COLLEGE OF NURSING SCIENCES, SOKOTO

SOKOTO STATE

DEPARTMENT OF NURSING

LECTURE NOTE

ON

FEMALE REPRODUCTIVE SYSTEM DISORDERS

(SEXUALLY TRANSMITTED INFECTIONS (STIs)

(CONTINUATION)

BY

MAL. ABDULLAHI MUSA (RN, RNE, RM, BNSc.)

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HEPATITIS

A viral infection affecting the liver, caused by Hepatitis Viruses (HBVs). Hepatitis is an acute,
systemic, viral infection that can be transmitted sexually. The viruses associated with hepatitis or
inflammation of the liver are hepatitis A, B, C, D, E, and G.

Hepatitis A is highly contagious and spreads primarily through the fecal–oral route from person-to-
person or by ingesting contaminated food or water. Hepatitis A can also be transmitted through
sexual intercourse. Worldwide, hepatitis B has the highest death rate (780,000 annually) of any STI
except HIV (WHO, 2015a).

Cause

Hepatitis Viruses (HVs)

Mode of Transmission

 Sexual contact

 Mother-to-child
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  Blood products

Signs and Symptoms

 Jaundice

 Fatigue

 Dark urine

 Abdominal pain

 Fever

 Joint pain

 Nausea and vomiting

 Anorexia

Diagnostic Investigations

I. HBsAg (Hepatitis B surface antigen)

II. HBeAg (Hepatitis B e antigen)

III. HBV DNA

IV. LFTs (Liver Function Tests)

Medical Management

Management involves anti-viral drugs such as:

I. Tenofovir

II. Entecavir

Prevention of mother to child transmission

Prevention of mother-to-child transmission (MTCT) of Hepatitis B (HBV) is very effective when the
right steps are followed.

1. Test the mother during pregnancy.

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 2. Give the mother antiviral drugs (Tenofovir) if her viral load is high within 28-32 weeks of
pregnancy until delivery

3. Give the baby the Hepatitis B vaccine at birth (within 24 hours).

4. Give the baby HBIG (within 12) if the mother is positive.

5. Complete the baby’s vaccine schedule.

6. Breastfeeding is safe after the vaccine.

7. Test the baby at 9–12 months.

Complications

a) Liver cirrhosis

b) Hepatocellular carcinoma

CHLAMYDIA

Chlamydia is a sexually transmitted infection caused by Chlamydia trachomatis. Newborns

delivered to infected mothers may develop conjunctivitis, which occurs in 1% to 12% of all
newborns. Ophthalmia neonatorum is an acute mucopurulent conjunctivitis occurring in the first
month of birth. It is essentially an infection acquired during vaginal delivery. The most frequent
infectious agents involved in are C. trachomatis and Neisseria gonorrhoeae (Moore & MacDonald,
2015).

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Cause

Bacteria: Chlamydia trachomatis

Mode of Transmission

 Vaginal, anal, or oral sex

 From mother to baby during delivery

Signs and Symptoms

 Often asymptomatic

 Abnormal vaginal/penile discharge

 Dysuria (painful urination)

 Pelvic pain

 Testicular pain in men

Diagnostic Investigations

I. NAAT (Nucleic Acid Amplification Test)

II. PCR (Polymerase Chain Reaction) test

III. Endocervical or urethral swab

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IV. First-catch urine test

Medical Management

 Azithromycin 1g orally, single dose

 OR Doxycycline 100 mg orally twice daily for 7 days

 Because of the common co-infection of chlamydia and gonorrhea, a combination regimen of

ceftriaxone (Rocephin) with doxycycline or azithromycin is prescribed frequently (CDC,
2015e).

 Treat sexual partners

Complications

o Pelvic Inflammatory Disease (PID)

o Ectopic pregnancy

o Infertility

o Epididymitis

GONORRHEA

A bacterial sexually transmitted infection caused by Neisseria gonorrhoeae. It is the second most
commonly reported infection in the United States and globally is an urgent problem because it is now
capable of rapidly developing resistance to multiple antibiotic classes. Gonorrhea is highly
contagious and is a reportable infection which increases the risk for PID, infertility, ectopic
pregnancy, and HIV acquisition and transmission (CDC, 2015f).

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Cause

Bacteria: Neisseria gonorrhoeae

Mode of Transmission

Vaginal, anal, and oral sex

Mother-to-child during delivery (causes ophthalmia neonatorum)

Signs and Symptoms

 Purulent (pus-like) discharge

 Dysuria

 Pelvic pain

 Sore throat (oral infection)

Diagnostic Investigations

A. NAAT (Nucleic Acid Amplification Test)

B. PCR (Polymerase Chain Reaction)

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 C. Gram stain (shows gram-negative diplococci)

Medical Management

1. Ceftriaxone 1,000 mg IM (Intramuscular) single dose

2. Treat for chlamydia simultaneously using doxycycline unless ruled out

Complications

I. PID

II. Infertility

III. Disseminated Gonococcal Infection (DGI)

IV. Neonatal conjunctivitis

TRICHOMONIASIS

A protozoal STI caused by Trichomonas vaginalis. Trichomoniasis is another common vaginal

infection that causes a discharge, but is not always sexually transmitted. The organism can live on
damp/wet surfaces and poorly cleaned and drains. The woman may be markedly symptomatic or
asymptomatic. Men are asymptomatic carriers.

Cause

Parasite: Trichomonas vaginalis

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Mode of Transmission

 Vaginal sex (most common)

 Sharing unclean sex toys

Signs and Symptoms

 Frothy yellow-green discharge

 Fishy odor

 Itching

 Dysuria

Diagnostic Investigations

a) Wet mount microscopy

b) NAAT (Nucleic Acid Amplification Test)

c) Urine culture

Medical Management

1. Metronidazole 400-800 mg single dose

2. OR Tinidazole

3. Treat sexual partners

Complications

 Premature delivery

 Increased HIV susceptibility

BACTERIAL VAGINOSIS (BV)

Bacterial Vaginosis is a non-sexually transmitted vaginal infection characterized by alterations in

vaginal flora in which lactobacilli in the vagina are replaced with high concentrations of anaerobic
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bacteria often called Gardnerella vaginalis. BV was named so because bacteria are the etiologic
agents and an associated inflammatory response is lacking.

Causes

BV occurs when the normal vaginal flora (dominated by lactobacilli) is replaced by harmful bacteria.

Main causes include:

 Overgrowth of Gardnerella vaginalis (most common)

 Overgrowth of anaerobic bacteria such as:

 Mobiluncus species

 Mycoplasma hominis

 Prevotella species

Predisposing factors

 Multiple sexual partners

 New sexual partner

 Vaginal douching

 Using perfumed soaps

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  Intrauterine devices (IUD)

 Smoking

 Low vaginal acidity

Types

Bacterial vaginosis does not have major clinical types, but may present as:

a. Symptomatic BV: with discharge and odor

b. Asymptomatic BV: no symptoms but abnormal flora on test

Mode of Transmission

BV is not strictly transmitted sexually, but sexual activity increases risk. Transmission-associated
factors:

 Exchange of vaginal flora during intercourse

 Shared sex toys

Signs and Symptoms

 Many women are asymptomatic.

 Thin, white or gray vaginal discharge

 Fishy odor, especially after intercourse

 Vaginal itching (mild or absent)

 Mild burning on urination (sometimes)

 Vaginal pH > 4.5

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Diagnostic Investigations

Diagnosis is made using Amsel Criteria or Gram stain (Nugent score).

Amsel Criteria (≥3 required):

i. Thin, homogeneous discharge (milky grey-white vaginal discharge)

ii. Clue cells on microscopy (vaginal epithelial cells covered with bacteria)

iii. Positive “whiff test” (fishy smell after adding KOH)

iv. Vaginal pH > 4.5

Other tests:

1. Gram stain (Nugent scoring system – gold standard)

2. DNA/NAAT tests for Gardnerella (if available)

3. Wet mount microscopy

Medical Management

First-line treatment

1. Metronidazole 500 mg orally twice daily for 7 days

OR

2. Metronidazole gel 0.75% intravaginally once daily for 5 days

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 OR

3. Clindamycin cream 2% intravaginally at bedtime for 7 days

Alternative options

I. Clindamycin 300 mg orally twice daily for 7 days

II. Tinidazole 2 g orally once daily for 2 days

III. Tinidazole 1 g orally once daily for 5 days

Management considerations

 Treat symptomatic pregnant women (Metronidazole is safe)

 Sexual partners do not need treatment

 Advise against douching and scented products

Recurrent BV may require:

 Metronidazole gel twice weekly for 4–6 months

 Probiotics (optional)

Complications

Reproductive complications

 Pelvic Inflammatory Disease (PID)

 Increased risk of acquiring STIs (HIV, chlamydia, gonorrhea)

 Increased risk of postpartum infections

Pregnancy complications

I. Preterm birth

II. Premature rupture of membranes

III. Low birthweight

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IV. Chorioamnionitis

CANDIDIASIS (VULVOVAGINAL CANDIDIASIS)

Candidiasis is a fungal (yeast) infection of the vagina caused mainly by Candida albicans. It occurs
when there is overgrowth of the yeast due to disruption of the normal vaginal flora.
Genital/vulvovaginal candidiasis (VVC) is one of the most common causes of vaginal discharge. It is
also referred to as yeast, monilia, and a fungal infection. It is not considered an STI because Candida
is a normal constituent in the vagina and becomes pathologic only when the vaginal environment
becomes altered. An estimated 75% of women will have at least one episode of VVC, and 40% to
50% will have two or more episodes in their lifetime (CDC, 2015b).

Causes/Aetiology

Overgrowth of Candida albicans (most common), Candida glabrata and Candida tropicalis

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Predisposing factors

 Pregnancy

 Diabetes mellitus

 Immunosuppression (HIV, steroids)

 Prolonged antibiotics

 Oral contraceptives

 Tight, non-breathable underwear

 Poor personal hygiene

 Use of contaminated sex toys

 Insertion of substances in to the vagina

Mode of Transmission

Not strictly sexually transmitted but may be associated with sexual activity.

Signs and Symptoms

 Thick, curdy “cottage cheese” vaginal discharge

 Severe vulvar itching

 Vulvar redness and swelling

 Pain during intercourse (dyspareunia)

 Burning sensation on urination

 No fishy odor (unlike BV)

 Vaginal pH usually normal (≤4.5)

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Diagnostic Investigations

 Microscopy (KOH wet mount) budding yeast or pseudohyphae

 Vaginal culture (for recurrent cases)

 Vaginal pH test (normal)

 NAAT or PCR (rarely needed)

 Blood glucose test (if diabetes suspected)

Medical Management

Treatment of candidiasis includes one of the following medications:

1. Miconazole (Monistat) cream or suppository

2. Clotrimazole (Mycelex) tablet or cream

3. Terconazole (Terazol) cream or intravaginal suppository

4. Fluconazole (Diflucan) oral tablet (Prabhu & Gardella, 2015).

First-line treatment

 Fluconazole 150 mg orally single dose

OR

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  Clotrimazole cream 1% intravaginally for 7–14 days

OR

 Miconazole 2% cream intravaginally for 7 days

For severe candidiasis

 Fluconazole 150 mg every 72 hours for 3 doses

For recurrent candidiasis

 Fluconazole 150 mg weekly for 6 months

In pregnancy

Topical azole creams for 7 days

(Oral fluconazole is NOT recommended)

Complications

I. Recurrent infection

II. Vulvar fissures and excoriation

III. Increased susceptibility to HIV

IV. Psychological distress

V. Severe infection in immunocompromised women

Prevention

i. Good genital hygiene

ii. Avoid douching

iii. Wear loose, cotton underwear

iv. Control blood sugar

v. Avoid prolonged antibiotics

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 vi. Change wet clothing promptly

vii. Use probiotics when on antibiotics (optional)

PELVIC INFLAMMATORY DISEASE (PID)

Pelvic Inflammatory Disease is an infection of the upper female reproductive tract, including the
uterus, fallopian tubes, ovaries, and surrounding pelvic structures. It is usually caused by ascending
infection from the vagina or cervix.

Causes/Aetiology

Main organisms:

i. Chlamydia trachomatis

ii. Neisseria gonorrhoeae

iii. Mycoplasma genitalium

Other causes:

Anaerobic bacteria

Gardnerella vaginalis

Streptococci/Staphylococci

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 Post-abortion or postpartum infections

Post-IUD insertion

Types

 Acute PID: sudden, severe symptoms

 Subclinical PID: mild or no symptoms but ongoing damage

 Chronic PID: long-term inflammation and scarring

Mode of Transmission

i. Mainly through untreated STIs (chlamydia, gonorrhea)

ii. Ascending infection from the vagina

iii. Sexual intercourse with an infected partner

iv. IUD insertion in the presence of infection

v. Unsafe abortion

vi. Childbirth complications

Stages/Severity

Stage 1: Endometritis (infection of uterus)

Stage 2: Salpingitis (fallopian tubes)

Stage 3: Oophoritis (ovaries)

Stage 4: Tubo-ovarian abscess

Stage 5: Peritonitis (pelvic or generalized)

Signs and Symptoms

 Lower abdominal pain

 Fever

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  Painful intercourse (dyspareunia)

 Abnormal vaginal discharge

 Irregular bleeding

 Lower back pain

 Nausea/vomiting

 Pain during urination

 Cervical motion tenderness

 Adnexal tenderness

Severe cases:

 High fever

 Fainting

 Signs of sepsis

Diagnostic Investigations

a) Pelvic examination

b) Pregnancy test (to rule out ectopic)

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 c) NAAT for chlamydia & gonorrhea

d) Full blood count

e) ESR

f) Pelvic ultrasound (abscess, fluid)

g) Endometrial biopsy (rare)

h) Culdocentesis (if abscess suspected)

Medical Management

Outpatient Treatment (recommended by WHO/CDC)

I. Ceftriaxone 500 mg IM single dose

PLUS

II. Doxycycline 100 mg orally twice daily for 14 days

PLUS

III. Metronidazole 500 mg twice daily for 14 days

Inpatient (severe cases):

1. IV Ceftriaxone + IV Doxycycline + IV Metronidazole

OR

2. Clindamycin + Gentamicin IV

Surgical Management

Indicated for:

 Tubo-ovarian abscess

 Peritonitis

 Ruptured abscess

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Severe cases not responding to antibiotics

Precedures:

 Drainage of abscess

 Laparoscopic/laparotomy surgery

Other Management

A. Treat all sexual partners

B. Abstain from sexual intercourse until completion of therapy

C. Manage pain with analgesics

D. IV fluids for severe infection

Complications

i. Infertility (due to tubal scarring)

ii. Ectopic pregnancy

iii. Chronic pelvic pain

iv. Tubo-ovarian abscess

v. Fitz-Hugh–Curtis syndrome (liver capsule inflammation)

vi. Recurrent PID

vii. Sepsis

ECTOPARASITIC INFECTIONS
Ectoparasites are a common cause of skin rash and pruritus throughout the world, affecting persons
of all ages, races, and socioeconomic groups. These infections include infestations of scabies and
pubic lice. Because these parasites are easily passed from one person to another during sexual
intimacy, clients should be assessed for them when receiving care for other STIs.

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SCABIES

Scabies is an intensely pruritic dermatitis caused by a mite. The worldwide prevalence has been
estimated at about 100 million cases annually (Monsel & Chosidow, 2015). In general, transmission
occurs by direct skin-to-skin contact.

The female mite burrows under the skin and deposits eggs, which hatch. The lesions start as a small
papule that reddens, erodes, and sometimes crusts.
Diagnosis is based on history and appearance of linear burrows in the webs of the fingers, on the
elbows, in the axillae, buttocks, and the genitalia (Mutasim, 2015). Aggressive infestation can
occur in immunodeficient, malnourished people, but healthy people do not usually suffer sequelae.

Scabies treatment includes topical administration of a scabicidal agent (e.g., permethrin,

crotamiton, or ivermectin), as well as an antibiotic if a secondary infection is present.

PUBIC LICE

Lice are parasitic insects that can be found on people’s head, body or pubic areas. Clients with
pediculosis pubis (pubic louse) usually seek treatment because of the pruritus, because of a rash
brought on by skin irritation from scratching, or because they notice lice or nits in their pubic hair,
axillary hair, abdominal and thigh hair, and sometimes in the eyebrows, eyelashes, and beards.
Infestation is usually asymptomatic until after a week or so, when bites cause pruritus and secondary
infections from scratching.

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Diagnosis is based on history and the presence of nits (small, shiny, yellow, oval, dewdrop-like eggs)
affixed to hair shafts or lice (a yellowish, oval, wingless insect (Guenther & Maguiness, 2015).
Treatment has two aspects: medication and environmental control measures. Medications used
include topical anti-louse agents such as permethrin shampoos, malathion, spinosad, or
ivermectin. Bedding and clothing should be washed in hot water and dried using a hot setting
on the dryer; dry cleaning or sealing clothes in plastic bags for 2 weeks to decontaminate them.
Sexual partners should also be treated, as well as family members who live in close contact with the
infected person.

GENERAL NURSING MANAGEMENT

Assessment

 Obtain detailed sexual history (use 5 Ps: Partners, Practices, Prevention, Past STIs, Pregnancy
intentions)

 Assess symptoms: discharge, pain, fever, ulcers

Education

 Explain disease condition

 Reinforce medication adherence

 Counsel on abstinence until treatment completion

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  Promote condom use

 Emphasize partner notification and treatment

Infection Prevention

o Teach hygiene

o Provide condoms

o Encourage regular STI screening

Psychosocial Support

 Address anxiety, stigma, fear

 Provide confidentiality

Medication Administration

 Administer prescribed antibiotics/antivirals

 Monitor for side effects

 Encourage completion of therapy

Follow-Up Care

 Schedule retesting (e.g., 3 months for chlamydia/gonorrhea)

 Ensure cure check for syphilis using RPR/VDRL titer

Documentation

 Document assessment findings

 Treatment given

 Counselling provided

PREVENTING SEXUALLY TRANSMITTED INFECTIONS

Education about safer sex practices and the resulting increase in the use of condoms can play a vital
role in reducing STI rates all over the world. Clearly, knowledge and prevention are the best defenses
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against STIs. The prevention and control of STIs is based on the following concepts (American
College of Obstetricians & Gynecologists [ACOG], 2015; U.S. FDA, 2015):

I. Education and counseling of persons at risk about safer sexual behavior such as STI
screening and limiting number of sexual partners

II. Recommending immunizations that prevent Hepatitis B and HPV pre-exposure

III. Educating people that latex condoms offer some protection and reduce risk of transmission

IV. Identifying asymptomatic infected individuals and symptomatic individuals unlikely to seek
diagnosis and treatment

V. Effectively diagnosing and treating infected individuals. Avoid sharing needles or sharp
objects

VI. Early evaluating, treating, and counseling sex partners of people who are infected with an STI

SELECTED NURSING STRATEGIES TO PREVENT THE SPREAD OF STIs

I. Provide basic information about STI transmission.

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 II. Outline safer sexual behaviors for people at risk for STIs.

III. Refer clients to appropriate community resources to reduce risk.

IV. Screen asymptomatic persons with STIs.

V. Identify barriers to STI testing and remove them.

VI. Offer pre-exposure immunizations for vaccine-preventable STIs.

VII. Respond honestly about testing results and options available.

VIII. Counsel and treat sexual partners of persons with STIs.

IX. Educate school administrators, parents, and teens about STIs.

X. Support youth development activities to reduce sexual risk-taking.

XI. Promote the use of barrier methods (condoms, diaphragms) to prevent the spread of STIs.

XII. Assist clients to gain skills in negotiating safer sex.

XIII. Discuss reducing the number of sexual partners to reduce risk.

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