Sexually Transmitted Infections Nursing CE Course for RNs and LPNs

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Sexually Transmitted Infections

Disclosure Statement

This activity aims to enable the learner to identify and understand the pathophysiology, transmission, signs and symptoms, and treatment of the most common sexually transmitted infections (STIs): chlamydia, gonorrhea, herpes, human papillomavirus (HPV), syphilis, and trichomoniasis.

After completing this module, the learner will be able to:

• identify how chlamydia, gonorrhea, herpes, HPV, syphilis, and trichomoniasis are transmitted
• discuss risk factors, signs, and symptoms for chlamydia, gonorrhea, herpes, HPV, syphilis, and trichomoniasis
• define screening recommendations and diagnostic testing for chlamydia, gonorrhea, herpes, HPV, syphilis, and trichomoniasis
• explore treatments for chlamydia, gonorrhea, herpes, HPV, syphilis, and trichomoniasis

             Globally, more than 1 million sexually transmitted infections (STIs) are acquired daily (World Health Organization [WHO], 2022). These infections may or may not have a cure; there is a risk for short-term and long-term impacts on quality of life (Pfizer, 2022a). Acquiring an STI is not merely a cost to the health of the human body; the fiscal costs are also high. As of 2018, 1 in 5 individuals contracted an STI in the US, contributing to $16 billion in healthcare spending (Centers for Disease Control and Prevention [CDC], 2022d).

Prolonged Impact

             STIs can impact a patient and their family for a significant amount of time. Having 1 STI places the patient at risk of acquiring others; more specifically, the risk for human immunodeficiency virus (HIV) transmission increases. The patient is at risk for cervical cancer (if infected with HPV) or hepatocellular carcinoma (if infected with hepatitis B). Women are at risk for developing infertility, pelvic inflammatory disease, and birth complications. The mother-to-fetus transmission of an STI can lead to stillbirth, neonatal death, low birth weight, premature delivery, sepsis, neonatal conjunctivitis, and neonatal deformities (WHO, 2022).

Infectious Organisms

                Infectious organisms consist of bacteria, viruses, fungi, and protozoa; STIs are transmitted during penetrative vaginal or anal sex, oral sex, or genital touching. The cellular impact on the patient may be localized (i.e., trichomoniasis) or whole-body (i.e., HIV). Depending upon the microorganism, attempting to eradicate the disease may lead to eliminating the disease, or the patient may require lifelong treatment (Cole & Kramer, 2016). Bacteria are single-celled and require antibiotic treatment; the class of antibiotics depends upon the specific bacteria present. Typically, antibacterial medications eradicate the bacteria and allow the patient to be cured of the infection. Viruses are easily spread amongst living cells and require treatment with antivirals. However, antiviral treatment focuses on disease suppression, as most antivirals cannot cure the infection. There are no fungal STIs. Protozoal infections are caused by microscopic parasites found on the skin, in fecal matter, blood, and insects; treatment for protozoal infections involves taking antiparasitic agents (Sepsis Alliance, 2021).

Chlamydia

Pathophysiology

             Chlamydia is an infection caused by the gram-negative bacterium, Chlamydia trachomatis, transmitted during vaginal, anal, or oral sex. It can also be passed from mother to baby during childbirth. It is an obligate intracellular parasite. Initially, the bacterium’s small elementary bodies invade the cell, where they become metabolically active within hours. Now active, the reticulate bodies create large inclusions within the cell. Within a few days, the cell ruptures, spreading newly organized small elementary bodies in the surrounding tissue to repeat the process in neighboring epithelial cells, replicating again. This relatively long cycle requires the use of antibiotic treatment with a longer half-life or a prolonged medication course to ensure effective treatment. Immunity is also limited in duration, making reinfection common. If untreated, it can lead to pelvic inflammatory disease (PID), infertility, scar tissue on the fallopian tubes, ectopic pregnancy, premature delivery, and chronic pelvic pain. In babies, chlamydia can cause an eye infection or pneumonia (CDC, 2022a; Hsu, 2022a; Pfizer, 2022a).

Risk Factors

             In 2018, 2.4 million individuals contracted chlamydia (CDC 2022a); in 2022, following SARS-CoV-2 infection (COVID-19), chlamydia is the most-reported disease in the US (Hsu, 2022b). Individuals that are at risk for contracting chlamydia include individuals less than 25 years old, individuals older than 25 years old with multiple sexual partners, or a partner with a history of STIs. Younger patients may be at increased risk due to multiple barriers to prevention, such as lack of finances, lack of transportation, and cultural/social stigma. A new (or multiple) partners within the last 3 months is a risk factor for infection, along with inconsistent use of barrier methods to prevent infection (e.g., condoms). Cervical ectopy (where cells from the endocervix are present on the ectocervix) may also increase risk. Men with multiple sexual partners, men who have sex with men (MSM), or those with a history of HIV are also at higher risk (CDC, 2022a; Hsu, 2022a; Pfizer, 2022a).

Screening and Prevention

             According to the CDC (2021), sexually active women should be screened annually for chlamydia. Pregnant women should be screened; if they are considered high risk for the disease or tested positive for chlamydia, they should be re-tested if in the third trimester. Men should be screened as needed for chlamydia; however, if they are at higher risk, they should be screened every 3 to 6 months. Individuals with HIV should be initially screened for chlamydia and then annually thereafter. Transgender patients should be screened based on their anatomy, sexual behaviors, and risk for exposure (CDC, 2021). Preventing chlamydia can occur by avoiding anal, oral, or vaginal intercourse, when condoms are correctly applied during each sexual encounter (see Table 1), or when two uninfected (tested negative) individuals engage in a monogamous relationship. If the disease is left untreated, there is an increased risk of acquiring HIV (CDC, 2022a; Pfizer, 2022a).

Table 1

Correct Usage of Male Condoms

(CDC, 2022e)

                If a condom is incorrectly placed, the risk of contracting an STI increases (CDC, 2022e). Areas exposed and not covered by a condom may also result in transmission (New Zealand HPV Project, 2022). Individuals at risk for not using condoms may include adolescents and those experiencing substance abuse, lower socioeconomic status, lower educational attainment, and a lack of access (Goldenberg et al., 2020). Nurses have a unique opportunity to assess and address all these factors through education and coordination of resources.

Signs and Symptoms

                Patients with chlamydia may or may not present with signs and symptoms; in women, 70% are asymptomatic. If symptoms occur, it tends to happen between weeks 1 and 3 following disease exposure. The patient may experience burning during urination or cloudy, white discharge from their genitals. In addition, men may experience pain and edema in their epididymis and testicles. When the disease occurs in the rectum, patients may experience pain, discharge, and bleeding from the rectum. Although uncommon, the patient is usually asymptomatic if chlamydia occurs in the throat. The patient may develop conjunctivitis if the eyes come into contact with infected seminal or vaginal fluid. If symptoms are not present or left untreated, the patient can continue to transmit the disease (CDC, 2022a; NHS, 2021; Pfizer, 2022a).

Diagnosis

             Chlamydia can be diagnosed through a health history, physical assessment, and laboratory testing. The health history can identify if the patient is at risk for contracting and transmitting the disease; the physical examination can assist the APRN in identifying any signs and symptoms of infection. During a pelvic exam, a specimen should be collected for nucleic acid amplification testing (NAAT). Chlamydia cannot be cultured on artificial media and must be grown on tissue culture, limiting culture to research and reference libraries only. In women, specimens can also be self-collected without affecting sensitivity or specificity. Alternatively, a first-void urine specimen can be used for NAAT (the preferred method for male patients). NAATs may also be used for oropharyngeal or rectal specimen testing due to enhanced sensitivity and specificity. Patients who test positive for chlamydia should be tested for other STIs, including gonorrhea, HIV, and syphilis (CDC, 2021, 2022b; Hsu, 2022a).

Treatment and Management

             Upon testing positive, patients are started on antibiotics to treat the infection. More specifically, patients are started on doxycycline (Monodox, preferred), azithromycin (Zithromax), or an alternative if required (see Table 2 and Table 3). In addition to safe sex practices, the nurse should educate patients on completing the course of treatment (to prevent reinfection and antibiotic resistance) and abstaining from sex for 7 days following treatment. Any sexual partners within the last 60 days (or the most recent partner if > 60 days) should be referred for treatment. Expedited partner therapy (EPT) should be offered where available if partner treatment is a concern. Test of cure (at 4 weeks following treatment) is not required for nonpregnant patients treated with one of the recommended regimens unless therapy adherence is a concern or symptoms persist. Follow-up testing at 3 months is recommended to reduce reinfection rates (CDC, 2021, 2022b; Hsu, 2022b).

Table 2

Medications to Treat Chlamydia

(CDC, 2021)

Table 3

Side Effects of Medications to Treat Chlamydia

(US National Library of Medicine, 2008, 2016, 2017, 2022b)

Gonorrhea

Pathophysiology

             Gonorrhea is the second most common STI and is caused by the bacterium Neisseria gonorrhoeae. The bacteria infect the mucus membranes along the reproductive tract, including the fallopian tubes, uterus, and cervix in women, and the urethra, gastrointestinal tract (mouth, throat, rectum), and eyes of any individual. Sexual contact and transmission of the disease during childbirth promote disease transmission. If it is not eradicated with antibiotics, patients are at risk for developing infertility, pelvic inflammatory disease, scar tissue on the fallopian tubes, ectopic pregnancy, and abdominal/pelvic pain (CDC, 2022c).

Risk Factors and Protective Measures

                Sexually active individuals are at risk. More specifically, those aged <25 and those with multiple sexual partners (or a new sexual partner) are at greater risk of contracting gonorrhea. Other risk factors include having a sexual partner with an STI or multiple concurrent partners, sporadic use of barrier methods (e.g., condoms), a prior or current history of another STI, and the use of sex to obtain drugs or money. MSM are at increased risk of infection if they engage in substance abuse or sex with multiple anonymous partners. Risk can be decreased when individuals practice safer sex (i.e., correctly and consistently apply condoms and minimize the number of sexual partners; CDC, 2021, 2022c).

Screening and Prevention

             Sexually active women under 25, as well as sexually active, at-risk women over 25, should be tested annually for gonorrhea. If the individual contracts gonorrhea, re-testing should be completed 3 months after treatment. If individuals are concerned about possible exposure to gonorrhea, they should be tested. Pregnant individuals should be tested if younger than 25 years old or deemed at high risk if over 25 years old; the same population of pregnant individuals should be re-tested in the 3^rd trimester. If the pregnant patient contracts gonorrhea, re-testing should be completed 3 months after the completion of treatment. Screening of asymptomatic sexually active women over 25 who are at low risk of exposure is not currently recommended (CDC, 2021).

             Currently, there are no clinical guidelines for screening asymptomatic sexually active heterosexual men who are at low risk of exposure to gonorrhea. MSM who engage in high-risk behaviors should be screened at all potential exposure sites every 3-6 months or annually if not engaging in high-risk behaviors. Transgender patients should be screened according to their anatomy. Individuals with HIV should be screened upon initial diagnosis of HIV, then annually unless considered at-risk. If the individual is at-risk, screening for gonorrhea should be determined based on the patient's sexual behavior history (CDC, 2021).

Signs and Symptoms

                Individuals with gonorrhea may be asymptomatic (especially females), which makes screening essential. If symptoms are present, they may mimic a bladder or vaginal infection in women, including pain or burning sensation when urinating, increased vaginal discharge, and bleeding between menstrual cycles. Men may experience pain or burning sensation when urinating, white or purulent penile discharge, or painful or edematous testicles. If the male or female has gonorrhea in the rectum, symptoms may include discharge, itching, soreness, painful defecation, and bleeding per rectum (CDC, 2022c).

Diagnosis

             Initially, a complete health history and physical exam are conducted to assess patient risk and determine if diagnostic testing for gonorrhea is required. Diagnosis may be made through the bacterial analysis of a urine sample or swab of potentially infected areas: cervix, rectum, urethra, or throat. As with chlamydia above, NAAT is the most widely available option for genitourinary infections, although culture and POC NAAT are also available. Urine samples, rectal swabs, and pharyngeal swabs can also be processed via NAAT and POC NAAT. Patient-collected samples can also be used with proper patient education/training. Culture and sensitivity testing should be performed in cases of suspected treatment failure. Urethral discharge can also be used for Gram staining in male patients. Additional testing for those diagnosed with gonorrhea should include HIV, chlamydia, and syphilis (CDC, 2021, 2022c).

Treatment and Management

             Treatment consists of antibiotics (see Tables 4 and 5). Sexual abstinence is crucial until the entire course of treatment has been completed and the patient is asymptomatic; patients should be advised to avoid sexual intercourse for 7 days following the completion of treatment. Patients should complete the full course of antibiotics to prevent antibiotic resistance; antibiotic-resistant strains of gonorrhea are becoming increasingly prevalent. Only ceftriaxone (Rocephin) is recommended for treating gonococcal infections in patients who have tested negative for chlamydial infection. If chlamydial infection cannot be ruled out, dual therapy with doxycycline, as described in table 1, is still recommended. Gonococcal infection treatment should be done on-site, administered, and directly observed. Test-of-cure is only recommended for pharyngeal infections at 7-14 days. Any sexual partners within the last 60 days (or the most recent partner if > 60 days) should be referred for treatment. Expedited partner therapy (EPT) should be offered where available if partner treatment is a concern (CDC, 2021, 2022c; Pfizer, 2022a).

Table 4

Medications to Treat Gonorrhea

(California Department of Public Health, 2022)

Table 5

Side Effects of Medications to Treat Gonorrhea

(US National Library of Medicine, 2020a, 2021a, 2022a, 2022b)

Genital Herpes

Pathophysiology

             Approximately 1 in 5 individuals have herpes in the US; however, many may be asymptomatic and not know they carry the disease. Herpes is a viral STI with two strains, herpes simplex type 1 (HSV-1) and herpes simplex type 2 (HSV-2). These strains can cause sores on the mouth, genital, or anal areas. Lesions around the mouth are known as cold sores or fever blisters and are typically associated with HSV-1. Genital warts are usually associated with HSV-2, although anogenital infections can be related to HSV-1. Herpes infection during pregnancy carries a risk of negatively impacting the fetus, particularly if acquired in the first trimester. The disease may remain dormant for several years before a reoccurrence/outbreak, but the average incubation period is 4 days (Albrecht, 2022a; Pfizer, 2022a).

Risk Factors and Protective Measures

Risk factors for HSV mirror those of other STIs, including multiple sexual partners, age under 50, and female sex. It is more commonly diagnosed in non-Hispanic Black patients versus non-Hispanic White patients. Consistent and appropriate use of a barrier method (e.g., condoms) most effectively decreases the risk of HSV transmission. It is more effective in limiting transmission from men to women but less effective in decreasing transmission from women to men. Medical male circumcision is still being investigated as a method for reducing transmission among adult heterosexual males. Antivirals cannot be used to prevent HSV transmission, although daily oral tenofovir/emtricitabine TDF/FTC may decrease the risk of transmission in heterosexual partners. Recent HSV infection is a known risk factor for HIV transmission (Albrecht, 2022a; CDC, 2021).

Screening and Prevention

             Screening for HSV-1 and HSV-2 should be done in patients with multiple sexual partners and if newly diagnosed with a genital tract infection. Pregnant patients should be screened for herpes if they have multiple sexual partners or engage in at-risk behaviors (CDC, 2021). Condoms can prevent the spread of herpes (Albrecht, 2022a).

Signs and Symptoms

Initial Infection. The mean time between sexual contact and the first genital lesions in an initial infection is 5 days (Ryan, 2018). After that, multiple lesions develop, and the typical progression begins with erythematous papules changing to 2-4 mm vesicles, which then develop into pustules. The vesicles are typically surrounded by erythema. Within 3 to 5 days, the pustules break and become painful ulcers that usually heal without scarring. Approximately one-third of patients also report headaches, fever, malaise, lymphadenopathy, dysuria, and myalgias. Vaginal or urethral discharge is common, and dysuria can occur if the lesions are near the urethra. For most patients, the signs and symptoms of an initial infection last an average of 19 days (Albrecht, 2022a; Corey, 2018; Ryan, 2018).

Recurrent Episodes. After the initial symptomatic episode, recurrent symptomatic episodes are pervasive, occurring in approximately 80-90% of all patients. It is unknown what causes recurrent symptomatic episodes, but fever, emotional stress, exposure to sunlight, and ultraviolet radiation can precipitate an episode. The number, frequency, and duration of recurrences vary from person to person (Corey, 2018; Ryan, 2018). The average number of recurrences per year is 4 to 5, which usually decreases over time. Before a recurrence, the patient may be asymptomatic, or the recurrence may be preceded by a prodromal syndrome characterized by local paresthesia in the buttocks, genitals, or perineum. Vesicular lesions appear, the patient has mild systemic symptoms like itching or pain, and recurrent episodes last about two to five days. Then the systemic effects stop, and the lesions disappear (Ryan, 2018a). Rarely infection with genital herpes can cause encephalitis and acute and recurrent aseptic meningitis (Gnann & Whitely, 2017; Noska et al., 2016; Ryan, 2018).

Diagnosis

NAAT or culture testing can be performed only when genital lesions are present. These virological tests are type-specific, allowing for patient education and counseling based on which HSV subtype is identified. NAAT assays are the most sensitive and can be used to diagnose genital or oral lesions. Alternatively, type-specific serological testing based on the HSV-specific glycoprotein G2 and G1 (i.e., gG2 and gG1) can be performed during asymptomatic periods (no active lesions present). PCR testing of the blood should be considered for suspected systemic HSV infections (e.g., meningitis, encephalitis, hepatitis, or neonatal herpes). Viral culture is associated with low sensitivity but may be used when better options are unavailable. Negative NAAT or culture results should not rule out infection, as viral shedding is intermittent. The risk for HIV is increased 2-3X in patients currently infected with HSV-2, so any patient diagnosed with an HSV-2 genital infection should also be tested for HIV (CDC, 2021).

Treatment and Management

                Being diagnosed with herpes can be stressful; patients should be advised of support groups and psychological services to help cope. In addition, patients should be educated that herpes can spread to their sexual partners even when active lesions are not present. Genital herpes is an incurable life-long viral infection, and no vaccine can prevent HSV infection, but there are approved drugs that can treat infections via suppression (Table 6). Antiviral drugs treat/suppress initial and recurrent episodes; treatment goals do not include eradication of the infection. Topical therapies have minimal effect and are generally discouraged (Albrecht, 2022b; CDC, 2021; Corey, 2018; Ryan, 2018).

Antivirals for long-term suppression therapy have been shown to prevent and shorten recurrent episodes of genital herpes, reduce asymptomatic shedding to decrease transmission between partners, reduce the risk of complications, and improve quality of life. Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) appear to be similarly effective in treating recurrences. The choice of drug is based on convenience, cost, and the prescriber's preference. Beginning treatment within 24 hours of the onset of symptoms will help shorten the symptoms' duration by 1 to 2 days. Although antiviral therapy effectively prevents, limits the duration, and decreases the severity of recurrent outbreaks, these beneficial effects only occur during active treatment with the drugs. Episodic treatment can be used to shorten the duration of recurrent outbreaks, or suppressive therapy can be used to reduce the frequency of outbreaks by 70-80% and decrease the risk of transmission. Famciclovir (Famvir) may be less effective in decreasing viral shedding, and once-daily dosing of valacyclovir (Valtrex) may be less effective for those with 10 or more outbreaks per year. Severe cases or complications requiring hospitalization are treated with intravenous acyclovir (Zovirax). This should be followed by oral antivirals for a minimum of 10 days of total treatment (Corey, 2018; CDC, 2021; Gnann & Whitely, 2016; Groves, 2016; Ryan, 2018).

Table 6

Antiviral Therapy for Genital Herpes in Immunocompetent Patients

(CDC, 2021; Corey, 2018)

Human Papillomavirus (HPV)

Pathophysiology

                HPV is the most common STI in the United States and was identified in 43 million Americans in 2018 (Hinkle & Cheever, 2018; Norris, 2020). The virus comprises a double-stranded deoxyribonucleic acid (DNA) that promotes lesions on the squamous epithelium. These lesions are visible condyloma acuminatum (i.e., genital warts; Hoffman & Sullivan, 2020). HPV is also responsible for nearly every case of cervical cancer; infection with HPV can also cause cancer of the anus, oropharynx, penis, vagina, and vulva (Pagliaro, 2016). Approximately 50-75% of sexually active Americans will develop an HPV infection at some time (Leung et al., 2018). While most HPV infections clear spontaneously and do not cause genital warts, infections that do not clear are a significant risk for cervical cancer (Senkomago et al., 2019).

HPV has over 40 types and 100 subtypes, affecting the genitals, mouth, and throat. The types are differentiated according to the risk of cervical cancer development. CIN-specific subtypes, such as 16 and 18, place individuals at a greater risk of developing uncontrolled cervical dysplasia and cervical cancer. These types are evident in 70% of cervical cancer patients. However, 90% of HPV cases are deemed low-risk and present asymptomatically or with condyloma acuminatum (genital warts). The incubation period for HPV ranges from 3 weeks to 8 months to decades; the longer the incubation period is, the more likely it will correlate with a cervical cancer diagnosis (Hoffman & Sullivan, 2020; Hinkle & Cheever, 2018; Norris, 2020).

HPV can be transmitted by anal, oral, and vaginal sex, skin-to-skin contact, and fomites (Hoffman & Sullivan, 2020; Leung et al., 2018). The disease thrives in moist environments rich in squamous epithelial cells, such as the vagina, cervix, vulva, inner foreskin, and urethra of the penis, and is present on cutaneous portions of the body as genital warts (American Cancer Society [ACS], 2022). HPV can be transmitted when there are no visible genital warts. It is assumed that the potential for HPV transmission from an asymptomatic infected person to an uninfected person is high (Hoffman et al., 2016).

Risk Factors and Protective Measures

                Those at the highest risk for HPV include young adults under age 25, individuals who are sexually active at a young age with a first partner at age 16 or younger, and those with multiple sex partners or a partner with multiple sex partners. In addition, lower socioeconomic status, smoking, poor nutrition, oral contraceptive use, douching, and herpes simplex virus type 2 are other risk factors for HPV. If a woman contracts HPV, her risk for cervical cancer increases if she smokes, is immunosuppressed, or is exposed to hormone alterations (including pregnancy and medications; Hoffman & Sullivan, 2020; Norris, 2020).

Screening and Prevention

             In sexually active women, ages 21-29, testing for HPV should occur at least every 3 years with cytology. In women ages 30-65, screening should occur every 3 years with cytology or every 5 years with cytology and HPV testing. Pregnant women should be screened at the same frequency as nonpregnant women. MSM should be screened if at risk for anal cancer; transgender patients should be screened if at risk for cervical cancer. Individuals with HIV should be checked for HPV if at risk for cervical cancer. HPV vaccination is now the most effective method of prevention (CDC, 2021). Typically, HPV vaccination is administered at ages 11-12 in males and females (Pfizer, 2022a). However, pediatric patients as young as 9 can be vaccinated. The HPV vaccination distributed in the US is Gardasil-9. It prevents viral types 16 and 18, which are attributed to the bulk of cervical cancer types. Vaccination may be given in two or three doses; the number of doses is based on the patient's age when given the first dose (patients 15 or younger should receive two doses) and if immunocompromised (requires three doses). Pregnant women should not be given the vaccination. Preventing HPV and HPV-related cancers is also possible through proper condom use and sexual monogamy (CDC, 2021). For additional details on HPV vaccination, please see the Human Papillomavirus NursingCE Course.

Signs and Symptoms

             Generally, HPV is asymptomatic and resolves without treatment in 2 years for 90% of patients. However, if an individual is immunocompromised or has specific subtypes of HPV, they are at risk for developing cervical dysplasia, genital warts, and cervical cancer. Genital warts on external surfaces tend to be small, flat, and flesh-appearing, with a rough surface and pedunculated features for all genders. Internal genital warts (i.e., on the vagina, urethra, anus, or mouth) may have a cauliflower-like appearance. Symptomatic patients may experience itching, burning, or tenderness in affected areas (Hoffman & Sullivan, 2020; Norris, 2020).

Diagnosis

                A health history, physical assessment, and laboratory diagnostic tests are utilized to diagnose HPV and HPV-related cancers. Genital warts may be visible upon inspection during a physical exam. During a Papanicolaou test (or pap smear), a sample from the cervix is used to test for HPV and HPV-related changes in cell structure (ACS, 2022). HPV DNA can be identified using a hybridization solution. The testing confirms whether high-risk HPV DNA is present, as it can contribute to cervical cellular malignancy. This testing can be done alone or with cytology (referred to as co-testing; Hoffman & Sullivan, 2020; Norris, 2020). According to the ACS, all women over 25 should receive HPV testing with their pap smears. Testing for HPV is based on an assessment of age and risk (ACS, 2021, 2022). According to the American College of Obstetricians and Gynecologists (ACOG, 2021) and the US Preventive Services Task Force, cervical cancer screening should begin earlier (at age 21). Please see Table 7 for recommendations from both groups.

Table 7

ACS 2020 Cervical Cancer Screening Guidelines versus 2021 ACOG/USPSTF Guidelines

(ACS, 2021; ACOG, 2021)

A colposcope—a low-power binocular microscope—allows visualization of the mucosal layers of the cervix and vagina. Acetic acid aids in the visualization of the columnar epithelium by removing mucus. Lugol’s solution is applied to examine the cervix and vagina during the procedure. The solution uses iodine, so nurses must assess patients for an iodine allergy. Biopsies may be required if the tissue stains by the Lugol’s solution appear lighter in color than the typical brown staining (Hoffman & Sullivan, 2020). For male patients, HPV biopsy results may demonstrate intraepithelial neoplasia of the penis and anus (Norris, 2020).

Treatment and Management

Managing HPV involves avoiding transmission to other individuals, preventing and eliminating genital warts, monitoring for changes in cervical cellular structure, and limiting psychological distress for patients (Norris, 2020). If a patient has external genital warts, they may be prescribed a topical ointment (applied by the clinician) of trichloroacetic acid or podophyllin (Podofin, Podocon). They may also require cryotherapy (thermal-induced cytolysis) or surgical removal of genital warts. Electrocautery or laser treatment may be warranted for abundant genital warts. Patients may be prescribed topical products that can be self-administered at home, such as podofilox (Condylox) 0.5% gel or solution, imiquimod (Aldara) 5% cream, or sinecatechins (Veregen) 15% ointment. These agents work by collapsing the area surrounding the wart and encouraging an immune response. While treatment for HPV is usually successful, the infection is viral, and treatments are not curative. They are designed to elicit an immune response. Given this, patients with weakened immune systems, those with diabetes, smokers, and pregnant people have an increased risk of pharmacological resistance. Nurses should educate patients on the risk of local skin irritation and pain with topical applications. If a patient is experiencing pain, nurses should provide analgesia and reassess the treatment’s efficacy (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020). Nurses should educate patients not to use over-the-counter wart removers for genital warts (ACOG, 2022).

If the tissue is high-grade neoplasia (CIN II or III), genital warts and the surrounding tissue should be extracted to assess for cervical cancer. Tissue can be removed by surgical ablation, excision, laser conization, or loop electrosurgical excision. Ablation utilizes temperature changes to remove the affected area via cryosurgery (freezing) or a laser. The impacted area may be excised using cold knife colonization (CKC). Using a laser, cervical tissue can be removed via laser conization. An electrosurgical excision uses a painless current to remove the tissue (Hoffman & Sullivan, 2020).

Syphilis

Pathophysiology

Syphilis is a multi-staged bacterial disease caused by Treponema pallidum. The disease is transmitted through direct contact with a chancre; a chancre is a visible but painless sore on the vagina, penis, rectum, lips, or mouth. Syphilis may also be transmitted from mother to fetus (CDC, 2021, 2022f). In 2021, the US had 2,000 babies born with syphilis, a 108% increase in cases from the previous year (Pfizer, 2022a). Individuals with a stillborn delivered after 20 weeks should be screened for syphilis, as untreated syphilis has been found to contribute to 40% of fetal deaths (CDC, 2022f).

Risk Factors and Protective Measures

High-risk individuals include pregnant women (especially those not receiving prenatal care), those with multiple sexual partners, those engaged in active drug abuse, incarcerated individuals or those with an incarcerated sexual partner, individuals experiencing homelessness, and MSM. Prevention can occur with proper use of condoms and being in a mutually monogamous relationship (CDC, 2022f).

Screening Guidelines

At-risk sexually active individuals should be screened for syphilis. Prenatal screening for syphilis should occur on the first visit. If the pregnant patient is found to be high-risk, has a new sexual partner since conception, or the sexual partner tests positive for an STI, additional screening during week 28 of gestation is advised. Heterosexual men should be screened for syphilis if considered high-risk or have a history of syphilis infection. In MSM, screening should be conducted every 3-6 months if at increased risk; if sexually active but not at high risk, annual screening is recommended. If a patient is transgender, annual screening should be done based on sexual activity and potential exposure. For patients with HIV, syphilis should be tested for on initial diagnosis of HIV and annually after that (CDC, 2021).

Signs and Symptoms

The clinical course of syphilis has been divided into stages. These stages are unique in their clinical presentation as well as their recommended treatment (CDC, 2021)

Primary Stage. 

The patient may present with a chancre or multiple chancres at the transmission site. Typically, the chancre is present for 3-6 weeks and heals without treatment. Patients need to be educated that a healed chancre does not mean the cessation of the disease. Without antibiotic treatment, syphilis will advance to the secondary stage and beyond (CDC, 2021, 2022f).

Secondary Stage. 

Like the primary stage, the second stage contains dermatological alterations. The patient may demonstrate rashes at multiple sites on their body, including the transmission site. The rash may be present on the hands and feet and be painless, rough, red, or reddish-brown in appearance. Furthermore, the rash may appear faint, making it challenging to identify. Another dermatological alteration the patient may present with is condylomas (white or gray bumps) in warm, moist areas such as the mouth, axilla, or groin. The patient may also present with hair loss and other systemic signs. For instance, they may have a fever, swollen lymph nodes, weight loss, fatigue, myalgia, headaches, and a sore throat. However, despite the loss of signs and symptoms, the patient must be informed that the disease will advance to the latent stage if not treated with antibiotics (CDC, 2021, 2022f).

Ocular syphilis occurs when the infection affects the visual system. It may present with panuveitis (inflammation of all components of the eye), conjunctivitis, optic neuropathy, retinal vasculitis, anterior uveitis, or posterior interstitial keratitis. Otosyphilis may cause hearing or balance dysfunction, such as vertigo, tinnitus, and hearing loss that is typically sudden in onset and rapidly progressive. Hearing or vision loss related to syphilis may be permanent (CDC, 2021).

Latent Stage. 

This stage is asymptomatic. However, they are still capable of transmitting syphilis to others. This stage can last for years and may be classified as early (if within 12 months of exposure) or late (CDC, 2021, 2022f).

Tertiary Syphilis. 

If an individual does not seek treatment, syphilis will go from the latent to the tertiary stage. To reach this final stage, the disease has been present in the body for 10-30 years. Tertiary syphilis causes significant multi-organ system damage and increases the risk of death in the individual. The disease can damage the brain, heart, blood vessels, liver, bones, joints, and skin. Of heightened concern is the risk of dysfunction in the nervous system. Neurosyphilis can cause loss of coordination, numbness, paralysis, severe headaches, cranial nerve dysfunction, meningitis, alterations in cognitive function, or stroke. Neurosyphilis can occur during any stage described here. All patients diagnosed with tertiary-stage disease should undergo CSF evaluation (CDC, 2021, 2022f; Pfizer, 2022a).

Neonatal Onset. 

Babies born with syphilis may be asymptomatic. However, the disease can overwhelm a baby's body and cause a cascade of future health problems, thus making early treatment imperative. If a baby is not treated for syphilis within the first few weeks of life, the baby may experience seizures, developmental delays, or death. If the mother is treated with penicillin while pregnant, disease transmission is reduced (CDC, 2022f).

Diagnosis

The risk of syphilis can be assessed through a health history. A physical assessment and specimen collection to isolate the bacterium in the laboratory are then done to confirm a suspected diagnosis. There are no commercially-available molecular NAATs for direct detection, although several labs have developed validated PCR tests available locally (CDC, 2021).

For a presumptive diagnosis, two serological tests are used to confirm a syphilis diagnosis. The traditional algorithm utilizes an initial quantitative nontreponemal immunoassay with a titer (rapid plasma regain [RPR] or venereal disease research laboratory [VDRL]). If this is positive, the lab utilizes the same specimen for another immunoassay (treponemal test) for treponemal antibodies. If this test identifies treponemal antibodies, the diagnosis of syphilis is confirmed (CDC, 2021).

Some labs will reverse the process, referred to as the reverse sequence algorithm. In this case, the serum sample is screened first using an automated treponemal immunoassay (EIA or CIA). If positive, the sample is immediately tested by the lab using a quantitative nontreponemal test with a titer (RPR or VDRL). If the nontreponemal test is positive, the diagnosis of syphilis is presumed. If the nontreponemal test is negative, a second treponemal test is then run on the same sample by the same lab (CDC, 2021, 2022f).

Babies. 

If syphilis is suspected in a baby, they may be subject to a battery of tests to confirm the presence of the disease. Suspicion of syphilis occurs when the mother tests positive for syphilis as there is a concern for maternal-fetal transfer of the disease. Using infant serum, a quantitative nontreponemal test can be analyzed for congenital syphilis (RPR or VDRL). The HCP may also request further testing of bodily fluids from the placenta, umbilical cord, or other tissues. A treponemal test (e.g., TP-PA, immunoassay-EIA, CIA, or microbead immunoassay) and commercially available IgM tests are not recommended; they are challenging to interpret due to passive maternal antibodies, which may remain for 15 months or longer. The testing may require the use of darkfield microscopy or PCR testing. In addition, testing may include a complete blood count (CBC) with differential and platelets; analysis of CSF for VDRL, cell count, and protein; and long-bone x-rays (CDC, 2022f).

Treatment and Management

Syphilis treatment utilizes antibiotics (Table 8) and depends upon the staging and patient population; penicillin is the primary medication used. The formulation, dose, and duration depend on the patient population and disease staging. Pregnant patients with a penicillin allergy should undergo penicillin desensitization prior to treatment. If a pregnant patient misses a dose, they should repeat the entire course of treatment (CDC, 2021).

Between 50-75% of patients with early syphilis develop the Jarisch-Herxheimer reaction from penicillin. The Jarisch-Herxheimer reaction begins within 24 hours after injection and is characterized by fever, headache, and myalgias. The response is short-lived, lasting approximately 24 hours, and resolves without sequelae; in pregnant women, it may precipitate early labor. Antipyretics can be used for symptomatic treatment (CDC, 2021; Whitely, 2019).

Table 8

Medications to Treat Syphilis

(California Department of Public Health, 2022)

Patients should be advised not to have sexual intercourse until the chancres are completely healed. Furthermore, patients should be counseled to inform their partners and advise them to seek treatment to prevent reinfection. Sexual partners within the last 90 days can be treated for syphilis presumptively. Those exposed > 90 days prior should be tested but may be treated presumptively if testing results are delayed, or follow-up is tenuous. Patients should be educated on proper condom application and limiting the number of sexual partners to prevent reoccurrence. Clinical and serological follow-up (typically with repeat quantitative nontreponemal titer, expected to decrease fourfold in 12 months) are recommended at 6 and 12 months following treatment. Those diagnosed with latent disease should follow up at 6, 12, and 24 months (CDC, 2021).

Trichomoniasis

Pathophysiology

Trichomoniasis is a parasitic infection; Trichomonas vaginalis is a protozoan that attacks the lower genital reproductive tract in women and the urethra in men during sexual intercourse (CDC, 2021). The disease can be transmitted during vaginal, oral, or anal sex or genital touching (Office of Women's Health, 2021).

Risk Factors and Protective Measures

The CDC estimates 2.6 million trichomoniasis infections annually. The disease is more common in women than in men. In addition, infection is found equally as often in those over the age of 24 as those under. The condition is more common in Black women than White or Hispanic women. Men experience fewer signs and symptoms and are therefore less likely to know they are infected, not seek treatment, and unknowingly transmit the disease to their partner. Rates of trichomoniasis are higher in those previously incarcerated or with two or more sexual partners in the previous 12 months. Other risk factors include less than a high school education and living below the national poverty level. Bacterial vaginosis, though not an STI, increases the risk of trichomoniasis infection, as does vaginal douching. Condom use is the best method of prevention (CDC, 2021; Office on Women's Health, 2021; Pfizer, 2022a).

Screening and Prevention

Although there are no formal screening recommendations, the CDC (2021) recommends consideration of annual screening for at-risk women, which includes those who are being cared for in a setting with high prevalence (i.e., correctional facilities and STI clinics), those with multiple sexual partners, a history of transactional sex, illicit drug use, or a prior history of an STI. Sexually active asymptomatic women with HIV should be screened annually. Women seeking evaluation for vaginal discharge should be screened (CDC, 2021). Due to the inflammation caused by the infection, patients with trichomoniasis are at a greater risk of contracting HIV, so the CDC recommends annual HIV testing in patients with trichomoniasis. Disease prevention can occur through the correct application of condoms, testing, communication of STI results with a sexual partner, monogamy, not douching, and not abusing drugs or alcohol due to risky lifestyle choices and behaviors (CDC, 2021; Office of Women's Health, 2021).

Signs and Symptoms

Approximately 70-85% of patients with trichomoniasis do not experience symptoms but can still carry and transmit the infection. If signs and symptoms are present, patients experience them in the genital tracts, which may occur 5 to 28 days after exposure to the disease. Women may notice itching, redness, burning or soreness in their genitals, discomfort during urination, and vaginal discharge that may appear clear, white, yellow, or green with a fish-smelling odor. The discharge may be thin or be increased in frequency. Although rare, women may experience lower abdominal pain. If pregnant, women are at risk for premature delivery and having a baby with low birth weight. Men may experience itching or irritation in the penis, discharge from the penis, and a burning sensation after urinating or ejaculating. Sexual intercourse may be uncomfortable for both women and men; signs and symptoms may be transient in women and men (CDC, 2021; Office of Women's Health, 2021).

Diagnosis

A health history, a physical assessment, and laboratory testing assist in testing and diagnosing a patient with trichomoniasis. Testing should be completed when a patient experiences any discharge from the genitals. During the pelvic exam, the clinician collects an endocervical or vaginal swab; the sample is placed under a microscope and examined for the presence of trichomonads. In addition, NAATs, DNA testing, or fluid culture may be utilized to enhance sensitivity. Urine specimens and liquid Pap smear specimens may also be used for some assays, such as the Aptima T vaginalis assay by Hologic. The probe Tec TV Q Amplified DNA Assay and Max CTGCTV2 assay by Beckton both allow for the use of patient-collected vaginal swabs. Cultures must be incubated and examined a week after collection to assess for the presence of the parasite. A pap smear is unable to detect the presence of T. vaginalis. Patients who test positive for trichomoniasis should be tested for other STIs, such as HIV, gonorrhea, syphilis, and chlamydia (CDC, 2021; Office of Women's Health, 2021).

Treatment

Trichomoniasis is the most common nonviral STI worldwide. If not treated, the infection may persist for months to years. Patients should be prescribed metronidazole (Flagyl) or tinidazole (Tindamax) for treatment and be advised to complete the entire course of treatment to promote disease eradication and prevention of reinfection (See Table 9 and 10; CDC, 2021; Office of Women's Health, 2021).

Table 9

Medications to Treat Trichomoniasis

(CDC, 2021)

Table 10

Side Effects of Medications to Treat Trichomoniasis

(CDC, 2021; Pfizer, 2022b; US National Library of Medicine, 2021b)

1 in 5 patients experience reinfection within 3 months of treatment; this can be prevented by nurses and HCPs educating patients on sexual abstinence during treatment and avoiding sexual intercourse with someone with trichomoniasis. The nurse should advise the patient that sexual partners be treated simultaneously and to avoid sexual intercourse until treatment has been completed and symptoms have resolved. To prevent reinfection, patients should be encouraged to apply condoms before sexual intercourse. Further patient education should include the need for follow-up testing, which should occur 3 months after the completion of treatment CDC, 2021; Office of Women's Health, 2021).

Nonpharmacological Nursing Care for STIs

Patients may require psychosocial care for anger and frustration related to developing an STI or not knowing who infected them. Nurses can provide support by acknowledging the patient’s distress, educating on transmission prevention, and coordinating care with social workers to tend to the patient’s psychosocial needs. Nurses should assess for pain and encourage the patient to report worsening pain or vaginal/penile discharge (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020).

Future Research

Emerging Infections

WHO (2022) noted monkeypox, Shigella sonnei, Neisseria meningitides, Ebola and Zika, and lymphogranuloma venereum as emerging and re-emerging diseases HCPs need to be aware of in terms of prevention, care, and control. Lymphogranuloma venereum is caused by the same bacteria as chlamydia.

Impact of COVID-19 on Disease Screening and Prevalence

Pfizer (2022a) identified that a decline in the prevalence of reported diseases might be artificial due to a decrease in screening during the COVID-19 pandemic. However, cases of gonorrhea are increasing, as are antibiotic-resistant forms of gonorrhea. The alarming trend of cephalosporin-resistant bacteria makes treating gonorrhea particularly difficult, as few options are available (CDC, 2022b; Pfizer, 2022a).

Post-Exposure Prophylaxis (PEP)

The CDC is currently evaluating the data regarding the potential utility of PEP to prevent bacterial STIs. Doxycycline 200 mg PO taken once following exposure to a bacterial UTI has been shown to reduce transmission of chlamydia (70% reduction) and syphilis (78%) but not gonorrhea. This was evaluated in MSM and transgender women within 24-48 hours of an episode of unprotected anal sex. Studies among women and heterosexual men are not finalized (CDC, 2021).

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