Module 7: STIs

Question 1

Diff Kinds of Infections

Answer 1

Bacterial infections
 Chlamydia
 Gonorrhea
 Syphilis

Parasitic/protozoan
infections
 Trichomoniasis

Viruses
 Genital herpes
 HIV
 Hepatitis B and C
 HPV
 Molluscum

Question 2

Chlamydial Infections
Etiology and Pathophysiology

Answer 2

Most common STI in the United States
 ~1.6 million new cases/year; increased incidence
 Etiology and pathophysiology

Caused by Chlamydia trachomatis
 Gram-negative bacterium
 Intracellular pathogen

Transmitted through exposure to sexual fluids; ejaculation not necessary
 1 - 3 week incubation period
 Reinfection possible even after treatment

Most common site in men—urethra (urethritis)
 Most common site in women—cervix (cervicitis)
 Anyone can get anal and/or oropharynx infections
 Serotypes: lymphogranuloma venereum (LGV) and
nongonococcal urethritis (NGU)

Often asymptomatic
 Men
* Pain with urination (dysuria) or urethral discharge
* Rare: testicular pain or swelling
 Women
* Mucopurulent vaginal discharge, abnormal vaginal bleeding, dysuria, pain with intercourse
 Rectal
* Anorectal pain, discharge or bleeding, anal pruritus,
tenesmus, mucus-coated stools, or painful BMs
 Throat
* Asymptomatic or sore throat

Question 3

Chlamydial Infection
Complications

Answer 3

Men
 Epididymitis can cause infertility
 Women
 Pelvic inflammatory disease (PID)
* Increased risk of ectopic pregnancy, infertility, and chronic
pelvic pain
* Risk of PID increases with repeated infections
 Rare: reactive arthritis
 Autoimmune response to infection with C. trachomatis

Question 4

Chlamydial Infections
Diagnostic Studies

Answer 4

Sexual history, physical exam, lab tests
 *Nucleic acid amplification testing (NAAT); used to
identify small amounts of DNA or RNA in test samples
* Endocervical or vaginal swabs (women)
* Urethral swabs (men)
* Urine (both)
* Rectal and oropharyngeal screening and diagnosis

Question 5

Chlamydial Infections
Interprofessional Care

Answer 5

Regular screening in high-risk populations
 Drug therapy
 Doxycycline twice a day for 7 days
 Alternates: erythromycin, ofloxacin, or levofloxacin

Patient education
 All sexual contacts within 60 days should be
evaluated and treated
 Abstain from sex for 7 days after treatment or until all
partners have been treated an abstained for 7 days
 High rate of recurrence of infection
* Review risk reduction methods
* Return for repeat testing 3 months after treatment to
ensure cure or detect reinfection
* Teach patients to return with persistent or recurrent
symptoms

Must treat sexual partner(s) to avoid “ping-pong”
effect – treatment, re-exposure, reinfection
 CDC recommends expedited partner therapy
(EPT); provide drugs or prescription without exam
* Not recommended for MSM; high risk for coinfection
* Not recommended for symptomatic women due to risk of PID

Question 6

Gonococcal Infections
Etiology and Pathophysiology

Answer 6

Second most common reportable STI
 Incidence increasing; reported 600,000 cases/year;
estimates of actual # around 1.6 million
 Caused by Neisseria gonorrhoeae
 Gram-negative diplococcus bacterium
 Transmitted by exposure to sexual fluids; ejaculation
not necessary
 Incubation period 1 to 14 days

Prior infection does not provide immunity to subsequent reinfection
 Most common site
 Men—urethra
* Dysuria, purulent discharge, epididymitis
 Women—cervix
* Increased vaginal discharge, dysuria, frequency of urination, bleeding after sex
 All persons- infection in rectum and oropharynx

Question 7

Gonococcal Infections
Clinical Manifestations

Answer 7

Symptoms of rectal gonorrhea
 Mucopurulent rectal discharge or bleeding, pain,
pruritus, tenesmus, mucus-coated stools, painful
bowel movements
 Symptoms of oropharyngeal gonorrhea
 Few, if any symptoms
 Some have a sore throat

Question 8

Gonococcal Infections
Complications

Answer 8

Men often seek treatment early due to symptoms;
less likely to develop serious complications
* Epididymitis can cause infertility
 Women often asymptomatic; serious complications
from lack of care
* Infection in Bartholin’s or Skene’s glands
* PID can cause ectopic pregnancy infertility, chronic
pelvic pain

Neonates can develop gonococcal conjunctivitis
(ophthalmia neonatorum)
 From exposure to an infected mother during delivery
 Can result in permanent blindness
 Almost all states require prophylactic treatment for
newborns so it is rare

Question 9

STI Gender Considerations

Answer 9

Men
 Syphilis, gonorrhea more
common, especially in MSM (men having sex with men)
 More likely have symptoms of
genital infection
 Genital infection results in
fewer complications
 Easier to diagnose – less
complex anatomy
 Less likely to seek medical
care unless symptomatic

Women
 Anatomy increases risk for
STIs
 Less likely to show early signs
of genital infection
 Trichomoniasis and herpes
simplex type 2 more common
 Screened for, thus more likely
to be diagnosed with HPV
 Have more frequent and
serious complications related
to STIs

Question 10

Gonococcal Infections Diagnostic Studies

Answer 10

History and physical exam

Lab tests
 Gram stain smears
 Culture
 NAAT
 Testing for other STIs

Question 11

Treatment

Answer 11

Drug therapy
 Often started before test results return
 N. gonorrhoeae has developed resistance to many
classes of antibiotics
 First-line treatment: high-dose IM ceftriaxone
* Do sensitivity testing on patients who persistently test
positive
 Patient education: treat all sexual contacts within last
60 days; abstain from sexual contact for 7 days;
return for repeat testing in 3 months

Question 12

Trichomoniasis (“trich”)

Answer 12

Caused by a protozoan parasite, Trichomonas
vaginalis
 Common in United States; 2.6 million
 Often overlooked; better testing methods have
improved detection
 Much more common among women than men
* Particularly among women with HIV

Transmitted by exposure to sexual fluids; ejaculation
not necessary
 Incubation period—1 week to 1 month or longer
 Infection provides no protection to future reinfection

Most common site for infection
 Men—urethra
 Women—cervix
 Uncommon to infect rectum
 Not known to infect oropharynx
 Routine screening for high risk women is
recommended

Question 13

Trichomoniasis
Clinical Manifestations

Answer 13

Most asymptomatic
 Men: burning with urination or ejaculation or urethral
discharge
 Women: painful urination, vaginal itching, painful
intercourse, bleeding after sex, or yellow-green
discharge with a foul odor
* Exam: “strawberry” appearance of cervix

Trichomoniasis Complications
Inflammation and irritation in genital track if left
untreated
 Makes a person more likely to acquire or
transmit another STI, particularly HIV
 Associated with PID in women with HIV

Trichomoniasis Diagnostic Studies
NAAT testing of vaginal or endocervical
secretions or urine
 Culture
 Point-of-care testing
 Direct visualization of trichomonads under a
microscope

Trichomoniasis
Interprofessional Care
Drug therapy
 Metronidazole (Flagyl) or tinidazole (Tindamax)
* Abstain from sex for 7 days after treatment; and all
partners abstained
* Treat all sexual partners within past 60 days
* Return with persistent or recurrent symptoms
* Use barrier methods
* Repeat testing in 3 months

Question 14

STIs

Answer 14

STIs characterized by genital lesions or ulcers
 Genital herpes infections
 Genital warts
 Syphilis

Question 15

Genital Herpes Infections

Answer 15

Life-long, incurable infection
 Very common, treatable

Two strains
 Herpes simplex virus type 1 (HSV-1)
 Herpes simplex virus type 2 (HSV-2)
* 18.6 million in US infected
* Rate of infection twice as high among women
* Hispanic and black persons more likely infected

 Most new infections transmitted by someone who
does not know they are infected

Question 16

Genital Herpes Infections
Etiology and Pathophysiology

Answer 16

Virus
 Enters through mucous membranes or breaks in skin
during contact with an infected person
 Virus reproduces inside cell and spreads to
surrounding cells
 Virus then enters peripheral or autonomic nerve
endings and ascends to the sensory or autonomic
nerve ganglion near infection site where it becomes
dormant
 Reactivation (recurrence or outbreak) may occur
when virus descends to initial site of infection

HSV-1 and HSV-2
 Transmission occurs through direct contact when an
infected individual is symptomatic
 Asymptomatic viral shedding occurs without
symptoms being apparent
* Impossible to predict when this will occur or for how
long
* HSV-2 more likely to shed than HSV-1

Formerly
 HSV-1 mainly associated with oral lesions (“cold
sores” or “fever blisters”)
 HSV-2 associated with anogenital disease
 Currently
 HSV-1 or HSV-2 can cause genital, anal, or orolabial
infections
 Rare to have HSV-2 infection of the mouth

HSV-1 infections
 More common “above the waist”
* Gingivae, dermis, upper respiratory tract
* Rarely, the CNS
 HSV-2 infections
 Almost always occurs “below the waist”
* Genital tract, perineum, or anus
 Having 1 type does not protect against getting the
other

Question 17

Genital Herpes Infections
Clinical Manifestations

Answer 17

Primary episode
 Incubation period: 2 to 12 days
 Primarily asymptomatic; if symptoms occur, follow
stages:
* Prodromal stage
 Period before lesions appear
 Burning, itching, tingling may occur at site of inoculation

Primary episode—stages
 Vesicular Stage
* Few to multiple small , painful vesicles appear on buttocks, inner thigh, penis, scrotum, vulva, perineum, perianal region, vagina, or cervix
* Contain large quantities of infectious particles
 Ulcerative stage
* Lesions rupture and form shallow, moist ulcerations
 Final stage
* Spontaneous crusting and epithelialization of erosions occur

Question 18

Genital Herpes Infections
Primary Episode

Answer 18

Process from prodrome to healing varies and may
take up to 3 weeks
 Local inflammation and pain
 Regional lymphadenopathy
 Systemic flu-like symptoms
 Urination may be painful
 Autoinoculation can occur if active lesions are
touched or scratched

Question 19

Genital Herpes Infections and Recurrent Episodes

Answer 19

Recurrence can occur in year following primary
episode
 Symptoms are less severe
 Lesions usually heal more quickly
 HSV-1 genital infections recur less frequently than
HSV-2 infections
* Over time, both decrease in frequency

Common triggers
 Stress, fatigue, sunburn, general illness,
immunosuppression, menses, local trauma at site of
infection
* May experience prodromal symptoms
 Greatest risk for transmitting infection exists when
active lesions are present
* Possible to transmit virus when no visible lesions or
symptoms are present
* Majority of HSV transmission occurs during
asymptomatic periods

Question 20

Herpes Infections Complications

Answer 20

Rare but serious complications
 Blindness, encephalitis, and aseptic meningitis
 Autoinoculation may cause extragenital lesions
 Genital ulcers increase risk of acquiring HIV
 HSV lesions can be more severe and persistent in
HIV-infected patients

Can be transmitted from mom to baby during birth
 Highest risk during primary episode
 Can infect skin, eyes, mouth, CNS
 Significant morbidity and mortality when disseminated
 An active genital lesion is usually an indication for
cesarean delivery

Can have an impact on psychologic well-being,
relationships, and sexual lives
 Teach patients how to talk to sexual partners
 Refer for counseling
 Help patients understand treatment options and
management of condition
* Non-life-threatening

Question 21

Genital Herpes Infections
Diagnostic Studies

Answer 21

Diagnosis
 History and physical exam
* Self-report; confirmation by visual exam
 Viral isolation by tissue culture
* Cultures of lesion can differentiate between HSV-1 and
HSV-2
 Antibody assay for HSV type
* Don’t show site of infection
* Usually appear by 12 weeks after exposure

Question 22

Genital Herpes Infections
Interprofessional Care

Answer 22

No cure for HSV infection
 Antiviral medications can
* Shorten duration of viral shedding
* Shorten healing time of lesions
* Reduce frequency of outbreaks by 80%
 Treatment should be started before diagnostic
confirmation
* Reduces duration of ulcers
* Reduces risk of transmission

Three antiviral agents—inhibit viral replication
 Acyclovir (Zovirax) – IV for very severe infections
 Famciclovir (Famvir)
 Valacyclovir (Valtrex)
 Prescribed for primary and recurrent infections
 Can be used daily as suppressive therapy for
anogenital recurrences
 Reduce but not eliminate risk of transmission to
others

Patient education
 Identify triggers
 Active outbreak: good hygiene; loose, cotton
undergarments; abstinence until lesions healed
 Keep lesions clean and dry
 Pour water on perineum during urination to reduce
pain
 Local anesthetics: lidocaine gel
 Analgesics
 Ice packs

Question 23

Genital Warts

Answer 23

Condylomata acuminata
 Caused by human papillomavirus (HPV)
 About 100 types of HPV; 40% sexually transmitted
 High-risk strains cause cancers of genital tract, anus,
or oropharynx
* 90% of genital and anal warts are caused by HPV types 6 and 11
* Types 16 and 18 cause 70% of cervical cancer, most anal and some throat cancers
 Most sexually active people will be infected at some
point in their lives
 Not reportable in most states

Question 24

Genital Warts
Etiology and Pathophysiology

Answer 24

HPV is transmitted:
 Skin-to-skin contact mostly during vaginal, anal, or
oral sex; nonpenetrative transmission possible
 Incubation period ranges from weeks to months to
years
 Infection with 1 type of HPV does not prevent
infection with another type

Basal epithelial cells infected with HPV undergo
transformation and proliferation to form a warty
growth
 HPV is transient
 Resolves spontaneously usually after 1 to 2 years
 Can persist when warts or no longer visible after
treatment
 Unclear if removal of warts clears, cures, or reduces
transmission of the virus

Question 25

Genital Warts
Clinical Manifestations

Answer 25

Most asymptomatic; unaware
 Genital or anal warts—single or multiple papillary
growths
 May grow and coalesce to form large, cauliflower-like
masses
 Most patients have few lesions
 Growths may be pink, pink-flesh colored, or
hyperpigmented (depends on skin type

Men
 Warts on penis and scrotum, in or around anus, or in
urethra
Women
 Warts on inner thighs, vulva, vagina, cervix,
perineum, internal or external anus

 Anogenital warts—itchy
 Anal warts—bleeding with defecation

Characteristic lesions  diagnosis
 Testing should be done to rule out other conditions
(e.g., syphilis, cancer, benign growth)
 Biopsy required for definitive diagnosis

Question 26

Genital Warts
Complications

Answer 26

Few long-term complications
 HPV strains that cause warts do not cause cancer
 Certain high-risk strains (types 16 and 18) can lead to
cancer of cervix, vagina, vulva, penis, anus, or oropharynx
 Psychosocial burden
* Cosmetic appearance and long treatment course
 Pregnancy—warts grow rapidly and increase in size

Question 27

Genital Warts
Interprofessional Care

Answer 27

May be possible to eradicate HPV types if all youths
are vaccinated
 9-valent vaccine (Gardasil 9) available in US

Protects against types 6, 11, 16, 18 plus 5 other
high-risk HPV types
 Given in 2-3 IM doses over a 6-month period
 Few side effects

CDC recommends all 11-12 year-olds be vaccinated
 Can start at age 9 up to age 26
 Recently approved for ages 27-45 who are at risk

Vaccine protects against strains causing 90% of
anogenital warts and cervical cancers; also penile,
anal and throat HPV-related cancers
 Does not treat active HPV infection
 Ideally, vaccination should occur before the start of
sexual activity or before the potential for infection

Question 28

Genital Warts Treatment

Answer 28

Primary goal of treatment—removal of symptomatic
warts
 Chemical methods (in office)
* Trichloroacetic acid (TCA) or bichloroacetic acid (BCA)
 Ablative methods
* Laser, electrocautery, or cryotherapy
 Patient applied topical treatments
* Podofilox liquid and gel, imiquimod cream, or
sinecatechin ointment

Treatment may or may not decrease infectivity; does not destroy virus, just infected tissue
 Modify treatment if no improvement or if can’t tolerate side effects
 Local alpha-interferon injections or surgical excision may be needed
 Recurrence and reinfection are possible
 Long-term follow-up is advised

Question 29

Syphilis

Answer 29

Sexually transmitted bacterial infection
 Can cause serious long-term complications if not
effectively treated
 In United States, over 35,000 cases reported annually
* Likely 150,000 cases due to undiagnosed infections
* Incidence increasing significantly
 Prevalent population affected
* MSM with highest rates among MSM of color

Question 30

Syphilis Etiology

Answer 30

Caused by Treponema pallidum (bacterial spirochete)
 Transmission direct contact with chancre (syphilitic
ulcer) or through mucosa of infected person
 Genitals, anus, lips, vagina, rectum, mouth or tongue
* Incubation period averages 21 days but can range from 10 to 90 days
 Infection does not provide protection from reinfection

Syphilis can be transmitted from an infected
pregnant woman to her fetus
 High risk for stillbirth or complications after birth
* Seizures
* Death
 Incidence of congenital syphilis in US has risen
185% since 2014

Question 31

Syphilis
Clinical Manifestations

Answer 31

“The Great Imitator”—mimics a number of other
diseases
 More difficult to recognize; delays treatment
 Progresses to specific clinical stages
 Can take weeks to years to progress through all
stages

Question 32

Stages of Syphilis

Answer 32

Primary
 Highly infectious
 Duration 3 to 6 weeks
 Single or multiple chancres
* Unnoticed if internal
 Regional lymphadenopathy
 Exudate and blood from chancre are highly infectious

Secondary
 Highly infectious; occurs a few weeks after primary
chancre heals
 Duration 1 to 2 years
* Systemic flu-like symptoms
* Mucous patches in mouth, tongue or cervix
* Symmetric, nonpruritic, maculopapular rash on palms,
and/or soles, and trunk or extremities
 Even without treatment, rash will resolve but patient still has syphilis and is infectious
 May be other systemic symptoms

Final stage - tertiary or late syphilis
 No obvious symptoms
 Organ damage is silently occurring over many years
 Gummas can lead to serious complications
* Inflammatory tumor-like response to syphilis
* Gummas cause irreparable damage to skin, bone, liver
* Cardiovascular aneurysm, aortic valve insufficiency, HF
* Neurosyphilis—invasion of CNS
 Impaired vision, tabes dorsalis, dementia (all are rare)

Question 33

Syphilis
Complications

Answer 33

Chancres on or inside genitalia or anus enhance
HIV transmission
 Patients with HIV and syphilis are at greatest risk for
significant CNS involvement; need more intensive
treatment than others

Question 34

Syphilis
Diagnostic Studies

Answer 34

Blood tests for screening and staging infection/ensuring
effective treatment
 Detect antibodies to T. pallidum
 FTA-Abs test – fluorescent treponemal antibody absorption test
 TP-PA test – T. pallidum particle agglutination test
 EIA test – syphilis qualitative enzyme-linked immunoassay
 Remains positive even after treatment so cannot be used to detect reinfection

Nontreponemal tests detect antibodies not specific
for syphilis
 VDRL and RPR tests
 Positive 10 to 14 days after chancre
 When positive or “reactive” test will read as a titer and
increase exponentially
* Continue to climb during primary and secondary stages of infection
* Fall back to negative or “non-reactive” several months
after treatment

False-negative and false-positive tests can occur
 During primary syphilis if done before antibodies are
produced
 If patients have other diseases
* Positive screening tests are always confirmed
* Once a person has tested positive, test may remain
positive in spite of successful treatment