1 Causes of Vaginal DischargeIncluding Sexually Transmitted Infections
2 This is a nursing training presentation. Some of the images are sensitive in nature and reflect graphic disease processes. It may be inappropriate for certain audiences. Many of the photos in this lecture depict human genitalia.
3 Learning Objectives Describe common causes of vaginitisProvide education on risks, symptoms, treatment, and prevention strategies for common vaginal infections including those that are sexually transmitted Understand the components of a good sexual history Appropriately triage women who present with vaginal discharge At the end of this presentation, you should be able to: Describe common causes of vaginitis Provide patient education on risks, symptoms, treatment, and prevention strategies for common vaginal infections including those that are sexually transmitted Understand the components of a good sexual history Appropriately triage women who present with vaginal discharge
4 Vaginitis Most frequent reason American women visit the providerMore than 10 million office visits per year Many related to infections that are transmitted by sexual contact Vaginitis is the most frequent reason why American women visit the provider. It results in more than 10 million office visits per year. Many, but not all, are transmitted by sexual contact.
5 Most Common Causes of VaginitisOvergrowth of vaginal flora Sexually transmitted infections Non-infectious causes Some conditions, like bacterial vaginosis and yeast are caused by an overgrowth of vaginal flora or organisms. Sexually transmitted infections can also often cause vaginitis. There are also multiple non-infectious causes: Discharge during pregnancy (leukorrhea) Atrophic vaginitis (vaginal dryness during menopause caused by thinning tissue and less lubrication) Lactation Progestin-only oral contraceptives Reactions to deodorants, latex, spermicides, and even semen Foreign bodies - those of us who have ER experience remember patients with retained tampons
6 The Pelvic Exam Let’s talk first about the exam…
7 Pelvic Exam Supplies This tray contains supplies for a pelvic exam.
8 Which items would you set out for a vaginitis exam?Poll Question Which items would you set out for a vaginitis exam? Speculum, battery, pH paper, saline, KOH, ThinPrep (Pap solution), cotton swabs Speculum, battery, gloves, pH paper, culture set Speculum, battery, gloves, cultures, pH paper, KOH, saline, cotton swabs None of the above Thinking of the supplies you just saw, which items would you set out for a vaginitis exam? A. Speculum, battery, pH paper, saline, KOH, ThinPrep (Pap solution), cotton swab B. Speculum, battery, gloves, pH paper, culture set C. Speculum, battery, gloves, cultures, pH paper, KOH, saline, cotton swabs None of the above We’ll come back to the answer in just a minute.
9 Vaginitis Exam Assessment of discharge (color, viscosity, odor, adherence to vaginal walls) Visualization of cervix to rule out cervicitis Lab tests (pregnancy, pH, wet mount) Opportunity for birth control and Plan B discussions The exam will include: An assessment of the discharge - color, viscosity, odor, adherence to vaginal walls Visualization of the cervix to rule out cervicitis Tests often include: Pregnancy test Vaginal pH Wet mount
10 STI Evaluation HIV test Hepatitis B screen Chlamydia/gonorrhea cultureVDRL/RPR for syphilis DNA probe (Affirm test) Rapid antigen test STI Evaluation Other tests may be warranted to rule out an STI including: HIV test Hepatitis B screen Chlamydia/gonorrhea culture VDRL/RPR tests for syphilis DNA probe (Affirm) Rapid antigen test Cervical cancer screening should be considered if the woman is over age 21, and she has not had a Pap test within the recommended screening interval Consider Pap (if over 21 and due for Pap testing)
11 Which items would you set out for a vaginitis exam?Poll Answer Which items would you set out for a vaginitis exam? Speculum, battery, pH paper, saline, KOH, ThinPrep (Pap solution), cotton swabs Speculum, battery, gloves, pH paper, culture set Speculum, battery, gloves, cultures, pH paper, KOH, saline, cotton swabs None of the above Let’s return to our poll question… Which items would you set out for a vaginitis exam? Speculum, battery, pH paper, saline, KOH, ThinPrep (Pap solution), cotton swabs Speculum, battery, gloves, pH paper, culture set Speculum, battery, gloves, cultures, pH paper, KOH, saline, cotton swabs None of the above The correct answer is #3.
12 Common Causes of VaginitisNow we’ll talk about some common causes of vaginitis…
13 Bacterial Vaginosis (BV)Lack of protective lactobacilli which keep anaerobes (bad bacteria in check) Present in 29% of women Most common cause of discharge, although 50% of women are asymptomatic ‘Fishy’ odor, milky-white discharge 30% of women have a recurrence in 3 months, 50% in 12 BV or Bacterial Vaginosis is caused by a lack of protective lactobacilli. Lactobacilli keep anaerobes (the bad bacteria) in check. Usually, lactobacilli outnumber anaerobes in the vagina; if anaerobic bacteria become too numerous, they upset the natural balance of microorganisms and bacterial vaginosis results. It is present in 29% of women It is the most common cause of discharge and ‘fishy odor’. More than 50% of women, however, are asymptomatic. As illustrated in the picture BV is characterized by a white milky discharge in the lower introitus area Recurrence rates are high: 30% of women have a recurrence in 3 mos, 50% in 12
14 Bacterial Vaginosis (BV)Women with BV may be at higher risk for: Acquiring STIs including HIV, gonorrhea, chlamydia, and herpes Post-op infections after gynecologic procedures Pregnancy complications (premature rupture of membranes, premature delivery, low‐birth weight) BV recurrence Often identified in female-female partnerships Women with BV may be at higher risk for: Acquisition of STIs including HIV, gonorrhea, chlamydia, and herpes Post‐operation infections after gynecological procedures Pregnancy complications including premature rupture of membranes, premature delivery, low‐birth weight delivery BV recurrence It is often identified in female same-sex partnerships
15 Patient Education for BVCaused by a lack of protective lactobacilli More likely to occur in situations where normal vaginal flora are altered such as douching or use of intravaginal preparations Use prescription oral or intravaginal medication as directed OTC medicines for yeast and other vaginal products don’t work Recurrence in 3-12 mos is common; treating male partner will not help Reduce risks: Abstinence, mutual monogamy, latex condoms, limit number of sex partners Wash sex toys Avoid douches and deodorant sprays Here are some tips for patient education: Caused by a lack of protective lactobacilli Take prescription medications as directed: oral till done, or intravaginal OTC medicines for yeast or other vaginal products don’t work Recognize the potential for recurrence; recurrence in 3-12 months is common Treating the male partner will not prevent recurrence Avoid using douches/feminine deodorant sprays to treat or prevent recurrence Wash sex toys “Golden rule’ for discharge and STI’s”: Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners
16 Vulvovaginal Candidiasis(Yeast infection) 75% of women experience it, and half have recurrences Overgrowth of normal vaginal flora Itching, redness, burning, ‘cottage cheese discharge’, no odor Usually not sexually transmitted; often found when evaluating for STIs Risk factors: Diabetes, antibiotics, spermicides, douching, contraceptive devices, HIV, pregnancy, corticosteroids Yeast infections are very common – 75% of women experience it, and half of those have recurrences They are caused by an overgrowth of yeast fungus that is part of the vagina’s normal flora. Symptoms include itch, burning, especially ‘cottage cheesy’ type discharge you can see in this picture - the thick white adhering to the vaginal walls. This infection is ‘odor free’. It’s not usually transmitted sexually, but is often found while evaluating for STI’s Risk factors include diabetes, antibiotics, spermicide use, douching, contraceptive devices, HIV, pregnancy, corticosteroid use.
17 Patient Education for CandidiasisLack of vaginal lactobacillus bacteria allows overgrowth of yeast fungus Can be spread through oral-genital contact Associated with antibiotics, pregnancy, diabetes, impaired immune system, douching, sexual activity Take medicine as directed Avoid douches or feminine sprays to treat or prevent recurrence Mineral oil in topical antifungal preparations may erode latex condoms and diaphragms. Use plastic or polyethylene condoms. Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners Tips for patient education include: Caused by a lack of vaginal lactobacillus bacteria, which allows an overgrowth of yeast fungus Yeast fungus can spread through oral-genital contact Is associated with antibiotics, pregnancy, diabetes, impaired immune system, douching, sexual activity Take medication as directed Avoid douches/feminine sprays to treat/prevent recurrence Mineral oil in topical antifungal preparations may erode latex condoms/diaphragms. Use plastic or polyethylene condoms. Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners
18 Sexually Transmitted Infections (STIs)
19 CDC Fact Sheet. Incidence, prevalence, and cost of sexually transmitted infections in the United States, Feb 2013. Estimated number of new and existing (total) sexually transmitted infections United States, 2008 Syphilis Gonorrhea Hep B HIV Chlamydia Trich HSV HPV 117, , , , mil mil mil mil 50,627,400 59,569,500 TOTAL 110,197,000
20 Trichomoniasis Very common STIItching, burning, redness, pain during urination and intercourse Frothy, thin, malodorous, yellow- green discharge, although 85% of women are asymptomatic Can be transmitted between female partners Risk factors: multiple partners, low SES, hx of STIs Pregnancy complications: associated with premature rupture of membranes, preterm delivery, and low birth weight Trichomonas infection in HIV‐infected women may enhance HIV‐transmission to sexual partners Trichomoniasis infections are common in the U.S. Trich can cause itching, burning, redness, pain during urination and intercourse. There is often a frothy, thin, malodorous, yellow-green discharge (but 85% of women are asymptomatic). Risk factors include multiple partners, low SES, hx of STIs, and lack of condom use It can be transmitted between female partners Complications of untreated trichomoniasis include transmission to sexual partners and adverse pregnancy outcomes, particularly premature rupture of membranes, preterm delivery, and low birth weight. Trichomonas infection in HIV‐infected women may enhance HIV‐transmission by increasing genital shedding of the virus.
21 Patient Education for TrichomonasCan last for years without treatment Metronidazole can trigger cramps, nausea, vomiting, headaches and flushing if combined with alcohol Avoid alcohol use during treatment and 24 hrs after Some providers advise avoiding alcohol for up to 3 days after Metronidazole should not be taken in first trimester of pregnancy No sex until patient/partner(s) complete treatment Douching may worsen discharge Can recur. Re-evaluate if symptoms persist. Trichomonas may facilitate HIV transmission Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners Without treatment, trichomonas can last for years Metronidazole can trigger cramps, nausea, vomiting, headaches and flushing if combined with alcohol. Avoid alcohol use during treatment and 24 hours after. Some providers advise avoiding alcohol for up to 3 days after. Metronidazole should not be taken during first trimester of pregnancy. Avoid sex until patient and partner(s) complete treatment Douching may worsen the discharge Recurrences/resistance happens - if signs and symptoms persist, re- evaluate Trichomonas may facilitate HIV transmission Golden Rule: Reinforce abstinence, monogamy, condom use, limiting sex partners Nurses are great at educating patients, especially those who are first diagnosed with an STI. This is a traumatizing event. Just listening or calling the next day, if possible, really helps.
22 Cervicitis Inflammation of the cervix (not always related to infection) Causes Chlamydia, gonorrhea most common (treat for both) Foreign objects, radiation, malignancy Mucopurulent discharge, pain during intercourse, bloody discharge or spotting between periods, burning upon urination if urethra is also infected. Can spread to uterus, fallopian tubes, or ovaries, resulting in pelvic inflammatory disease (PID) Cervicitis is inflammation of the cervix (not always related to infection) Chlamydia and gonorrhea are the most common causes. Treat for both. Other causes include foreign objects, radiation, and malignancy. Women may present with mucopurulent discharge, pain during intercourse, bloody vaginal discharge or spotting between periods. If the urethra is also infected, they may feel burning upon urination. Can spread to uterus, fallopian tubes, or ovaries, resulting in PID.
23 Common in cervix and vagina Gonorrhea Common in cervix and vagina Also grows in urethra, mouth, throat, eyes, anus Painful urination, vaginal discharge, bleeding between periods; 50% of women asymptomatic Associated with ectopic pregnancy, PID, infertility, Bartholin’s cyst Gonorrhea most commonly appears in the cervix and vagina – see the reddish discharge in the top photo of a cervix It also grows in the urethra, mouth, throat, eyes, anus Symptoms include painful urination, increased vaginal discharge, vaginal bleeding between periods (50% of women, however, are asymptomatic) Gonorrhea is associated with ectopic pregnancy, PID, infertility, and Bartholins cyst (see the very erythemetous swelling on the patient’s right vulva in lower photo)
24 Gonorrhea Diagnosis and TreatmentNAATs (Nucleic Acid Amplification Testing) Endocervical culture Treatment Dual antibiotic therapy Ceftriaxone as single IM dose, plus either azithromycin orally in single dose or doxycycline twice daily x 7 days Retest at 3-6 mos or whenever the patient seeks care in next 12 mos Evaluate and treat partners Gonorrhea is diagnosed by NAATs (Nucleic Acid Amplification Testing) or with an endocervical culture It is treated with dual antibiotic therapy. First line treatment includes ceftriaxone as a single IM dose, plus either azithromycin orally in a single dose or doxycycline twice daily for 7 days. The CDC recommends retesting at 3-6 months, or whenever the patient seeks medical care in the next 12 months Partners should be evaluated and treated
25 Patient Education for GonorrheaIn 15% of infected women, untreated gonorrhea spreads to fallopian tubes, where it can cause scarring and infertility Increases susceptibility to HIV infection Treated with two medications. Take oral medication as directed. Some strains are resistant. Retest in 3-6 months. Return earlier if symptoms persist. No sex until patient/partner(s) complete treatment Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners Patient education is important: In about 15% of infected women, untreated gonorrhea spreads to the fallopian tubes, where it can cause scarring and infertility It also increases susceptibility to HIV infection Dual antibiotic therapy includes ceftriaxone plus azithromycin or doxycycline. Take oral medication as directed. Return in 3-6 months for a retest Some strains can be resistant to certain antibiotics: If symptoms continue after completing course of treatment, another culture may be necessary. Avoid sex until patient and partners complete treatment Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners Avoid sex until patient and partner(s) complete treatment
26 Chlamydia 1.6 million new infections/yearFound in cervix, urethra, throat, rectum Frequent/urgent urination with burning, vaginal discharge, light bleeding post-intercourse, lower abdominal pain; however, 75% of women asymptomatic Associated with infertility, PID, ectopic pregnancy Perinatal transmission results in neonatal conjunctivitis in 30-50% of exposed babies There are 1.6 million new infections of chlamydia yearly in the U.S. Chlamydia can be found in the cervix, urethra, throat, rectum. The picture shows an ‘angry’ reddened cervix, swollen with infection. Symptoms include burning upon urination, frequent and urgency, vaginal discharge, light bleeding after intercourse, pain in lower abdomen 75% of women, however, are asymptomatic Chlamydia is associated with PID, infertility, ectopic pregnancy Perinatal transmission results in neonatal conjunctivitis in 30-50% of exposed babies
27 Chlamydia Screening US Preventative Services Task Force recommends screening asymptomatic women… Yearly for all sexually active women ≤ 24 years Yearly for sexually active women > 24 years with risk factors African American, new male sex partner, two or more partners in preceding year, inconsistent barrier contraceptive use (condoms) and hx of prior STI All pregnant women at first prenatal visit The US Preventative Services Task Force recommends screening asymptomatic women… Yearly for all sexually active women ≤ 24 years Yearly for sexually active women > 24 years with risk factors Risk factors include African American, new male sex partner, two or more partners in preceding year, inconsistent barrier contraceptive use (condoms) and hx of prior STI All pregnant women at first prenatal visit
28 Chlamydia Diagnosis and TreatmentNAATs Endocervical swab Urine test Treatment Antibiotics (azithromycin 1 g orally in single dose or doxycycline 100 mg orally twice daily x 7 days) Retest at 3 mos or when patient seeks care in next 12 mos Evaluate and treat partners Chlamydia can be diagnosed by NAATs Swab specimen from endocervix Urine test Treatment is with antibiotics; either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days Retest at 3 months or whenever patient seeks medical care in the next 12 months Evaluate and treat partners
29 Patient Education for ChlamydiaIf untreated, can lead to tubal pregnancy, chronic pelvic pain, infertility 30% of women develop PID 50,000 become infertile yearly due to untreated chlamydia and gonorrhea Complete medication as directed No sex until patient/partner(s) complete treatment Women should be screened at least once a year if < 25 or if at high risk or if become pregnant Pregnant women may need repeat testing 3 wks after treatment Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners Patient education tips for chlamydia: Untreated chlamydia can lead to infertility, chronic pelvic pain, tubal pregnancy % of women with chlamydia develop PID. 50,000 women become infertile every year due to untreated chlamydia and gonorrhea. Women should undergo screening at least once a year if under age 25 or if at high risk or if become pregnant Pregnant women may need repeat testing 3 weeks after completion of therapy Complete medication as directed Avoid sex until patient and partner(s) complete treatment Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners
30 Genital Herpes Simplex Virus (HSV)25% of population has serological evidence HSV-2 is genital, most common (1 in 4 women, 1 in 5 men 15-45) Transmission Kissing, skin-to-skin contact, vaginal/oral/anal sex Can be transmitted when symptoms are not present Outbreaks can occur 4-5 times/year; most frequent in first year C-section at delivery to prevent newborn infection After resolution, asymptomatic intermittent viral shedding occurs even in absence of genital lesions Complications: most common cause of viral encephalitis; 3rd most common cause of sexually transmitted proctitis 25% of the US population has serological evidence of herpes HSV-2 is genital and the most common subtype (present in 1 in 4 women and 1 in 5 men age 15-45) It is transmitted by kissing, skin-to-skin contact, vaginal/oral/anal sex Herpes can be transmitted when symptoms are not present The primary outbreak usually occurs about 1 week after contact. Symptoms include fever, chills, headache, painful lymph nodes in groin. Usually pain or itch can precede blisters/skin ulcers, however approximately 75% of patients with primary genital HSV infection are asymptomatic). After resolution of the primary infection, asymptomatic intermittent viral shedding occurs even in the absence of genital lesions Outbreaks can reoccur 4-5 times per year; outbreaks are most frequent in the first year A C-section is recommended for pregnant women with visible ulcers at delivery to prevent newborn infection Herpes can cause multiple complications: It is the most common cause of viral encephalitis and the 3rd most common cause of sexually transmitted proctitis
31 Genital Herpes Primary outbreak occurs 1 wk after contactFever, chills, headache, painful lymph nodes in groin Pain or itch usually precedes blisters/skin ulcers 75% of patients with primary genital HSV infection are asymptomatic. Initial lesions Genital Herpes The first picture shows raised new painful blisters The second photo shows an ulcer that is healing, but still contagious Granulating ulcer
32 Genital Herpes Herpes Cervicitis DiagnosisOften inaccurate if based on H&P Viral culture for active lesions PCR (polymerase chain reaction) to detect asymptomatic virus shedding Direct fluorescent antibody for clinical specimens (can determine herpes subtype ) Treatment Antiviral meds treat primary herpes/suppress recurrent outbreaks (daily antivirals can decrease recurrences by 70-80% for patients with 6+ episodes/year) Topical treatments do not work The picture illustrates herpes cervicitis. A diagnosis based only on a history and physical is often inaccurate Viral culture for active lesions Tzanck prep for lesion scrapings PCR (polymerase chain reaction) to detect asymptomatic virus shedding Direct fluorescent antibody for clinical specimens *Can determine herpes subtype Treatment Antiviral medications treat primary herpes and suppress recurrent outbreaks Daily antiviral medication can decrease recurrences by 70-80% for people with 6+ episodes per year
33 Partner check! Partner check! Note the lightish/white blistering across the penis. Painful.
34 Patient Education for Genital HerpesNo cure. Symptoms may recur; recurrence varies by person. First attack is usually worst; 40% never have second outbreak. Outbreaks can be related to menses, intercourse, sunbathing, stress Inform all partners; abstain from sex when symptomatic Can be transmitted without symptoms; use latex condoms People with herpes more likely to become infected if exposed to HIV through sex; people with HIV + herpes more likely to spread HIV Take meds to prevent symptoms from returning/make recurrences less severe Topical treatments don’t work; analgesics help painful lesions Inform provider if you become pregnant Tips for patient education include: There is no cure. Symptoms can return periodically. Recurrence varies by person. Outbreaks can be related to menses, intercourse, sunbathing, stress HOPE: First attack is usually worst; 40% of people never have second outbreak. Abstain from sex when symptoms occur. Inform all partners about infection. Even without symptoms, it can be transmitted. Use latex condoms. People with herpes are more likely to be infected if exposed to HIV through sex, and people with HIV and herpes more likely to spread HIV to others. Take medications as prescribed to prevent symptoms from returning or to make recurrences less severe Topical treatments don’t work. Analgesics can help with painful lesions Inform your provider if you become pregnant
35 Syphilis Stage 1: Primary Stage 2: Secondary Stage 3: Tertiary40,000 new cases/year caused by bacterium Trepomema pallidum Chancre or ulcer Stage 1: Primary Skin rash Lymphadenopathy Stage 2: Secondary Years later, neurologic infection through body Stage 3: Tertiary Condyloma lata lesions (secondary syphilis) Syphilis is still occurring… there are up to 40,000 new cases yearly The photo shows condyloma lata lesions of secondary syphilis Syphilis is caused by the bacterium Trepomema pallidum It has 3 stages: Primary: chancre or ulcer occurs at the infection site Secondary: skin rash and lymphadenopathy appear Tertiary: years later, a neurological infection spreads through the body
36 Syphilis Diagnosis and TreatmentVenereal Disease Research Laboratory (VDRL) and RPR (Rapid Plasma Reagin) Treponemal test (FTA-ABS ) can confirm diagnosis Treatment Early infections: single-dose benzathine penicillin Late latent infections of unknown duration: benzathine penicillin in 3 doses each at 1 wk intervals Clinical and serological follow-up tests at 6 mos and 12 mos post-treatment Treat partners presumptively Diagnosis is done via Venereal Disease Research Laboratory (VDRL) and RPR (Rapid Plasma Reagin) A Treponemal test (FTA-ABS ) can confirm the diagnosis Early infections are treated with a single dose of benzathine penicillin Late latent infections of unknown duration are treated with benzathine penicillin in 3 doses each at 1 week intervals Clinical and serological follow-up tests should be performed at 6 months and 12 months post-treatment Treat partners presumptively
37 Patient Education for SyphilisComply with medication instructions Return for 6 and 12 month follow-up appts No sex until patient/partner(s) complete treatment Pregnant women should have a blood test for syphilis to prevent passing infection to the baby People with syphilis more likely to become infected if exposed to HIV through sex; people with HIV + syphilis more likely to spread HIV to others Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners Patient education for syphilis: Comply with medication instructions Return for the 6 and 12 month follow-ups No sex until patient/partner(s) complete treatment Pregnant women should have a blood test for syphilis to prevent passing infection to the baby People with syphilis are more likely to become infected if exposed to HIV through sex. People with HIV and syphilis are more likely to spread HIV to others. Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners
38 HPV-Related Genital WartsCaused by human papillomavirus (HPV) subtypes 6 and 11 Benign but very contagious Pink or flesh-colored, raised/flat spots resemble cauliflower Inside/outside vagina or anus, on nearby skin, on cervix, lips, mouth, tongue, throat Women can be infected and not have symptoms Can take 6 mos to develop Genital warts are caused by human papillomavirus subtypes 6 and 11, which are considered benign but very contagious As you see in the illustration, they are raised, pink- or flesh-colored, flat, and resemble cauliflower Multiple sites can be infected including the inside/outside of the vagina or anus, nearby skin, or on the cervix, lips, mouth, tongue, throat Women can be infected and not have symptoms Warts can take up to 6 months to develop
39 HPV-Related Genital WartsTreatment: Creams Polophyllin TCA, Aldara or imiquimod 5% Cryosurgery, laser therapy, electro-cauterization, surgical excision Examine partners and treat if warranted Treatments include: Creams like polophyllin TCA, Aldara or imiquimod 5% Cryosurgery, laser therapy, surgery, or electro-cauterization, surgical excision Partners should be examined and treated
40 HPV Cervical CondylomaIf cervix is infected, follow with Pap smears every 3-6 mos after first treatment Remember HPV vaccine for females ages If the cervix is infected, the woman may need Pap smears every 3 to 6 months after the first treatment
41 Patient Education for Genital WartsEven though warts may be removed, viral infection can't be cured Warts often return; they are benign but very infectious No sex until patient/partner(s) complete treatment Get regular Pap smears Best prevention is abstinence or sex with only one uninfected partner; condoms help prevent infection, but don’t cover all affected skin Gardasil immunization for uninfected partners <27 years of age Even though warts may be removed, the viral infection can't be cured. Warts often return; as stated earlier, they are benign but infectious. Don’t treat genital warts yourself with OTC drugs that remove warts on the hands Avoid sex until patient/partner(s) complete treatment Get regular Pap smears The best prevention is abstinence or sex with only one uninfected partner. Condoms help prevent infection, but they don’t cover all affected skin. Gardasil immunization for uninfected partners <27 years of age
42 Rectal condylomas sometimes require surgeryHPV Infection Rectal condylomas sometimes require surgery The photo shows rectal condylomas from HPV. They sometimes require surgery.
43 25% of patients with first episode of genital ulceration have no detectable cause despite full diagnostic eval… Genital Ulcers Painless ulcers - think syphilis, but herpes can also present this way Multiple ulcers - think herpes, but could also be syphilis Diagnosis based on only a history and physical is often inadequate 25% of patients with a first episode of genital ulceration have no detectable cause despite a full diagnostic evaluation Painless ulcers - think syphilis, but herpes can also present this way Multiple ulcers - think herpes, but could also be syphilis Diagnosis based on only a history and physical is often inadequate
44 Herpes patient: initial visit and 4 days later when ulcers have begun to heal with medicationYou can see the ulcers have begun to heal with medication – there is much less erythema
45 Poll Question HIV testing is accurate immediately after exposure to the virus. True False Before we talk a bit about HIV, I want to ask a poll question… True or false: HIV testing is accurate immediately after exposure to the virus
46 Poll Question HIV testing is accurate immediately after exposure to the virus. True False Most people develop detectable antibodies 2-8 wks after exposure (avg 25 days); 97% develop antibodies in first 3 mos. Some take longer. In very rare cases, it can take up to 6 mos to develop antibodies to HIV. Therefore, if initial negative HIV test was done in first 3 mos after possible exposure, CDC recommends considering repeat testing >3 mos after exposure to account for possibility of false-negative result. This statement is false. Most people will develop detectable antibodies in 2 to 8 weeks after exposure (the average is 25 days). Ninety-seven percent will develop antibodies in the first 3 months. Some individuals will take longer; in very rare cases, it can take up to 6 months to develop antibodies to HIV. Therefore, if the initial negative HIV test was done within the first 3 months after possible exposure, the CDC recommends considering repeat testing >3 months after the exposure to account for the possibility of a false-negative result.
47 Human Immunodeficiency Virus (HIV)CDC recommends screening everyone for HIV, any time at any site at least once, and yearly for anyone at risk Women are 4x more likely to contract HIV through vaginal sex with infected men, than men are to contract HIV through vaginal sex with infected women Growing problem for women: Black/Hispanic women represent <29% of US women, but account for 79% of female AIDS cases Patient education Viral infection, not curable at this time Transmitted by vaginal/anal/oral sex, needle sharing, occupational exposure, transplant, artificial insemination, and contaminated transfusions Best prevention is abstinence or sex with only one uninfected partner. Condoms help prevent infection. HIV- The CDC recommends screening everyone for HIV, any time at any site at least one time, and yearly for anyone at risk. Women are 4x more likely to contract HIV through vaginal sex with infected men, than men are to contract HIV through vaginal sex with infected women. HIV is a growing problem for women: Black and Hispanic women represent <29% of US women, but account for 79% of female AIDS cases. Patient education tips include HIV is a viral infection, not curable at this time It is transmitted by vaginal/anal/oral sex, needle sharing, occupational exposure, transplant, artificial insemination and contaminated transfusions Best prevention is abstinence or sex with only one uninfected partner. Condoms help prevent infection.
48 Encourage vaccination for prevention:3 shots over 6 mos Hepatitis B Patient education: Preventable with vaccine Adult recovery rate is 95% Transmitted via intercourse, contaminated blood, occupational exposure Can survive for 7 days outside the body Don’t share needles, razors, toothbrushes, nail clippers, earrings Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners Let’s talk a bit about Hepatitis B. Hep B is preventable by administering 3 doses of the vaccine over 6 months Patient education tips: Hep B is transmitted via intercourse, contaminated blood, occupational exposure. The adult recovery rate is 95%. HBV can survive for 7 days outside the body Don’t share needles, razors, toothbrushes, nail clippers, earrings! Reduce risks: abstinence, mutual monogamy, latex condoms, limiting number of sex partners
49 The Sexual History and Prevention CounselingThis next section comes from the CDC publication, A Guide to Taking a Sexual History. A booklet version of it is on the CDC website… Now let’s talk about the sexual history and prevention counseling
50 Think of sharing these questions with your provider…Start the sexual hx by normalizing the discussion I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health. Just so you know, we ask these questions to all adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health. Add… Like the rest of our visit, this information is kept in strict confidence. Do you have any questions before we begin? Think of sharing these interview questions with your provider. Start by normalizing the discussion: I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health. Just so you know, we ask these questions to all adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health. Add… Like the rest of our visit, this information is kept in strict confidence. Do you have any questions before we begin?
51 Providers should utilize the “Five P’s”Sexual History Providers should utilize the “Five P’s” 1. Partners Are your sex partners men, women, or both? In the past 2 months, how many sex partners have you had? In the past 12 months, how many sex partners have you had? One partner in last 12 mos: ask about length of relationship and partner’s risk factors (current or past sex partners, drug use) More than one partner in last 12 mos: explore more specific risk factors (condom use, or non-use, and partners’ risk factors) First, ask about sexual partners. Are your sex partners men, women, or both? In the past 2 months, how many sex partners have you had? In the past 12 months, how many sex partners have you had? One partner in last 12 months: ask about length of the relationship and partner’s risk factors (current or past sex partners, drug use) More than one partner in last 12 months: explore more specific risk factors (condom use, or non-use, and partners’ risk factors)
52 Sexual History Providers should utilize the “Five P’s” 1. Partners2. Prevention of pregnancy 3. Protection from STIs 4. Practices 5. Past history of STIs When questioning and counseling, use a nonjudgmental and caring manner Questioning and counseling should be provided in a nonjudgmental and caring manner
53 Be aware of factors that increase the risk for an STI…Unprotected sex Young age Unmarried Multiple sexual partners Prior STI Illicit drug use Contact with sex workers New sex partner in past 60 days No vaccination (HPV, hepatitis) You want to be aware of these factors that increase the risk for an STI: Unprotected sex Young age Unmarried Multiple sexual partners Prior STI Illicit drug use Contact with sex workers New sex partner in past 60 days No vaccination (HPV, hepatitis)
54 Summary of STI Screening for WomenHIV: Screen all women ≤ 65 regardless of risk at least once; annual screen for those at increased risk HPV: Encourage vaccination for all women ≤ 26 Chlamydia: Screen all women ≤ 24, and any at high risk Trichomonas and Gonorrhea and Syphilis: Screen women at risk Consider screening all women under ≤ 24 for gonorrhea Hepatitis B: Consider vaccinating women at risk In summary, here is the recommended screening for women: HIV: Screen all women ≤ 65 regardless of risk at least once; annual screen for those at increased risk HPV: Encourage vaccination for all women ≤ 26 Chlamydia: Screen all women ≤ 24, and those at high risk - remember are 75% asymptomatic Trich: Remember, this is a common STI, and 85% of women are asymptomatic Gonorrhea and Syphilis: Screen women at risk Hepatitis B: Consider vaccinating women at risk Gonorrhea- consider all those under 25 yo- remember 50% asymptomatic * At risk = Multiple current partners, new partner, inconsistent condom use, sex while under the influence of alcohol or drugs, sex in exchange for money or drugs.
55 STI Summary STIs cost US health care system $17 billion/yearYoung people represent only 25% of sexually experienced population, but account for nearly half of new STIs Less than half of people who should be screened actually receive recommended STI screening services Providers are required to report gonorrhea, chlamydia, and syphilis to local or state public health authorities Nursing can help track/report STIs cost the U.S. health care system $17 billion every year Young people represent only 25% of the sexually experienced population in U.S., but account for nearly half of new STIs Less than half of people who should be screened actually receive recommended STI screening services Nurses are the ‘best’ for building patient confidence, providing emotional support and clarifying follow up instructions. Consider contacting your patients with a new STI or other conditions to ‘check on them’ ... it’s an incredible quality measure that we know raises patient satisfaction
56 Case Study A call comes in from a woman veteran who complains of new vaginal discharge. What questions would you ask? Before we end the program, let’s discuss one case study… A call comes in from a woman veteran who complains of new vaginal discharge. What questions would you ask?
57 Helpful References CDC. A Guide to Taking a Sexual History. CDC. Self Study STD Modules/Vaginitis CDC. Sexually transmitted diseases treatment guidelines Seattle STD/HIV Prevention Training Center. The Practitioner’s Handbook for the Management of Sexually Transmitted Disease. Workowski KA, Berman SM. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis ;44(s3):S73-6 You may find these resources helpful.
58 Questions?