The long incubation period introduces added risk of infecting others or of contracting the disease.

A vaccine to help prevent HPV infection has been developed (see Enrichment box).

Patient Teaching

Counseling about all aspects of prevention and transmission of genital warts is important.

Description

Syphilis is a chronic, systemic, sexually transmitted infection that consists of four stages.

Symptoms and Signs

Syphilis begins with the presence of a painless but highly contagious local lesion called a chancre on the male or female genitalia (Figure 12-7). Without early treatment during the primary stage, it becomes a systemic, chronic disease that can involve any organ or tissue. In 1 to 2 months, when the primary lesion heals, the causative organism (the Treponema pallidum spirochete) has disseminated throughout the body and multiplied, producing lesions wherever the organisms are most prevalent, including the skin, lymph nodes, cardiovascular system, brain, and spinal cord.

The disease continues to be contagious during the secondary stage, when there is systemic manifestation. This stage can present many symptoms, including fever, headaches, aching of the joints, mouth sores, and rashes on the palms of the hands and soles of the feet (Figure 12-8). Then a latent period, lasting from 1 to 40 years, may follow, during which the infection is generally subclinical or asymptomatic. In the late stage, the lesions, called gummas, have invaded body organs and systems, causing widespread damage to the point of being disabling and life threatening.

When a fetus is infected, the child may die in utero or be born with congenital syphilis and multiple abnormalities.

Patient Screening

It is important to treat syphilis in the early stage. Note: Syphilis is on the rise, especially in men, in the United States for the first time in many years.

Etiology

Syphilis is caused by infection with the T. pallidum spirochete through sexual contact or other direct contact with infected lesions or infected body fluids. It is highly contagious when a chancre is present (see Figure 12-7). The rising rate of syphilis among men is driven by men having sex with men (MSM). Congenital transmission can occur during pregnancy.

Diagnosis

Standard screening tests are the Venereal Disease Research Laboratory test (VDRL) and the rapid plasminogen reagent test (RPR). A smear taken from the primary lesion is examined microscopically for the spiral bacteria T. pallidum. Antibodies can be detected in the patient’s serum.

Treatment

Syphilis can be easily cured in its early stages with a course of antibiotic therapy using penicillin G. If the patient is allergic to penicillin, other antibiotics are used, such as doxycycline or tetracycline. The disease is best treated in the primary and secondary stages, before it causes irreversible damage to the body. Patients are monitored with follow-up blood tests for the presence of T. pallidum for up to a year.

Prognosis

Treatment for syphilis can cure the disease. Untreated syphilis progresses to long-term severe systemic complications.

Syphilis facilitates the spread of HIV.

Prevention

Health care providers should practice standard precautions. Avoid sexual contact with an infected individual and avoid contact with body fluids. Syphilis can be transmitted in the first few years of the latent stage and in the first two stages. When in doubt, a VDRL test should be performed to detect infection. See the list of risk factors for STDs. Syphilis cases are reportable to the local department of health.

Patient Teaching

Emphasize the importance of finishing the course of medication, even if symptoms improve. Urge the patient to inform sexual partners of the infection so they can seek treatment if needed. Instruct the patient to avoid all risk factors for STDs.

Description

Chancroid, also called soft chancre, is a bacterial infection of the genitalia that causes a necrotizing ulceration and lymphadenopathy.

Symptoms and Signs

The shallow and painless lesion appears on the skin or mucous membrane, at the site of entry, 7 to 10 days after sexual contact with an infected person (Figure 12-9). Tender superlative inguinal adenopathy is noted upon physical examination. The ulcer usually deepens and becomes purulent and can be spread to other areas of the body by autoinoculation.

Patient Screening

The presence of a lesion on or near the genitalia usually prompts a request for an appointment for an examination.

Etiology

The causative agent of chancroid is the bacterium Haemophilus ducreyi.

Diagnosis

The diagnosis is based on the clinical appearance of the lesions. In the laboratory, Gram stain smears of the exudate are performed to confirm the cause of the infection. The presence of syphilis infection and herpes simplex virus is ruled out.

Treatment

The patient usually responds well to antibiotic therapy (i.e., azithromycin, clarithromycin, or ceftriaxone). The lesions sometimes must be drained surgically. Good personal hygiene is advised. The patient is told to keep the infected areas clean and dry and to refrain from sexual contact during the entire time of treatment.

Prognosis

Antibiotic therapy is usually curative. Severe infection may cause scarring.

Prevention

No vaccine is available. Use of a condom helps prevent spread of the infection. Chancroid is a reportable STD.

Patient Teaching

All regular sexual partners should be examined and treated if needed. Serologic testing for HIV is recommended for patients treated for chancroid.