1. Sexually Transmitted Infections Matthew Joel Brooks, MSN, FNP-c Spring 2012

2. Reproductive Tract and Sexually Transmitted Infections Urinary Tract Infection (UTI) Urinary Tract Infection (UTI) Bacterial Vaginosis (BV) Bacterial Vaginosis (BV) Candidiasis Candidiasis Chancroid Chancroid Chlamydia Chlamydia Genital Herpes Genital Herpes Genital Warts Genital Warts Gonorrhea Gonorrhea Hepatitis B Hepatitis B Molluscum Contagiosum Molluscum Contagiosum Pelvic Inflammatory Disease (PID) Pelvic Inflammatory Disease (PID) Syphillis Syphillis Trichomoniasis Trichomoniasis

3. For Each Infection We Will Cover: Overview Overview Symptoms Symptoms Diagnosis Diagnosis Treatment Treatment Potential Complications Potential Complications

4. UTI: Overview Can be caused by E.Coli, C. trachomatis, N. Gonorrhoeae, or other Gram Negative Bacteria Can be caused by E.Coli, C. trachomatis, N. Gonorrhoeae, or other Gram Negative Bacteria Not necessarily sexually transmitted but sexually associated Not necessarily sexually transmitted but sexually associated

5. Urinary Tract Infections One of the most common primary care diagnosis in the US (AFP, 2005) One of the most common primary care diagnosis in the US (AFP, 2005) Symptoms: Painful, urgent and frequent urination. Patient may have a chief complaint of hematuria. Symptoms: Painful, urgent and frequent urination. Patient may have a chief complaint of hematuria. HPI: What questions will you ask?? HPI: What questions will you ask??

6. UTI: HPI Have you had a fever? Have you had a fever? Have you seen blood in your urine? Have you seen blood in your urine? Have you been having back pain? Have you been having back pain? Do you have any vaginal discharge? Do you have any vaginal discharge? Vaginal itching? Vaginal itching? Painful Intercourse? Painful Intercourse?

7. UTI Diagnosis Order a Urinalysis Order a Urinalysis Is it normal to have a few RBC’s in the urine? What about WBC’s or Nitrites? Is it normal to have a few RBC’s in the urine? What about WBC’s or Nitrites? UA: How many bacteria in the urine to diagnose UTI? UA: How many bacteria in the urine to diagnose UTI?

8. UTI Treatment Ciprofloxacin 250mg bid for 3 days or Bactrim (TMP/SMZ) 160/800mg bid for 3 days for uncomplicated UTI Ciprofloxacin 250mg bid for 3 days or Bactrim (TMP/SMZ) 160/800mg bid for 3 days for uncomplicated UTI If UTI is untreated, what are some of the potential complications? If UTI is untreated, what are some of the potential complications? What will you teach your patients? What will you teach your patients?

9. Bacterial Vaginosis Occurs when several species of vaginal bacteria (Gardnerella vaginalis, Mycoplasma hominis, and various anaerobes) replace lactobacillus species and cause vulvovaginitis symptoms Occurs when several species of vaginal bacteria (Gardnerella vaginalis, Mycoplasma hominis, and various anaerobes) replace lactobacillus species and cause vulvovaginitis symptoms Sexually associated condition Sexually associated condition

10. BV Symptoms Malodorous “fishy” discharge Malodorous “fishy” discharge Erythema, edema, and pruritis of the external genitalia Erythema, edema, and pruritis of the external genitalia

11. Diagnosis of BV Elevated Vaginal pH (>4.7) Elevated Vaginal pH (>4.7) Identification of Clue Cells with saline wet mount Identification of Clue Cells with saline wet mount Whiff test with KOH Whiff test with KOH

12. Treatment of BV and Complications if Not Treated Metronidazole (Flagyl) or Clindamycin either intravaginally or orally Metronidazole (Flagyl) or Clindamycin either intravaginally or orally Complications: Excoriation, recurrent infections, associated with adverse pregnancy outcomes including preterm delivery and low birthweight Complications: Excoriation, recurrent infections, associated with adverse pregnancy outcomes including preterm delivery and low birthweight Patient Teaching Patient Teaching

13. Candidiasis Overview Caused by Candida albicans Caused by Candida albicans Can grow as oval, budding yeast cells and as chains of cells known as hyphae Can grow as oval, budding yeast cells and as chains of cells known as hyphae

14. Candidasis Symptoms May have no symptoms May have no symptoms May include erythema, edema, and pruritis of the external genitalia May include erythema, edema, and pruritis of the external genitalia In the male patient: may have balanitis (inflammation of the glans penis) In the male patient: may have balanitis (inflammation of the glans penis)

15. Candidasis Diagnosis Yeast is seen in KOH (potassium hydroxide) wet mount of vaginal discharge Yeast is seen in KOH (potassium hydroxide) wet mount of vaginal discharge Woman has symptoms Woman has symptoms

16. Candidasis Treatment Single dose of Fluconazole 150mg Single dose of Fluconazole 150mg OTC Miconazole OTC Miconazole Longer treatment for more severe cases Longer treatment for more severe cases What if the pt has recurrent infections?? What if the pt has recurrent infections?? Patient teaching Patient teaching

17. Chancroid Overview Caused by Hemophilus decreyi a gram negative bacillus Caused by Hemophilus decreyi a gram negative bacillus More common in developing countries and in the US where sex is exchanged for drugs or money More common in developing countries and in the US where sex is exchanged for drugs or money

18. Chancroid Symptoms Single painful sore Single painful sore Painful lymphadenopathy in about ½ of the cases Painful lymphadenopathy in about ½ of the cases Lymph node may rupture in 25-60% of cases Lymph node may rupture in 25-60% of cases

19. Chancroid Diagnosis and Treatment Differentials: Syphilis, HIV, Herpes Differentials: Syphilis, HIV, Herpes Send serologic tests for syphillis and HIV Send serologic tests for syphillis and HIV Send a culture of the ulcer/lesion Send a culture of the ulcer/lesion Antibiotics for 7days, re-evaluate (Cipro or Azithromycin) Antibiotics for 7days, re-evaluate (Cipro or Azithromycin) Aspiration of lymph nodes Aspiration of lymph nodes

20. Genital Herpes Overview Caused by HSV1 and HSV2 Caused by HSV1 and HSV2 HSV2 is the more common genital disease HSV2 is the more common genital disease One out of 5 people are infected with genital herpes One out of 5 people are infected with genital herpes Most people transmit the disease when they are asymptomatic Most people transmit the disease when they are asymptomatic Not a commonly screened STI due to prevalence, testing is based upon clinical presentation. Not a commonly screened STI due to prevalence, testing is based upon clinical presentation. Also, tests usually take several days and are expensive. Also, tests usually take several days and are expensive.

21. Genital Herpes Symptoms Single or multiple vesicles, which are usually pruritic, can appear anywhere on the genitalia Single or multiple vesicles, which are usually pruritic, can appear anywhere on the genitalia Vesicles spontaneously rupture and form shallow ulcers that may be very painful Vesicles spontaneously rupture and form shallow ulcers that may be very painful Initial infection ulcers last about 12 days, subsequent ulcers about 4.5 days Initial infection ulcers last about 12 days, subsequent ulcers about 4.5 days

22. HSV Treatment Oral acyclovir 200mg five times per day x 7days or 400mg tid Oral acyclovir 200mg five times per day x 7days or 400mg tid Prophylaxis: Acyclovir 400mg bid. This will also help prevent transmission to partners Prophylaxis: Acyclovir 400mg bid. This will also help prevent transmission to partners

23. HSV Complications Women: Pregnancy loss and preterm delivery Women: Pregnancy loss and preterm delivery Women with active genital infection during vaginal delivery can transmit neonatal herpes which can cause disseminated infection that effects the CNS of the baby and can have a high fatality rate Women with active genital infection during vaginal delivery can transmit neonatal herpes which can cause disseminated infection that effects the CNS of the baby and can have a high fatality rate Patient teaching Patient teaching

24. Gonorrhea Overview Caused by Neisseria Gonorrhoeae, a gram negative diplococcus Caused by Neisseria Gonorrhoeae, a gram negative diplococcus Symptoms in men: Dysuria, increased frequency of urination, purulent urethral discharge. ¼ of men are asymptomatic Symptoms in men: Dysuria, increased frequency of urination, purulent urethral discharge. ¼ of men are asymptomatic Symptoms in women: Abnormal vaginal discharge, abnormal menses, dysuria, or asymptomatic Symptoms in women: Abnormal vaginal discharge, abnormal menses, dysuria, or asymptomatic Gonorrhea can also be contracted via oral intercourse, so that bizarre sore throat could be… Gonorrhea can also be contracted via oral intercourse, so that bizarre sore throat could be…

25. Gonorrhea Diagnosis Gram stain and culture are done from the urethral discharge in a man or sample from the cervix in a woman Gram stain and culture are done from the urethral discharge in a man or sample from the cervix in a woman Or Gonorrhea and Chlamydia can be screened for with a urine sample (NAAT-nucleic acid amplification test, DNA probe test, ELISA-finds Chlamydia antigens) Or Gonorrhea and Chlamydia can be screened for with a urine sample (NAAT-nucleic acid amplification test, DNA probe test, ELISA-finds Chlamydia antigens)

26. Gonorrhea Treatment About ¼ of men and 2/5 of women with gonococcal infections also have chlamydial infection – Always check for both. About ¼ of men and 2/5 of women with gonococcal infections also have chlamydial infection – Always check for both. Treatment: Cefixime 400mg po x 1 or Ceftriaxone (Rocephin) 250mg IM x 1* Treatment: Cefixime 400mg po x 1 or Ceftriaxone (Rocephin) 250mg IM x 1* Or ciprofloxacin 250mg po x 1, but preferred treatment is cefixime or ceftriaxone as there is resistance against fluroquinolones Or ciprofloxacin 250mg po x 1, but preferred treatment is cefixime or ceftriaxone as there is resistance against fluroquinolones

27. Gonorrhea Complications Women: if untreated 40% of women will develop PID and are at risk for infertility and abscess formation Women: if untreated 40% of women will develop PID and are at risk for infertility and abscess formation Men: Risk of epididymitis, urethral stricture, and sterility. Men: Risk of epididymitis, urethral stricture, and sterility. Newborns: ophthalmia neonatorum, scalp abscess, rhinitis, anorectal infection. Newborns: ophthalmia neonatorum, scalp abscess, rhinitis, anorectal infection.

28. Chlamydia Overview Leading cause of preventable infertility and ectopic pregnancy Leading cause of preventable infertility and ectopic pregnancy Most common STD in the US Most common STD in the US Many infections are chronic and asymptomatic so screen, screen, screen. Many infections are chronic and asymptomatic so screen, screen, screen.

29. Chlamydia Symptoms Women: Women: Abnormal Vaginal Discharge Abnormal Vaginal Discharge Bleeding between periods Bleeding between periods Burning with urination/Dysuria Burning with urination/Dysuria Low back pain Low back pain Dyspareunia Dyspareunia Men: Men: Discharge from the penis Discharge from the penis Burning with urination Burning with urination Swelling of testicles Swelling of testicles Burning/Itching around urethral meatus Burning/Itching around urethral meatus

30. Chlamydia Diagnosis CDC Recommends: Screen all sexually active women age 25 years or younger annually CDC Recommends: Screen all sexually active women age 25 years or younger annually This is via urinalysis or vaginal swab. This is via urinalysis or vaginal swab. Treatment: Azithromycin 1gm x1 dose. Other options include: doxycycline, ofloxacin, levofloxacin, amox, erythro Treatment: Azithromycin 1gm x1 dose. Other options include: doxycycline, ofloxacin, levofloxacin, amox, erythro

31. Chlamydia Complications Pelvic Inflammatory Disease (PID) Pelvic Inflammatory Disease (PID) Infertility Infertility Ectopic Pregnancy Ectopic Pregnancy Non-Gonoccoccal Urethritis Non-Gonoccoccal Urethritis Screen mothers during 3 rd trimester may cause conjunctivitis, PNA, or OM in baby Screen mothers during 3 rd trimester may cause conjunctivitis, PNA, or OM in baby

32. Molluscum Contagiosum Occurs infrequently- about 1 case per 100 cases of gonorrhea Occurs infrequently- about 1 case per 100 cases of gonorrhea Caused from DNA virus from the poxvirus group Caused from DNA virus from the poxvirus group Symptoms- lesions are 1-5 mm in size, firm, shiny, flesh colored and have a characteristically umbilicated center. Most commonly seen on the trunk or anogenital region and are asymptomatic Symptoms- lesions are 1-5 mm in size, firm, shiny, flesh colored and have a characteristically umbilicated center. Most commonly seen on the trunk or anogenital region and are asymptomatic

33. MC Treatment May resolve spontaneously May resolve spontaneously Can remove with cutterage after cryoanesthesia Can remove with cutterage after cryoanesthesia Use caustic chemicals (podophyllin, TCA, silver nitrate) Use caustic chemicals (podophyllin, TCA, silver nitrate)

34. Pelvic Inflammatory Disease Can be caused by varying combinations of N. gonorrhoeae, C. trachomatis, anaerobic bacteria, E. coli, Mycoplasma hominis, and others Can be caused by varying combinations of N. gonorrhoeae, C. trachomatis, anaerobic bacteria, E. coli, Mycoplasma hominis, and others Infection moves from the cervix to the uterus, fallopian tubes, and ovaries Infection moves from the cervix to the uterus, fallopian tubes, and ovaries One in seven women reports having been treated for PID in her lifetime One in seven women reports having been treated for PID in her lifetime

35. PID Differentials Abortion, Threatened Abortion, Threatened Acute Appendicitis Acute Appendicitis Diverticulosis Diverticulosis Endometriosis Endometriosis Gastroenteritis Gastroenteritis Ovarian Cysts Ovarian Cysts Ovarian Torsion Ovarian Torsion Ectopic Pregnancy Ectopic Pregnancy Urinary Tract Infection Urinary Tract Infection

36. PID Diagnosis Adnexal tenderness Adnexal tenderness Temp >38.5 or 101F Temp >38.5 or 101F Abnormal cervical or vaginal discharge Abnormal cervical or vaginal discharge Elevated ESR Elevated ESR WBC’s seen on wet Mount WBC’s seen on wet Mount Laboratory documentation of Chlamydia or Gonorrhea Laboratory documentation of Chlamydia or Gonorrhea

37. PID Treatment A minimum of 2 antibiotics. Example Ceftriaxone 250mg IM x 1 and Doxycycline 100mg PO bid for 14 days A minimum of 2 antibiotics. Example Ceftriaxone 250mg IM x 1 and Doxycycline 100mg PO bid for 14 days Clinical decision to admit the patient to the hospital or discharge with PO antibiotics Clinical decision to admit the patient to the hospital or discharge with PO antibiotics Follow up with patient next day and in 2 weeks. Follow up with patient next day and in 2 weeks.

38. Syphilis Overview Caused by Treponema pallidum, a spirochete Caused by Treponema pallidum, a spirochete Can cause very serious symptoms if not treated Can cause very serious symptoms if not treated Cannot invade intact skin, however only a few need to cross friable mucosal tissues and abraded skin to result in infection. Cannot invade intact skin, however only a few need to cross friable mucosal tissues and abraded skin to result in infection. Hence, can be acquired orally Hence, can be acquired orally

39. Syphilis Symptoms Primary: Painless chancre, indurated ulcer, located at the site of exposure. Syphilis should be in the list of differentials for any genital lesion Primary: Painless chancre, indurated ulcer, located at the site of exposure. Syphilis should be in the list of differentials for any genital lesion Secondary: Highly variable skin rash (especially on palms and soles), mucous patches, lymphadenopathy, alopecia, etc. Secondary: Highly variable skin rash (especially on palms and soles), mucous patches, lymphadenopathy, alopecia, etc. Latent: Patients have no clinical signs of infection Latent: Patients have no clinical signs of infection

40. Syphilis Diagnosis RPR- Rapid Plasma Reagin will detect Syphilis antibodies RPR- Rapid Plasma Reagin will detect Syphilis antibodies This is a titer… Once positive, always positive This is a titer… Once positive, always positive Not very specific, but is a nice, cheap test. Not very specific, but is a nice, cheap test.

41. Syphilis Diagnosis RPR RPR Level of titer describes level of infection. Level of titer describes level of infection. Levels tend to wane over time, even if not treated. Levels tend to wane over time, even if not treated. Thus titer of 1:2 is likely old exposure. 1:1064 is likely brand new. Thus titer of 1:2 is likely old exposure. 1:1064 is likely brand new.

42. Syphilis Diagnosis FTA, TP-PA, TP-EIA… FTA, TP-PA, TP-EIA… Treponemal antibody tests. Treponemal antibody tests. These are expensive and are usually done for confirmation purposes. Labs these days generally auto-reflex to one of these after a positive RPR. These are expensive and are usually done for confirmation purposes. Labs these days generally auto-reflex to one of these after a positive RPR.

43. Syphilis Diagnosis RPR RPR Subsequent infections are possible Subsequent infections are possible Thus if a person was treated and had a titer of 1:4, and was newly reinfected, titers afterwards would likely show dramatic increase. Thus if a person was treated and had a titer of 1:4, and was newly reinfected, titers afterwards would likely show dramatic increase.

44. Syphilis Diagnosis Direct fluorescent antibody testing (Darkfield) Direct fluorescent antibody testing (Darkfield) The gold standard, as this directly identifies T. pallidum The gold standard, as this directly identifies T. pallidum Very expensive and usually reserved for difficult-to-diagnose cases Very expensive and usually reserved for difficult-to-diagnose cases

45. Syphilis Treatment Primary, Secondary or early syphilis of less than one year duration: Benzathine Penicillin G (Bicillin) 2.4 million units IM x 1 Primary, Secondary or early syphilis of less than one year duration: Benzathine Penicillin G (Bicillin) 2.4 million units IM x 1 Longer than one year (Latent): 3 injections over 3 weeks (7.2 million units total) Longer than one year (Latent): 3 injections over 3 weeks (7.2 million units total) OR OR Doxycycline 100mg PO bid for 14 or 28 days Doxycycline 100mg PO bid for 14 or 28 days Always test for concurrent HIV Always test for concurrent HIV

46. Trichomoniasis Overview Motile Protozoan with an undulating membrane and four flagella Motile Protozoan with an undulating membrane and four flagella Most common worldwide STD Most common worldwide STD

47. Trichomoniasis Symptoms Women: Excessive, frothy, diffuse, yellow green vaginal discharge or could have no clinical s/s or erthyema, edema, and pruritis of the external genitalia. Dysuria and dyspareunia are also common. Women: Excessive, frothy, diffuse, yellow green vaginal discharge or could have no clinical s/s or erthyema, edema, and pruritis of the external genitalia. Dysuria and dyspareunia are also common. Men: urethritis, balanitis, lesions, majority have no symptoms Men: urethritis, balanitis, lesions, majority have no symptoms

48. Trichomoniasis Treatment Metronidazole 2 gms PO x 1 or Metronidazole 2 gms PO x 1 or Metronidazole 500 mg PO bid x 7 days Metronidazole 500 mg PO bid x 7 days

49. General Screening Considerations… A strong risk factor for contracting STIs, is having a history of previous infection. A strong risk factor for contracting STIs, is having a history of previous infection. Don’t just ask about condom usage, ask about lubricant usage! Don’t just ask about condom usage, ask about lubricant usage! And don’t forget condom storage! And don’t forget condom storage! Male circumcision status... Male circumcision status... Decreased rates of transmission and infection of HIV, HSV, Syphilis, Gonorrhea, Chlamydia, Trich, and HPV amongst circumcised males. Decreased rates of transmission and infection of HIV, HSV, Syphilis, Gonorrhea, Chlamydia, Trich, and HPV amongst circumcised males. This is not a promotion of circumcision, just providing an awareness This is not a promotion of circumcision, just providing an awareness

50. Condom Efficacy HIV – 85+% reduction in transmission risks HIV – 85+% reduction in transmission risks Gonorrhea, Chlamydia, Trichomonas – About 70-80% reduction in transmission risks Gonorrhea, Chlamydia, Trichomonas – About 70-80% reduction in transmission risks HSV – Close to 99% reduction in risk HSV – Close to 99% reduction in risk HPV – 50-70% reduction in risk HPV – 50-70% reduction in risk