AIDS is not the only sexually transmitted disease to have burgeon in the 1980s. Can you spot the symptoms of the five other much more common STDs? Can you answer the questions that your patients will have about treatment and transmission? By Priscilla McElhose, RN, BSN, MN
The post-MI patient who breaks out with genital blisters, the trauma patient who develops urethral discharge, the patient who’s admitted for severe pelvic inflammatory disease — all have one thing in common: Each has a sexually transmitted disease.
While AIDS may be the most feared and best publicized STD, it is by no means the most common. In fact, while everyone talks about AIDS, up to one American in 10 has become infected with chlamydia, gonorrhea, syphilis, genital warts, or genital herpes.
The possible consequences of these five most prevalent STDs include sterility, miscarriage, birth defects, and, perhaps, cervical and other genital cancers.
Every nurse has an important part to play in the fight against sexually transmitted diseases. You need to recognize the symptoms and teach infected patients how to comply with treatment and take measures to prevent further transmission. You must respond accurately and sensitively to your patient’s pressing questions: “Is it curable? How can I tell my partner? Can I still have sex? Will it make me sterile?” The law also requires you to report certain cases of sexually transmitted disease to the health authorities.
Though these five diseases — two bacteria and three viral — are not as dramatic as AIDS, they are equally deserving of your careful attention.
Chlamydia: The silent menace
Chlamydia, an infection caused by the Chlamydia trachomatis bacteria, strikes an estimated three million to five million Americans each year.
Within three weeks after becoming infected, men may experience burning on urination and a white or clear discharge from the penis, indicating urethral infection — or specifically, non-gonococcal urethrists, or NGU.
Women may develop a yellowish endocervical discharge, painful urination, or spoting after intercourse or between menstrual periods. Chlamydia infection of the rectum can produce itching, constipation, slight bleeding, and mucuscovered stools.
Patients who experience such early symptoms might be considered fortunate: Chlamydia’s greatest threat by far lies in the fact that it’s often asymptomatic.
As a result, the patient feels no need to seek treatment, and the disease may go undiagnosed until a complication sends him to see the physician.
In men that may be epididymitis — inflammation of the sperm ducts that can cause sterility — or Reiter’s syndrome, which includes urethristis, conjunctivitis, arthritis, and skin lesions. Women may develop pelvic inflammatory disease (PID), which can result in infertility and increased risk of ectopic pregnancy.
Infants who are born to infected women are at risk. For a complete discussion of how STDs effect infants in utero and at birth, see the box on page 57.
Chlamydia can almost always be cured by a seven-day course of oral antibiotics. Most patients will receive tetracycline 500 mg qid or doxycycline (Doxy-Caps) 100 mg gib. Pregnant women, who should avoid these first-line drugs, may take erythromycin 500 mg four time a day.
Be sure the patient understands that the disease is dangerous even when asymptomatic. Stress the importance of completing the entire course of antibiotics to eradicate all bacteria. And make sure he knows how and when to take the medication. Tell the patient receiving tetracycline, for example, to take the drug one hour before or two hours after meals. Remind him to avoid dairy products, antacids, mineral supplements, and direct sunlight. Advise him to have follow up cultures taken two to three weeks after finishing the medication.
Explain that chlamydial infections are transmitted only by sexual intercourse, never through casual contact. Encourage the patient to notify all sexual partners within the past three weeks, so they, too, can be treated. Urge abstinence from sex until follow-up cultures are negative and thereafter use of condoms lubricated with a spermicide containing nonoxynol-9 to prevent reinfection from chlamydia and other STDs.(*)
(*)For more information on how to prevent the spread of STDs, see “What you and your patients need to know about safer sex” in the Sept. 1987 issue of RN.
Gonorhea: On the rise among heterosexuals
Nearly a million new case of gonorrhea — or, “clap,” as it’s called on the street — are reported to public health officials each year. While the disease appears to be declining among homosexual men, it’s increasing in all other groups.
Like chlamydia, gonorrhea is caused by bacterial infection. In this case, the infective organism is a gram-negative diplococcus, Neisserig gonorrhoeae.
Most infected men usually develop symptoms of gonococcal urethritis — painful urination and a profuse yellowish discharge from the penis — with two to five days of initial infection. Only about half of infected women develop symptoms, which can include vaginal discharge and burning or pain on urination.
People can also acquire anorectal and pharyngeal gonococcal infections as a result of sexual activity. Anorectal gonorrhea is usually asymptomatic, but patients may experience itching constipation, or blood or mucus in the stool. Pharyngeal infection occasionally causes sore throat.
Patients who remain untreated are at risk for the same complications as those with chlamydia — PID in women and, infrequently, epididymitis in men — as well as systemic gonorrheal infection, which can result in septicemia, arthritis, or skin lesions.
Preferred treatment for anogenital gonorrhea in women and heterosexual men is either amoxicillin 3 gm PO or ampicillin 3.5 gm PO, plus probenecid 1 gm PO. Since these patients often have concurrent chlamydial infections, they are also put on the seven-day regimen to tetracycline or doxcycline.
Homosexual men, who are more likely to have multisite gonorrheal infections, are given IM penicillin 4.8 million units or ceftriaxone sodium (Rocephin) 125 mg to 250 mg IM. Patients with anogenital infections caused by penicillin-resistant strains of gonorrhea are also given ceftriaxone, and ceftriaxone is used as a first-line drug in some communities where resistant strains are common. Patients who are allergic to penicillin may weel be allergic to ceftriaxone too: They receive spectinomycin 2 mg IM.
Most patients respond to treatment within 12 hours and experience complete resolution of symptoms within three days.
Inform the patient that you’re required to report all cases of gonorrhea to public health officials and explain what kind of follow-up is customary in your area. In our community, someone from the department of health contacts each patient, gives information on the prevention of STDs, and asks partners that they’ve been exposed.
Instruct patients to avoid sex while they’re receiving treatment and to have follow-up cultures taken a week after they’re finished their medication.
Urge patients to use condoms to avoid future infection and to seek treatment promptly if symptoms recur. Remind women that they won’t always have symptoms and urge them to go for screening if their partners become infected.
Syphilis: Resurgence of an ancient plague
Despite a widely held misconception that syphilis has been all but wiped out in this country, nearly 28, 000 new case were reported last year. The majority of patients are homosexual men. Some experts anticipate, however, that the rising incidence among heterosexuals may return the annual case load to the 70, 000 level of the early 1980s, before fear of AIDS brought about changes in gay sexual activity.
Syphilis, caused by the Treponema pallidum bacteria, is characterized by four well-defined stages. Symptoms of the earliest stage, primary syphilis, appear three weeks to 90 days after initial infection. Patient may first noticed one or several painless, papular lesions on their gentials, anus, or mouth. The lesions, called chanres, break down into indurated ulcers with firm, raised borders and then disappear again within three weeks. Women with chancres on the cervix may never detect their presence.
After several more weeks or months, patients can progress to secondary syphilis. Its main symptom, which can last two to six weeks, is a skin rash that is highly variable — in fact, it can resemble almost anything.
The next stage, latent syphilis, can last up to 30 years. The patient will have no symptoms, though blood tests will remain positive.
The final stage, tertiary syphilis, can affect the heart and blood vesles, the brain and central nervous system, and occasionally the liver, bones, and skin. Complications in the central nervous system can cause seizures or convulsions; those in the heart can cause death.
Patients with primary, secondary, or early latent syphilis receive a single IM infection of benzathine pencillin G (Bicillin) 2.4 million units. Those who’ve been in the latent state for longer than a year are given 7.2 million units IM, divided into three weekly doses. Patients with tertiary syphilis must be hospitalized for a 10-day regiement of IV pencillin G, 10 to 20 million units a day, followed by three weekly IM injections of benathine pencillin G, 2.4 million units in each does. Patients who have penicillin may be given oral tetracycline 500 mg four times a day for 15 to 30 days, depending on the stage of their illness.
With treatment, syphilis is curable at any stage. Up to 10% of patients, however, don’t respond to the first round of antibiotics and may require a subsequent course of treatment with higher doses over a longer period of time. It’s essential that patients receiving tetracycline understand the importance of adhering missing only a few doses increases the chance of drug failure. Urge these patients to obtain repeat blood tests one, six, 12, and 24 months after therapy to be sure of a cure.
Caution all patients with primary or secondary syphilis about the possibility of a Jarisch-Herxheimer reaction, a flu-like syndrome that can develop within four hours of starting antibiotic therapy. Symptoms usually disappear within 24 hours.
Instruct patients with primary syphilis to avoid intercourse until all lesions are healed to keep from infection their partners. Instruct those with primary and secondary syphilis to notify everyone they’ve had sex with since becoming infected. After the secondary stage, the disease is no longer contagious. Be sure to tell patient that you must report all cases of syphilis to public health authorities and explain local follow-up procedures.
To help patients avoid future infection, encourage them to check all partners for lesions or rashes. Also stress the importance seeking prompt medical attention if symptoms recur. Be sure your patients understand that just because lesions clear up without treatment, it does not mean the infection has gone away.
Genital warts: A strong link to cancer
Each year an estimated 400,000 to 600,000 Americans develop genital warts — a disease caused by the human papilloma virus.
Warts — one or more painless, soft, fleshy, growths — usually appear one or two months after exposure, but can take a long as nine months to incubate. Some warts are so small they can be identified only with a colposcopic exam of the cervix and vagina or a Pap smear
Although much remains to be learned about how the papillomavirus progresses, doctors have observed that the warm, moist environment in the genital area seems to favor wart growth. Outbreaks appear to be exacerbated during pregnancy and in patients with defective immune systems.
Patients with a history of genital wart may be at increased risk for certain types of cancer. The human papilloma virus is associated with up to 90% of cervical malignancies and may play a role in cancers of the vagina, anus, vulva, and penis.
Genital warts treatments used to resolve symptoms can be uncomfortable and vary in effectiveness. Cryotherapy with liquid nitrogen offers the best combination of effectiveness and freedom from unpleasant effects. Electrocautery, excision, and laser surgery are used, but they’re more painful and carry more risk of scarring.
Many doctors treat warts with weekly topical applications of 10% podophyllin in tincture of benzoin. The patient leaves the medication on four to six hours and then washes it off. Podophyllin, however, can be locally or systemically toxic and should not be used extensively on mucosal tissue or during pregnancy. Patients with warts inside the urethra may be given antimetabolites, such as 5-fluorouracil.
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If a patient on your unit has genital warts, urge him to visit his doctor or a sex disease clinic after discharge. Tell him that treatment may be needed for up to eight weeks to destroy the growth be examined and female partners should have a Pap smear.
Recommend use of a condom during intercourse while treatment is going on and for several months afterwards, when the rate of recurrence is high. Urge female patients to have regular gynecologic exams, including a Pap test, to screen for cervical abnormalities.
Herpes: Discomfort, but not doom
Genital herpes is a disease caused by the herpes simplex virus, types I and II. Each year there are between 400,000 and 600,000 new cause of herpes. Some 20 million people have yearly recurrences.
Primary herpes is characterized by one or more genital blisters that usually appear seven to 10 days after initial infection. The blisters progress to shallow, painful ulcerations that resolve without treatment in about two to four weeks. Other symptoms may include muscle pain, headache, and swollen, tender lymph nodes in the groin.
Symptoms are milder during recurrences than during a primary attack. In fact, patients with histories of childhood cold sores or other non-genital herpes outbreaks usually escape altogether the severe symptoms of primary genital herpes. In recurrences, there are fewer, less painful lesions that heal in a shorter period of time — typically, four to seven days. Between outbreaks, patients are symptomatic.
The most common complication of genital herpes is the spread of lesions to other sites, usually the mouth, eyes, or cuticles. Rarely, patients with primary herpes can develop central nervous system complications including stiff neck, headache, intolerance to light, or aseptic meningitis.
Treatment is aimed at speeding resolution of symptoms and reducing the frequency and severity of recurrences. Patients with primary herpes infections receive oral acyclovir (Zovirax) 200 mg five times a day for 10 days. Those suffering a severe recurrence may be given the same regimen, though usually for only five days. For patients with frequent recurrences — six or more a year — the physician may order a continuous regimen of acyclovir 200 mg two to five times a day. Pregnant patients who experience a severe first attack of genital herpes are treated with a topical ointment form of acyclovir, since they must avoid the oral drug.
Suggest other local treatments patients can use at home to supplement drug therapy — such as, frequent washing and drying of genitals with a warm, gentle soap and drying them with a warm hair dryer. Stress the importance of washing hands after using the bathroom to a avoid spreading the infection. Patients can also reduce by maintaining their overall health and avoiding stress as much as possible.
Counseling is especially important for patients with herpes. Reassure then that having the disease lives. Discuss when and how they might tell prospective partners about their disease. You can suggest sex until they know a new partner well enough to discuss so sensitive an issue. Suggest, too, that that not wait until lovemaking has already been started to initiate the discussion.
Urge patients to avoid sex during outbreaks. During the year after the first outbreak, providing they use condoms to contain shedding virus, patients can have intercourse in the symptom-free periods without too much danger of infecting partners. Subsequently, the rate of viral shedding during symptom-free periods decline and condoms — though they will maximize safety — may no longer be needed.
If your patient seems unable or unwilling to accept the changes in lifestyle the disease demands, you might want to refer him for psychological counseling. Some communities have support groups for herpes suffered and hotlines to answer questions about the disease. Find out what services are available in your area and prepare the information as a handout to give patients when they’re discharged.
Good nursing support is important to all patients with sexually transmitted diseases. By helping them understand the symptoms, treatment, and possible complications of their infections and teaching them how to avoid passing it on to their partners you can give your patients a much needed feeling of control over their disease — and their lives.