20.2 Sexually Transmitted Infections

Chlamydia and Gonorrhea

Chlamydia trachomatis, commonly known as chlamydia, is a bacterium that is spread through infected bodily fluids, including vaginal fluid and semen, and is transmitted orally and rectally. Often, patients who become infected with chlamydia also have a coinfection with gonorrhea, a bacterial infection caused by the bacterium Neisseria gonorrhoeae. These bacterial STIs can be spread through all kinds of sexual contact, including vaginal, anal, and oral sex, and the sharing of sex toys. They can also be spread from a parent to child during a vaginal childbirth.

Chlamydia (CDC, 2024a) and gonorrhea (CDC, 2024b) infections are often asymptomatic especially in female individuals, but if symptoms do occur, they will likely become evident between a week and three months after transmission. Clinical manifestations of chlamydia and gonorrhea in women often mimic those of a urinary tract infection (UTI), such as foul-smelling vaginal discharge, painful urination, increased urinary frequency, itching, or burning of the vagina, and a dull ache or pain in the lower abdomen. As many as 15% of untreated women will develop pelvic inflammatory disease (PID) (Jennings & Kryko, 2023). In men, symptoms may manifest as a white, yellow, or green discharge from the penis and painful urination. Both chlamydia and gonorrhea are diagnosed by using specific tests, such as Gram stains or nucleic acid amplification tests, to detect the presence of bacteria in the urine or from vaginal or urethral swabs. Additionally, the provider or nurse should obtain a full sexual history and perform a physical examination to look for symptoms that assist in confirming the diagnosis. Typically, patients with a suspected STI are tested and treated for both chlamydia and gonorrhea at the same time because they often occur together and cause similar symptoms. Standard guidelines for treatment are doxycycline for chlamydia and single-dose ceftriaxone intramuscular injection for gonorrhea (American Family Physician, 2022).

Herpes Simplex Virus

Herpes simplex virus (HSV) causes a viral infection that can be classified into two different types: herpes simplex type 1 (HSV-1) and herpes simplex type 2 (HSV-2). Although both types of herpes are caused by the same virus, they cause different symptoms. HSV-1, known as oral herpes, causes cold sores on the mouth and lips (Figure 20.6) and HSV-2 (“genital herpes”) results in a type of sore called a genital vesicle, or a painful fluid-filled lesion on the genitals. The herpes virus is spread through sexual contact, including vaginal, anal, and oral sex, or contact with a sore (either on the mouth or on the genitals). Although usually asymptomatic, individuals infected with HSV will have “outbreaks” during which they develop oral or genital sores that last approximately one week. Occasionally, these outbreak periods are accompanied by flu-like symptoms, such as a fever or chills. Typically, the first outbreak is the worst one, and there may be long periods of remission between outbreaks. Herpes virus infection is a lifelong condition, and the frequency and severity of outbreaks will vary depending on the person and health status. Diagnosis is made by the provider or nurse through clinical assessment of active sores on the mouth or genitals. If a diagnosis is unable to be made based on clinical assessment alone, a swab of the sore can be tested to determine the presence or absence of the virus. Additionally, there is an antibody test that can be used to detect whether the body has previously made antibodies to HSV, indicating that the individual has been exposed before.

Figure 20.6 Cold sore lesions are caused by the HSV-1 virus. (credit: Robert E. Sumpter/CDC/Public Health Image Library, Public Domain)

Human Papillomavirus

Human papillomavirus (HPV) is the most common STI in the United States. There are more than 100 different types of HPV, encompassing a wide range of severity. Most types do not cause symptoms or require treatment, but more severe types can result in the development of genital warts. The most severe types of HPV can cause cancers of the cervix, vagina, or anus. Human papillomavirus has also been linked to the development of oral-laryngeal cancers, especially in men. Because even asymptomatic infections can eventually cause cancer, it is important for sexually active individuals to be tested for HPV frequently. Current practice guidelines recommend testing every three years between the ages of 21 and 29. For patients who test positive for HPV, further testing may be indicated to identify the specific type and determine if early cancer screening should be instituted. Fortunately, a vaccine for HPV was developed in 2009 that decreases the risk of contracting the virus. This vaccine is recommended for all children between the ages of 11 and 12 years as a prophylactic measure to prevent HPV infection and potential cancers later in life (Quinlan, 2021).

Syphilis

Syphilis is a bacterial STI caused by Treponema pallidum. It is transmitted through sexual contact, blood exposure, and close contact with open skin lesions. The first clinical sign of a syphilis infection is the presence of a chancre, a painless sore that develops where the organism entered the body (Figure 20.7). Chancres are most commonly found on or around the penis, vagina, anus, lips, and/or mouth. Typically, the chancre becomes noticeable within a few weeks of the initial infection and heals on its own.

Figure 20.7 A chancre is the first clinical sign of a syphilis infection. (credit: CDC/Public Health Image Library, Public Domain)

If the chancre goes undetected, the patient may not be aware they are infected and may not seek treatment until further symptoms occur months later, marking the more severe, secondary phase of the infection. In this stage of infection, the patient will exhibit flu-like symptoms, such as fever, sore throat, swollen lymph nodes, and headaches. They also usually develop a skin rash on the palms of the hands or soles of the feet. Figure 20.8 shows an image of a typical syphilis rash on the palms of the hands. The lesions of the rash are highly contagious and should not be touched with bare hands. This rash will clear up on its own within a few months, marking the start of the latent phase of infection. During this phase, the patient does not have any noticeable symptoms, but the infection remains present in the body. The later stage of syphilis, also called the tertiary stage, is systemic and life-threatening, and is characterized by neurological dysfunction. Symptoms during this stage include headache, uncoordinated muscle movements, mental status changes, and dementia. Because syphilis can be effectively treated with antibiotics, it does not typically enter the tertiary stage. This stage of the disease is possible, however, especially in populations with limited access to health care and other resources.

Figure 20.8 A syphilis rash on the palms of the hands may be seen during the secondary stage of infection. (credit: CDC/Public Health Image Library, Public Domain)

Recognizing and Analyzing Cues

Though many STIs can be asymptomatic, most do have some associated symptoms that should be assessed for by the nurse. To effectively detect and diagnose STIs in their early stages, the nurse must be able to recognize specific symptoms associated with each type of infection. Common clinical manifestations of different types of STIs are listed in Table 20.2.

Prioritizing Hypotheses, Generating Solutions, and Taking Action

Once the nurse identifies symptoms of an STI, the nurse should refer the patient to the appropriate resources for further diagnostic testing. If the patient is being cared for in the hospital setting, the next step would be to notify the care team and request any necessary further testing and treatment. In outpatient centers, the nurse may be able to perform point-of-care STI testing and initiate a request for immediate treatment by a provider with antibiotics or other medications. Actions taken by the nurse will vary depending on the practice setting and specific STI present, but the goals of care include early diagnosis and intervention to effectively eradicate the infection. Another important aspect of nursing care of patients with STIs is caring for the mental aspects associated with the disorder. There is a stigma associated with STIs that can negatively affect the mental health of those affected, so nurses must be aware of this stigma and treat patients without judgment.

Evaluating Outcomes

The purpose of evaluating outcomes after a patient has been treated for an STI is to determine whether the treatment was effective and if the patient requires further care. During the evaluation,

• The nurse should ask the patient about their symptoms and if they feel as though they have been fully resolved.
• The nurse will also perform a physical assessment to determine if the physical symptoms such as rashes or warts have cleared up completely.
• If treatment appears to have been effective, the next step in the evaluation process is to provide counseling and appropriate resources to the patient. Patient education should include information about safe sexual practices to help limit their risk of developing another STI in the future.
• The nurse will provide information about the future course of the disease. Although some STIs, like chlamydia and gonorrhea, can be effectively treated with antibiotics, other infections, such as herpes, are lifelong conditions with chronic symptoms and flare-ups.
• Nurses should evaluate the patient’s knowledge about symptoms of infertility. In these cases, the nurse should provide information about testing and treatments that may be necessary throughout the patient’s lifetime so they are prepared and know what to expect in the future.