Sexually Transmitted Diseases
Introduction:
Sexually transmitted diseases (STD), is also known as sexually transmitted infection.
spread from person to person through intimate contact.
Mostly sexually transmitted infections spread during vaginal sex or anal sex but other form of
sexual contact, such as oral sex, can also spread diseases.
STD Definition:
Sexually transmitted disease or infection are diseases, primarily transmitted through sexual
intercourse or close and intimate physical contact from an infected person although there are other
modes of transmission like placental, infected needles or inoculation on the infant’s mucosa
when passes through the birth canal.
Sexually transmitted disease or infection:
Syphilis (Treponema Palladium)
Gonorrhea (Neisseria gonorrhea)
Chlamydia infection
Herpes genital
Genital warts
Candidiasis
HIV/AIDs
Hepatitis B, C etc.
Syphilis
Definition:
Syphilis is a sexually transmitted disease caused by the spirochete Treponema Palladium and
usually transmitted by sexual contact or kissing.
Transmission occurs through the abraded skin or mucosal surface. A fetus carried by a women with
syphilis may contact the disease, a condition is called congenital disease.
The incubation period ranges between 9-90 days.
Clinical features:
The primary stage: characterized by a small lesion called a Chancre, this appears at the site of
infection three to six weeks after exposure.
Fluid from chancre is extremely infectious. Chancre may be single or multiple and is usually
located in the labia or penis which is quickly eroded to form an ulcer. The margins are raised with
smooth shiny floor. The ulcer is painless without any surrounding inflammatory reaction. The
inguinal glands are enlarged. The primary chancre heals spontaneously in 1-8 week leaving behind
a scar.
Chancre
The Secondary syphilis: occurring about six weeks to 6 months from the onset of primary
chancre, the secondary syphilis may be evidenced in the vulva in the form of condylomata lata.
These are coarse, flat-topped, moist. Patient may present with systemic symptoms like fever,
headache, and sore throat. Maculopapular skin rashes are seen on the palms and sole.
The primary and secondary stages can last up to 2 years and during the period, an individual is a
source of infection.
Secondary syphilis
Latent syphilis: It is the quiescence phase after the stage of secondary syphilis has resolved. Latent
syphilis is defined as having serologic proof of infection without symptoms of disease. It may be
early (duration less than 2 years from the onset of disease) or late duration more than 2 years from
the onset of disease.
Tertiary syphilis: About one-third of untreated patients progress from late stage to tertiary
syphilis. The risk are the development of neurosyphilis and cardio syphilis.
Diagnostic Investigations
History taking of exposure to an infected person.
Physical examination.
Identification of organism by taking smear from the exudate.
Serological test: VDRL: This is the common test performed and is positive after 6 weeks of
initial infection.(positive after 6 weeks)
Treponema pallidum hemagglutination assay (TPHA) & Treponema pallidum
immobilization (TPI) test.
ELISA.
PCR
Management
Early syphilis: Benzathine penicillin G 2.4 million units is given intramuscularly in single dose
half to each buttock.
In penicillin hypersensitive cases, tetracycline or erythromycin 500mg, 4 times a day orally for 14
days is effective.
Late syphilis:
Benzathine penicillin G 2.4 million units is given IM weekly for three weeks.
Alternative regimen: Doxycycline 100mg orally twice daily or tetracycline 500mg orally 4 times
day for 4 weeks.
Serological test is to be performed 1, 3, 6, and 12 months after treatment of early syphilis. In late
syphilis serological test is to be done annually.
Gonorrhea:
It is infectious sexually transmitted disease caused by bacteria called Neisseria gonorrhea, a gram
negative diplococcus which produces inflammation and infection of the lining of the genital tract.
The incubation period is 3-7 days.
The principle site of invasion is the columnar and transitional epithelium of genitourinary tract. As
such, the primary sites of infection are endo cervix, urethra, skene’s gland and Bartholin’s
gland. The organism may be localized in the lower genital tract to produce urethritis, anorectal
region and conjunctiva.
Causes
Gonorrhea is caused by the bacteria (Neisseria gonorrhea) which is found mainly in the semen
and vaginal fluid.
Unprotected vaginal, anal or oral sex.
Infected mother can transmit gonorrhea to her new born during child birth.
Men have a 20 % risk of getting the infection from single act of vaginal intercourse with an infected
woman. The risk of men who have sex with men is higher. Women have 60-80% risk of getting
from a single act of vaginal intercourse with an infected man.
Clinical features:
About 50-80% of patients with gonorrhea are asymptomatic and even when the symptoms are
present they are non-specific.
Symptoms usually present two to seven days after infection, in some cases, the first symptoms
may not appear for 30 days.
Women:
The clinical features of acute gonococcal infection are following: Acute unilateral pain and
swelling over the labia due to involvement of Bartholin’s glands.
Burning micturition and frequent urination, often.
Purulent vaginal discharge.
Rectal discomfort due to associated proctitis.
Infection occurs in the urethra, vagina or cervix.
Speculum examination reveals congested ectocervix with increased mucopurulent cervical
secretions escaping out through the external OS.
Men:
An unusual discharge from the tip of penis, scant at the start, and later the discharge become
progressively thicker and heavier.
Painful urination
Pain and tenderness in the testicles.
Lower abdominal pain and backache
Diagnostic investigations
History taking and physical examination.
Culture and sensitivity test of the fluid from the part of the body .
Nucleic acid amplification testing (NAAT) of Urine or endocervical discharge detects the
bacteria.
Management:
The specific treatment for gonorrhea is single dose regimen of any one of the following drugs:
Ceftriaxone 250mg IM or Ciprofloxacin 500mg orally, or ofloxacin 400mg orally, or
spectinomycin 2gm as a single dose IM, ampicillin 3 mg orally.
It is recommended that sexual partners be tested and potentially treated.
The patient with gonorrhea must be suspected of having syphilis or chlamydial infection. As much
the treatment should cover all the three.
Avoid multiple sex partners.
Practice safe sex.
Complications
Chronic PID
Infertility
Ectopic pregnancy
Tubo-ovarian mass and
Bartholin’s gland abscess
Herpes genitals
It is also one of the sexual transmitted diseases which are caused by herpes simplex virus (HSV)
type 1 and type 2. It is usually transmitted sexually by an infected partner but may possibly be
transmitted by oro-genital contact or direct skin to skin touch. The incubation period is 2-14 days.
Herpes genitals
Clinical features:
Symptoms of the first attack usually appear less than 7 days after sexual contact.
In early stages, red painful inflammatory area appears commonly on the clitoris, labia,
vestibule, perineum and cervix.
Multiple vesicles appear that may progress into multiple shallow ulcers and heal spontaneously
by crusting. It takes about three weeks to complete the process.
Inguinal lymphadenopathy occurs.
Other symptoms include fever, malaise, and headache and dysuria
There may be vulvar burning, pruritus
The first episodes are severe compared to the recurrent disease. Frequency of recurrent infection
is high with HSV-2
Herpes genitals
Diagnostic investigations
Virus tissue culture and isolation – confirmatory.
Detection of virus antigen by ELISA or immunofluorescent method.
PCR test to identify the HSV is the new and most accurate test.
Management:
The specific treatment is yet to be explored.
Rest and analgesics are helpful.
Acyclovir which inhibits the intracellular synthesis of DNA by the virus has been found to be
effective in acute attack.
Acyclovir is better to be given orally in doses of 200 mg 5 times a days for 7 days.
Its prophylactic use can reduce the episodes of recurrence. Famciclovir 250 mg orally thrice
daily for 7 days can be used alternatively.
Saline bath may relieve pain.
The women should have annual cervical smear.
Chlamydial infection:
Chlamydial caused by bacteria (Chlamydia trachomatis: an obligatory intracellular gram
negative bacteria) that commonly infects the genitals, anus and throat.
Chlamydial infection transmits through contact with infected semen and vaginal fluids by
unprotected vaginal, anal or oral sex. The organism affects the columnar and transitional
epithelium of the genitourinary tract. The lesion is limited superficially. The infection is mostly
localized in the urethra, Bartholin’s gland and cervix.
Chlamydia has incubation period 6-14 days.
Clinical features:
About 80% of women may be asymptomatic
Symptoms usually develops within 1 to 3 weeks after exposure
Abnormal vaginal discharge. (mucoid with few pus cell).
Burning sensation during urination.
Lower abdominal pain and low backache.
Nausea and fever
Painful intercourse and post coital bleeding.
Bleeding between menstrual periods.
women may have features of acute PID, urethritis and Bartholinitis.
Diagnostic investigations
History taking and physical examination.
Vaginal or penile fluid culture and sensitivity test.
Urine culture for the detection of chlamydia.
Chlamydia antigen can be detected by ELISA techniques.
Endocervical smear.
PCR is very sensitive test, first void urine specimen is most effective and specific.
Medical Management:
Both sexual partners should be treated with the same drugs regimen.
Azithromycin 1gm orally single dose followed by 500mg once a day for 2 days or,
Doxycycline 100 mg orally BD for 7 days or,
Ofloxacin 200mg orally BD for 7 days or,
Erythromycin 500mg orally BD for 7 days.
Genital wart (Condyloma acuminate)
Condylomata are papillary lesions caused by (HPV type 9 and 11).
Multiple in nature and transmitted sexually.
Associated vaginal discharge and pregnancy favors their growth.
Typically, they grow in clusters along a narrow stalk giving it a cauliflower appearance.
Anatomic distribution; cervix 70%, vulva 25%, anus 20%
and vagina 10%
condyloma acuminata
Treatment
HPV vaccine Type 6 and 11 can prevent 90% of condyloma.
Different treatment modalities used are; cryotherapy, laser therapy, surgical excision or topical use
of imiquimod cream, trichloro acetic acid, intralesional interferon or photodynamic therapy.
HIV/AIDS
Causative agent- HIV 1 and HIV 2
Retro virus (double stranded RNA) family
INCIDENCE
Spreading alarmingly fast both in the developed and developing countries and now has become a
global problem.
Modes of Transmission of HIV
Sexual intercourse
Intravenous drug abusers
Transfusion of infected blood
Use of contaminated needles
Breastfeeding
Perinatal transmission
Risk factors for AIDS
Multiple sex partners
Commercial sex workers
Homosexual males
Intravenous drug abusers
Multiple transfusions of blood or blood products
Sexually transmitted disease
Mother to baby
Clinical manifestation
Acute infection syndrome- flu like syndrome, fever, skin rash, arthralgia, lymphadenopathy, and
diarrhea lasts for 2-3 weeks
After initial exposure the person remains asymptomatic for many years
AIDS related complex refers to symptoms of weight loss, fever, diarrhea, skin rash,
lymphadenopathy, herpes simplex, oral or recurrent genital candidiasis oral or genital ulcers, PID,
tubo-ovarian abscess and thrombocytopenia
What is definition of AIDS?
Any HIV infected individual with a CD4 T cell count of <200/µl has AIDS by definition regardless
of the presence of symptoms or opportunistic diseases.
Gynecological Symptomatology
Infection of the genital tract
Vaginitis
Pelvic inflammatory diseases
Neoplasm of the genital tract are increased
Increased morbidity following gynecological surgery
Menstrual abnormality
Fertility is not affected, pregnancy does not worsen the disease
Diagnosis
The organism can be isolated from the blood, semen, vaginal secretions, breast milk, or saliva of
the infected persons.
Diagnostic test for HIV
IgG antibody
Viral P-24 antigen detection
ELISA
Western blot or immunoblot
HIV RNA by PCR is the gold standard
Causes of death
Widespread infection
Profound immunodeficiency leads to opportunistic infection
Development of unusual malignant lesions
Treatment
Preventive
definitive
Preventive
Safer sex
Male circumcision
Use of blunt tipped needles
Screening of donor blood
HIV negative frozen semen for donor insemination
Post exposure prophylaxis
Termination of pregnancy
Avoiding breast feeding
Maintain protocol
Widespread integrated counselling and testing
Definitive
Antiretroviral therapy
Nucleoside reverse transcriptase inhibitors; Zidovudine, Lamivudine, Abacavir
Non-nucleoside reverse transcriptase inhibitors; Nevirapine, Efavirenz
Protease inhibitors; Indinavir, Ritonavir
Entry inhibitors; Enfuvirtide
Integrase inhibitor;Raltegravir
Combination of these drugs are effective in increasing CD4 counts and reducing viral load.
Monotherapy is not preferred as it hastens drug resistance. Combination therapy is known as
HAART( Highly Active Antiretroviral Therapy)
When to start therapy?
Acute HIV infection syndrome
Symptomatic HIV infection
Asymptomatic but CD4 Cell count low
Post exposure prophylaxis
Patients with CD4 count <200/mm3
Opportunistic infections should be treated simultaneously
When to change the therapy?
Failure to reduce viral load
Persistently declining CD4+ T cell count
Clinical deterioration
In presence of side effects due to drugs
Post exposure prophylaxis
A combination of 2 NRTI is given for 4 weeks. Prophylactic use of zidovudine and lamivudine for
a period of 4 weeks immediately following an exposure may reduce the risk of seroconversion.
Precautions to prevent occupational transmission of HIV
Consider all blood and body fluid potentially infectious
Noninvasive procedure whenever possible
Barrier precautions:
Cap, mask, gown, double gloves, eye wear
Use of blunt tipped needle
Washing any body fluid contamination off the skin immediately
Precautions to prevent occupational transmission of HIV cont.
Use of disposable syringes, needles, and anesthetic circuits
Thorough theater disinfection after the operation
STIs management
STIs case management includes education and counseling of the client on risk reduction,
promotion, provision of condoms, partner notification, treatment and follow up.
Education on……
Educational message and counseling for STIs patients:
The cause and consequences of present infection.
The need for completion of the treatment course.
The need for sexual partner treatment.
Risk reduction- condom.
The need to seek early treatment in the future cases of suspected infection.
The risk of HIV/AIDs from unsafe sex.
The follow up time.
These educational message and counseling are summarized as 4Cs.
Compliance;
Completing all the treatment as prescribed.
Counseling/education:
About the disease.
Contact tracing:
Making sure all sexual partners are notified and encouraged to seek treatment.
Condom:
Promoting condom use and providing them.
Nursing management
Nursing assessment
Accessing characteristic of pain ( location, intensity, duration)
Accessing the types and nature of lesion.
History of re-occurrence.
Accessing the risk factors.
Accessing the level of knowledge regarding treatment, personal care, diet etc.
Site of lesion should be assessed.
Accessing any signs of complications.
Nursing Diagnosis
Infection related to sexual exposure as evidenced by urethral discharge, genital lesion, dysuria
etc.
Pain related to extension of infection as evidenced by sore around genital; enlarge lymph nodes,
patient’s facial expression.
Poor genital hygiene related to inadequate knowledge.
Knowledge deficit related to embarrassment about the disease.
Fear related to new diagnosis of STD.
Nursing interventions:
Minimizing the infection
Advice to maintain and improve personal and vaginal hygiene.
Ask the patient to empty the bladder.
Advice to change the underpants daily and wearing well-ventilated clothes & avoid cotton under
garment.
Advice the patient to take antibiotic regularly with full course.
Advice not to have any intimate or close contact with partner.
The patient’s clothes and under garment should be washed and dried properly.
Frequently assess any signs of complication.
Managing the pain
Identify the intensity of pain, its duration.
Maintain comfortable position of patient.
Do not hold the urine due to fear of painful voiding.
Warm saline bath can be used in genital area.
Communicate with patient about his or her feelings.
Avoid tight under pants.
Local topical application can be used as per order.
Encourage for warm fluid intake.
Maintaining hygiene
Wash genital after each voiding.
Advise to change under pants daily.
Inform the patient that further infection can occur due to poor personal and genital hygiene.
Inform about STD
Teach the client about process of transmission, complications and treatment modality.
Importance of having full course of antibiotic and other prescribed medicine.
Involve the patient’s family member in patient care.
Teach the patient:
Both partners should be treated.
Avoid sexual contact until the partner gets fully cured.
Avoid multiple sexual contacts.
Void immediately after sexual contact.
Instruct patient to have safer sexual contact.
Avoid anal & oral sex.
About importance of maintaining hygiene.
Managing fear of patient.
Talk about patient’s feeling as much as possible.
Inform him or her that after proper treatment and full course of medicine disease will be cured.
Hygiene is necessary to maintain to promote healing of infection.
Ask him to inform if he or she have any difficulty and signs of extension of disease.
Provide therapeutic touch as necessary.
Try to ventilate patient’s feeling with family member as well as other near one.
Counseling about safer sex and avoidance of multiple sex partner.
