Chapter 57: Sexually Transmitted Infections

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Welcome to the Deep Dive.

If you are listening to this, you are probably a nursing student staring down a massive exam or, you know, maybe you're gearing up for your clinicals and need a serious refresher.

Right.

Whatever brought you here, we are totally thrilled to have you.

Think of us as your personal Last Minute Lecture team.

Exactly.

We are taking the dense material from your medical surgical nursing text, specifically focusing on chapter 57, which covers sexually transmitted infections or STIs.

And we want to turn it into a conversation you can actually remember.

Yeah, because our goal today is to give you a framework.

We want to understand what these infections, what they actually look like at a patient, how we diagnose them, and most importantly, your role in managing that care.

Because when you understand the why behind a disease process, you really don't have to memorize a hundred random facts for the NCLIX.

The answers just, they sort of make sense.

They really do.

I love that approach.

So let's zoom out for a second and look at the clinical landscape you are about to step into.

We are seeing STI rates in the United States hitting all time highs.

I mean, we are talking about 26 million new infections diagnosed every single year.

It's a staggering number.

It is.

But when you look at the demographics of who is actually getting sick, and this is laid out really well in box 57 .1 and table 57 .2, it is not an even split across the population.

No, far from it.

STIs disproportionately affect youth and young adults under age 25,

also men who have sex with men, transgender women, and racial and ethnic minorities.

Right.

And the crucial thing to understand as a nurse is that this isn't just bad luck or biology.

These high rates are heavily driven by socioeconomic factors.

Like barriers to care.

Exactly.

We are looking at communities dealing with decreased access to quality care, a deep -seated fear or distrust of healthcare institutions, and massive cuts to public health programs.

So it's a systemic issue, which means you will be seeing this constantly in your practice.

But before we get into the specific bugs, there is a foundational concept we need to clear up.

The incubation period.

Yes, that is so important.

How does that dictate our entire approach to STI screening?

Well, the incubation period is the time from the initial infection to when symptoms actually appear, or when a screening test finally turns positive.

With STIs, that window is critical because of something called asymptomatic transmission.

Right, meaning they feel totally fine.

Exactly.

A person can contract an STI, have absolutely no visible symptoms, and still pass the disease to someone else during that incubation phase.

Which means we cannot just wait for patients to complain about symptoms.

We would be way too late.

By the time symptoms show up, the infection has likely already been transmitted.

This is why routine screening for sexually active individuals is the absolute cornerstone of public health.

You have to actively go looking for it.

Let's start looking for it, then.

We can divide these infections into categories based on how they present clinically.

Let's tackle the infections primarily characterized by discharge first.

Good place to start.

And we should probably start with the most common reportable STI in the country.

Chlamydia.

What exactly are we dealing with here?

So we are dealing with Chlamydia trichomatis.

It is a gram -negative bacterium, but its defining feature is that it is an intracellular pathogen.

Intracellular.

So it goes inside the cell.

Right.

It cannot survive on its own.

It literally has to hijack the host cells, live inside them, and reproduce there.

And when it does this, it causes intense inflammation.

In men, that inflammation usually hits the urethra, causing urethritis.

In women, it targets the cervix, causing suficitis.

But the tricky part with Chlamydia is that a massive percentage of people, especially women, they don't have any symptoms at all, do they?

That is the most dangerous aspect of Chlamydia.

Because it is often completely silent, a woman might carry it for months or even years without knowing.

And while it is just sitting there untreated, it travels up the reproductive tract.

This leads to Pelvic Inflammatory Disease, or PID.

I know PID is a major red flag in clinicals.

What is actually happening inside the body when a patient develops that?

The chronic inflammation from the bacteria causes severe scarring inside the fallopian tubes.

That scarring acts like a roadblock.

So if an egg tries to travel down the tube, it gets stuck.

Leading to an ectopic pregnancy.

Exactly.

Which is a life -threatening emergency.

Or the scarring can completely block the tubes, resulting in chronic pelvic pain and permanent infertility.

So the stakes for catching this early are incredibly high.

If a patient comes into the clinic and we suspect Chlamydia, what is the gold standard way to test for it?

You will want to look for the NATE.

That stands for Nucleic Acid Amplification Test.

It is incredibly sensitive because it looks for the specific DNA or RNA of the bacteria.

You can run NATE on a vaginal swab or even just a simple urine sample.

And once that test comes back positive, I know the preferred treatment is Doxycycline.

But the NCLEX loves to use Doxycycline as a trap for medication safety questions.

Oh absolutely.

What are the major patient education points a nursing student absolutely cannot forget when handing over this prescription?

You have to be very specific with your drug alert instructions.

First,

Doxycycline needs to be taken on an empty stomach to maximize absorption.

Second, the patient must avoid antacids, iron products, and dairy products.

Because of the calcium.

Right.

The calcium and minerals in those items will bind to the antibiotic in the gut and render it completely useless.

And what about physical positioning?

I remember something about not laying down right away.

Good memory.

They need to stay upright for at least 30 minutes after taking the pill to prevent severe esophageal irritation or ulceration.

You also need to warn them to avoid excessive sunlight or tanning beds because it causes intense photosensitivity.

They will burn very quickly.

And the big one for safety.

It is strictly contraindicated in pregnancy.

Lock those into your brain.

Empty stomach, no dairy, stay upright, use sunscreen, and check for pregnancy.

Now say we successfully treat the patient.

How do we stop them from going right back home, having sex with their partner, and getting infected all over again?

That ping -pong effect of reinfection is a huge clinical hurdle.

To combat it, we use a public health tool called expedited partner therapy, or EPT.

How does that work in practice?

If your state allows it, a provider can give the diagnosed patient extra medication or a prescription to take directly home to their partner.

The partner gets treated without ever having to step foot in the clinic or be examined.

That is such a practical workaround.

Let's move to the second bug in our discharge category.

Gonorrhea.

How does Neisseria gonorrhea behave differently from Chlamydia?

Gonorrhea is caused by a gram -negative diplococcus picture.

Two microscopic spheres join together.

The biggest difference clinically is how it presents across biologic sexes.

Men tend to show symptoms very quickly and very dramatically.

What does that look like?

Within a few days of exposure, they often develop dysuria, which is a burning painful urination and a profuse purulent discharge from the urethra.

It is usually too uncomfortable to ignore, so they seek treatment.

But women, again, draw the short straw here and are often asymptomatic.

Unfortunately, yes.

Or their symptoms are so mild, like a slight change in vaginal discharge, that they just write it off as a normal fluctuation.

Because they do not seek early treatment, they are at a very high risk for developing that same devastating pelvic inflammatory disease we just discussed.

I also read about a rare but intense complication called disseminated gonococcal infection, or DGI.

What does that look like?

DGI happens when the localized infection breaks into the bloodstream and goes systemic.

The patient will present with skin lesions, severe joint pain, arthritis, and in the worst cases, it can even cause endocarditis, infecting the heart valves.

Let's talk about maternal newborn safety for a second.

If a pregnant woman has an active gonorrhea infection when she goes into labor, what is the risk to the baby?

The risk is a condition called ophthalmia neonaturum.

As the neonate passes through the infected birth canal, the bacteria attacks their eyes.

It causes a severe conjunctivitis that can rapidly lead to permanent blindness.

This is the exact reason why almost every state in the U .S.

mandates prophylactic antibiotic eye drops for all newborns immediately after delivery, regardless of the mother's known STI status.

That makes perfect sense now.

For diagnosing gonorrhea, we use the same NAIT test we use for chlamydia.

But treating it has become incredibly complicated over the last few years, right?

I keep hearing about super gonorrhea.

Antimicrobial resistance is a massive clinical problem with this bug.

Gonorrhea has mutated to become highly resistant to multiple classes of antibiotics that used to work perfectly.

Because of this, the standard first -line treatment is no longer a simple oral pill.

It requires a high -dose intramuscular injection of ceftriaxone.

An IM injection is definitely a step up in intensity.

Let's round out the discharge category with something completely different.

Not a bacteria, but a parasite, trichomoniasis.

Also known as trich.

It is caused by a protozoan parasite called trichomonas vaginalis.

It is incredibly common, yet it frequently flies under the radar.

When it doesn't fly under the radar, what is the classic textbook presentation that a student might see in a clinical vignette?

If a woman is symptomatic, she will typically present with a very foul -smelling, frothy, yellow -green vaginal discharge.

But the dead giveaway on a physical exam is what the textbook calls a strawberry cervix.

A strawberry cervix.

Yes.

The parasite causes micro hemorrhages on the cervical tissue, making it look bright red and speckled exactly like a strawberry.

And how do we eradicate a parasite?

We use anti -parasitic medications like metronidazole or tinidazole.

And the golden rule of STI treatment applies here.

Just like with chlamydia and gonorrhea, all sexual partners must be treated simultaneously.

And everyone must completely abstain from sexual contact for seven days after the treatment is finished to ensure the infection is fully cleared.

So we have covered the discharge infections.

Let's pivot to a completely different clinical presentation.

Infections that show up as painful genital lesions or ulcers.

The big heavyweights here are genital herpes and HPV.

Let's start with herpes.

What is the virus actually doing once it gets inside the body?

Genital herpes is caused by the herpes simplex virus or HSV.

And its survival strategy is brilliant and frustrating.

The virus enters through tiny breaks in the mucous membranes.

From there, it travels up the peripheral nerves and sets up camp in the sensory nerve ganglion.

And then it just waits.

Exactly.

Once it is there, it goes completely dormant.

It hides from the immune system and persists in the patient's body for the rest of their life.

If it is hiding out in the nerve roots, how is it spreading to other people?

Through asymptomatic viral shedding, the virus periodically travels back down the nerve to the skin surface and sheds infectious particles even when there are absolutely no visible sores or symptoms.

Most people who contract genital herpes get it from a partner who had no idea they were actively shedding the virus.

That is a critical education point for patients who think they are only contagious during an active outbreak.

Speaking of outbreaks, what does a primary episode actually look and feel like?

It follows very distinct clinical stages.

First is the prodromal stage.

The patient will feel a localized tingling, burning, or itching sensation before anything is visible.

Next is the vesicular stage, where highly infectious painful blisters or vesicles erupt.

And then those break open.

Yes, that's the ulcerative stage.

Those blisters rupture, leaving shallow, moist, excruciatingly painful ulcers.

Finally, the lesions crust over and heal.

We mentioned neonatal safety with gonorrhea, but what happens if a mother has active herpes lesions near the time of delivery?

The risk is catastrophic.

Neonatal herpes can be fatal or cause profound central nervous system damage to the baby.

Because of this, if a woman has active genital lesions or even prodromal symptoms at the onset of labor, it is an absolute indication for a cesarean section.

If you only remember one thing for your OB rotation, let it be that.

Active lesions equal a C -section.

Now, we tell the patient there is no cure, which is a tough conversation.

Looking at table 57 .5, what can we offer them to manage it?

We can offer antiviral drugs like acyclover or valacyclover.

These can be used in two ways.

Epicyclic therapy means the patient takes the medication at the very first sign of that prodromal tingling to shorten the duration of the outbreak.

And the other way is preventative.

Suppressive therapy.

That means taking the antiviral every single day to reduce the overall frequency of outbreaks and significantly lower the risk of transmitting the virus to a partner.

I also want to ask about nursing comfort measures.

Having open ulcers in the genital area sounds incredibly painful, especially when trying to use the bathroom.

It is.

Acidic urine touching those open, moist ulcers causes severe burning.

A very simple, effective nursing tip is to teach the patient to pour warm water over their perineum from a peri -bottle while voiding.

The water dilutes the urine before it hits the ulcers, providing significant pain relief.

It is the simple interventions that patients remember most.

Let's look at the other major viral STI.

Genital warts caused by the human papillomavirus or HPV.

I know there are over a hundred types of HPV.

How do we categorize the ones transmitted sexually?

We generally divide them into two camps,

low -risk and high -risk strains.

The low -risk strains, specifically type 6 and 11, are the ones that cause actual genital warts.

Those fleshy, cauliflower -like growths on the skin.

They are symptomatic and annoying, but they do not cause cancer.

And the high -risk strains?

The high -risk strains, like type 16 and 18, are insidious.

They typically do not cause visible warts.

Instead, they cause microscopic cellular changes that can eventually lead to cancers of the cervix, vagina, vulva, anus, penis, and the oropharyngeal area or the throat.

Let's do a quick clinical scenario based on the decision framework in box 57 .3.

Imagine a 19 -year -old guy sitting in your exam room.

You offer him the Gardasil 9 vaccine and he says, why do I need that?

HPV only causes cervical cancer in women, right?

How do you correct that misconception?

You walk him through the evidence.

You tell him that Gardasil 9 protects against the specific strains responsible for 90 % of antigenital warts and 90 % of HPV -related cancers.

Then you hit it with the most important fact.

There is no routine screening test for most HPV -related cancers in men.

Right.

Women have pap smears.

Exactly.

Women have pap smears to catch cervical changes early.

Men do not have an equivalent screening for penile, anal, or throat cancer.

The vaccine is literally his primary defense.

What a vital piece of advocacy.

Now, if someone already has the physical warts from a low -risk strain, how do we handle that?

We can use chemical treatments like applying trichloroacetic acid to burn them off or ablative methods like cryotherapy to freeze them.

But the key patient education here is that these treatments only remove the symptomatic wart.

They do not eradicate the underlying HPV virus from the body.

Okay.

We have covered discharge.

We have covered lesions.

Let's discuss a systemic disease historically known as the great imitator, syphilis.

Why does it get that dramatic nickname and what actually causes it?

It's caused by a bacteria called treponema pallidum.

But this isn't your standard bacteria.

It's a spear shit.

Picture a microscopic, aggressively spiraled corkscrew.

Because of that shape, it literally corkscrews its way into tissues, allowing it to enter the bloodstream and travel anywhere in the body.

So it spreads everywhere.

Yes.

We call it the great imitator because the symptoms it causes along the way can look exactly like a dozen other common diseases, making it incredibly easy to misdiagnose.

If a patient contracts it, walk me through the progression shown in Table 57 .6.

What is the very first thing that happens?

The first stage is primary syphilis.

The hallmark sign is a chancre, a painless hardened ulcer that appears right at the site where the spear shit entered the bottle.

Because it is painless, if it develops internally, like inside the vagina or the rectum, the patient usually has no idea it is there, but it is highly infectious.

If that chancre heals on its own and they think they're fine, what happens next?

Weeks later, they enter secondary syphilis.

The infection has now gone systemic.

The patient will feel flu -like symptoms and they will develop a classic, bilateral rash on the palms of their hands and the soles of their feet.

This is where it imitates things like an allergic reaction.

Or psoriasis.

They might also develop moist, warty patches in the genital area called condylamatolata.

They are still highly contagious at this stage.

And if they still don't get treated?

The visible symptoms fade and they enter the latent stage.

It is clinically silent, they feel fine, but the spear shit is quietly replicating inside them.

Finally, years or even decades later, they progress to the later or tertiary stage.

This is the scary stage.

It is devastating.

They are no longer infectious to other people, but the disease is destroying their own organs.

They develop gummas, which are destructive, tumor -like lesions that eat away at skin, bone, or the liver.

I read it can affect the heart and brain too.

Yes.

The spear shit can weaken the aorta, causing massive cardiovascular aneurysms.

And it can invade the central nervous system, neurosyphilis, leading to severe dementia, personality changes, or a total loss of motor function.

Diagnosing a disease that hides and imitates sounds like a nightmare.

I know there are two types of blood tests for syphilis.

Tryponemal tests and non -tryponemal tests.

Can you explain the difference simply?

Think of the tryponemal test, like the FTA -ABS, as a permanent tattoo.

It looks for specific antibodies to the syphilis bacteria.

Once you contract syphilis, that test will stay positive for the rest of your life, even after you're completely cured with antibiotics.

It simply tells us, yes, you have been exposed to this bug at some point in your life.

Okay, so a positive tryponemal test doesn't necessarily mean they are sick right now.

How do we figure out if the infection is currently active?

For that, we use the non -tryponemal tests, like the VDRL or the RPR.

Think of these like a thermometer for the infection.

They give us a ratio like 1 to 4, 1 to 16, or even 1 to 2048.

So a higher number means a worse infection.

Exactly.

When the infection is raging and active, that titer number climbs very high.

When we give the patient antibiotics and successfully treat them, we monitor that titer over several months and watch it drop back down to zero.

Are there any blind spots with these tests we should watch out for?

Yes.

Beware of the false negative during the early primary stage.

If you test a patient the exact day their primary shanker appears, their VDRL might come back negative.

Not because they don't have syphilis, but because their immune system hasn't had enough time to build up the antibodies the test is looking for.

That is a tricky window to navigate.

If we do catch it, what is the heavy artillery we use to cure it?

The absolute gold standard is penicillin G -bentathine, given as an intramuscular injection.

If it has progressed all the way to neurosyphilis, we use aqueous -procane penicillin G intravenously.

All right.

We have covered the pathophysiology, the bugs, and the drugs.

Let's bring this back to the human being sitting on the exam table, because knowing the science is only half the battle.

Looking at table 57 .8, let's talk about the nursing assessment, specifically taking a sexual history.

It can be deeply uncomfortable for both the student nurse and the patient.

How do we approach this?

You have to establish a private,

completely non -judgmental environment.

You cannot make assumptions about who a person is sleeping with based on how they look.

Use inclusive language.

Ask about their pronouns.

And be specific about the types of sex they're having.

Right.

Ask specifically what kind of sex they're having.

Insertive, receptive, oral, anal, because that dictates where you need to swab for tests.

Also, ask if they use networking apps to meet partners, as public health departments often track localized STI outbreaks linked to those platforms.

And we definitely cannot forget our older adult populations.

I feel like they get completely overlooked in sexual health discussions.

It is a huge blind spot in healthcare.

Sex and sexuality are dynamic across the entire lifespan.

Older adults are actually experiencing rising rates of STIs.

Often they are less likely to use condoms because pregnancy is no longer a concern, and providers routinely fail to screen them simply because of ageist assumptions.

Every sexually active individual needs a risk assessment, regardless of their birth year.

When we are doing health promotion, we obviously talk about barrier methods.

But there is a massive safety warning regarding a specific lubricant ingredient called nonoxynol 9, or N9.

I've heard stories of patients thinking this is a great hack to prevent infections.

Why is it so dangerous?

Nonoxynol 9 is a spermicide.

Some people use it, hoping it adds an extra layer of chemical protection against STIs.

It does the exact opposite.

It is incredibly harsh and severely irritates the vaginal and rectal mucous membranes.

It creates microscopic tears in the tissue.

Which just lets the virus right in.

Precisely.

Those microtears act as an open door, actually increasing the risk of contracting an STI, including HIV, by giving the pathogens a direct route into the bloodstream.

You have to keep a straight face while explaining that their life hack is actually inviting the virus right in.

Beyond physical safety, we have to acknowledge the psychological impact of an STI diagnosis.

The emotional toll is heavy.

Patients experience intense shame,

anger, guilt, and profound relationship stress.

As a nurse, your role is not to judge their choices.

Your role is to normalize the condition,

educate them that these are manageable and often curable infections, and refer them to counseling or support groups when they are struggling to cope.

Which leads us to a fascinating ethical and legal dilemma from Box 57 .5.

Let's say you have a patient who tests positive for chlamydia, but they flat out refuse to tell their partner because they don't want to admit they were unfaithful.

What do you do?

You know the partner is at risk.

This is the classic conflict between hyperconfidentiality and public health mandates.

As a nurse, you are strictly bound by HICL to maintain that patient's absolute privacy.

You cannot unilaterally pick up the phone, call their partner, and breach that trust.

But the state needs to know.

Yes.

However,

you are mandated by state law to report positive cases of chlamydia, gonorrhea, and syphilis to the public health department for surveillance.

So you are stuck in the middle.

How do you handle the patient sitting in front of you?

You manage it through fierce, compassionate education.

You explain the clinical reality of the ping -pong effect.

You help them understand that if their partner goes untreated, that partner could suffer irreversible damage, like infertility, or pass the infection right back to them.

You try to empower the patient to take responsibility.

And if your state allows it, you offer that expedited partner therapy so they can hand their partner a pill without needing to explain a clinic visit.

It is about establishing a partnership with your patient,

not an adversarial dynamic.

So let's tie a bow on this.

Mastering STIs for your exams and your practice isn't about memorizing flashcards.

It's about following the logic.

It's understanding that an intracellular bacteria like chlamydia causes silent damage, leading to PID.

And it's visualizing a spear shit drilling into tissue, explaining why syphilis mimics systemic diseases.

It's knowing why a troponemal test is a permanent tattoo, while a non -troponemal test is a thermometer.

Above all, it's stepping into your role as an impartial, educated advocate in a clinical space that is frequently clouded by stigma and shame.

To leave you with a final thought to mull over as you close your textbooks tonight, we have discussed how bacterial STIs like gonorrhea are rapidly mutating and facing severe, escalating antibiotic resistance.

Meanwhile, viral STIs like herpes and HPV remain incurable and rely on lifelong latency.

Given this trajectory, how might the next generation of nursing completely shift its focus from treating infections post -exposure to strictly managing cellular immunity and defense beforehand?

It is a paradigm shift that you, the future of healthcare, will be responsible for navigating.

Something to really think about as you prepare to enter the field.

Thank you so much for letting us crash your study session.

From everyone here on the Last Minute Lecture team, we are wishing you the absolute best of luck on your exams, your NCLEX, and your clinical rotations.

You are going to be amazing.