Urogenital and Sexually Transmitted Diseases

Mode of Transmission Transurethral route (ascending infection often from fecal contamination; sexual intercourse) Hematogenous spread Direct extension by means of a fistula from the intestine CYSTITIS Inflammation of the bladder from an infection, obstruction of urethra, irritants (e.g. soaps, spray, bubble bath, perfumed sanitary napkins), hormonal changes, invasive UT procedures, indwelling urinary catheters, synthetic underwear and pantyhose, urinary stasis, use of spermicides, poor-fitting vaginal diaphragms, wet bathing suits The most common EA are E. coli, Enterobacter spp., Pseudomonas spp., Serratia spp. More common in women because of shorter urethra and close proximity of of urethra and anus Assessment Findings Frequency and urgency Burning on urination Voiding in small amounts Inability to void Incomplete emptying of the bladder Lower abd discomfort or back discomfort Cloudy, dark, foul-smelling urine Hematuria Malaise, chills, fever N&V Nursing Interventions Before administering AB, obtain a urine specimen for culture and sensitivity, if prescribed Urinary culture and sensitivity (C & S): A urine test that identifies the presence of microorganisms and determines the specific AB to treat the existing pathogen appropriately Clean the perineal are and urinary meatus with a bacteriostatic solution Collect the midstream sample in a sterile container Send the specimen to the laboratory immediately Encourage increase in fluid intake up to 3L/d, especially if the client is taking Sulfonamides which can form crystals in concentrated urine Admin prescribed meds Instruct client about foods to consume to maintain acidic urine (pH 5.5) Acid ash diet: bread, cereals, whole grains, cheese, eggs, corn, legumes, cranberries, plums, prunes, tomatoes, meat, fish, oyster, poultry, pastry Use strict aseptic technique when inserting urinary catheter Maintain closed urinary drainage systems for the client with an indwelling catheter and avoid elevating the urinary drainage bag above the level of the bladder Provide meticulous perineal care for the client with indwelling catheter Client education Avoid alcohol Take meds as prescribed Take AB on schedule and complete the entire course of medications as prescribed, which may be 10-14 d Prevent recurrence: Good perineal care (wiping front to back) Avoid bubble baths, tub baths, and vaginal deodorants or spray

Urogenital Urinary Tract Infection (UTI) Leptospirosis Toxic Shock Syndrome STD Gonorrhea Syphilis Herpes Simplex infection Genital warts HIV/AIDS Trichomoniasis

URINARY TRACT INFECTION UTI is defined as significant bacteriuria in the presence of symptoms. This common clinical entity accounts for a significant number of emergency department (ED) visits. It affects an estimated 20% of women at some time during their lifetimes. UTI is an extremely common medical problem, with an unpredictable natural history. Many infections resolve spontaneously, but others can progress to destroy the kidney, or via gram negative sepsis. The term UTI implies causation by gram negative gut flora of the group Enterobacteriaciae. Rarely, UTI can result from virus, fungus, TB, staphylococcus, or other creatures, but the pathophysiology is entirely different. Classification of UTI Lower UTIs Cystitis; prostatitis; urethritis Upper UTIs Acute/chronic pyelonephritis; renal abscess; interstitial nephritis Uncomplicated UTIs Community-acquired infx; common in young women and not usually recurrent Complicated UTIs Often nosocomial and related to catheterization; occur in aeg w/ urologic abnormalities, pregnancy, immunosuppression, DM, and obstruction, and are often recurrent Pathophysiology For infection to occur, the bacteria must gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out w/ voiding, evade host defense mechanism, and initiate inflammation. Many UTIs result from fecal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces. Epidemiology UTI accounts for over 6 million patient visits to physicians per year in the United States. Internationally: As 1 in 5 adult women experience UTI at some point, it is an exceedingly common, clinically apparent, worldwide patient problem. The largest group of patients with UTI is adult women.

Void every 2-3hrs Wear cotton pants and avoid wearing tight cloths or pantyhose Avoid sitting in a wet bathing suit for prolonged periods of time If pregnant, void every 2 hrs Use water-soluble lubricants for intercourse, esp after menopause Void and drink a glass of water after intercourse

Mode of Transmission Direct or indirect contaminated urine Ingestion Incubation Period 5-14days

(swimming)

contact

with

PYELONEPHRITIS Inflammation of the renal pelvis and the parenchyma commonly caused by bacterial invasion Most common EA is E. coli Assessment Findings Fever and chills Nausea Flank pain in the affected side HA Dysuria Frequency and urgency Cloudy, bloody or foul-smelling urine Leukocytosis Nursing Interventions Monitor V/S esp elevated temp Increase fluid up to 3L/d Monitor I & O (ensure output is a minimum of 1500ml/24hr Monitor weight High calorie, high protein diet Provide warm, moist compress to the flank Encourage to take warm baths for pain relief Administer analgesics, antipyretics, AB, antiemetics, urinary antiseptics as prescribed Monitor for signs of renal failure Treatment Urinary antiseptics Nitrofurantoin (Furadantin, Macrobid) Nalidixic acid (NegGram Sulfonamides TMP-SMZ (Bactrim, Septra) Fluoroquinolones Ciprofloxacin (Cipro) Levofoxacin (Levaquin) Ofloxacin (Floxin)

Signs and Symptoms Early stage: fever (40degrees); tachycardia; skin warm, flushed; petechiae; myositis Severe (multi-organ): conjunctival suffusion; jaundice; purpura; ARF; hemoptysis Diagnosis Leptospira Agglutination Test (LAT) Leptospira Ag-Ab Test (LAAT) U/A, CBC, serology Treatment Doxycycline (Vibramycin) Pen G Na Nursing Interventions Medications as ordered Standard precautions

TOXIC SHOCK SYNDROME Presence of toxins in the blood steam caused by infection due to Staphylococcus aureus. Most cases are associated with use of vaginal tampons; some are associated with surgical procedures. Pathophysiology TSS is a toxin-mediated disease. Exotoxin toxic shock syndrome toxin-1 (TSST-1) is the major toxin produced by strains of S. aureus that are responsible for causing TSS. The toxins activate production of superantigens, such as tumor necrosis factor, interleukin-1, M protein, and gamma-interferon. Almost every organ system can be involved, including the cardiovascular, renal, skin, mucosa, GI, musculoskeletal, hepatic, hematologic, and central nervous systems. Epidemiology Incidence higher in women

LEPTOSPIROSIS Also Weils disease; Mud Fever; Swineherds Disease. Worldwide zoonosis caused by Leptospira interrogans. Pathophysiology Leptospire invasion across the epithelium is followed by proliferation and widespread dissemination and every major organ system may be affected. The most consistent pathologic finding in leptospirosis is vasculitis of capillaries manifested by endothelial edema, necrosis, and lymphocytic infiltration. Capillary vasculitis is found in every affected organ system. The resulting loss of red blood cells and fluid through enlarged junctions and fenestrae, which cause secondary tissue injury. Epidemiology Phil stat: 0.2/100,000 population Source: urine of infected wild and domestic animals (rats, dogs, cats, livestock)

Signs and Symptoms Fever with diarrhea and vomiting Diagnosis (+) cervical and vaginal culture for EA Treatment Nafcillin (Unipen) Clindamycin (Cleocin) Nursing Interventions Administer IV fluid therapy as ordered, to restore circulating blood volume Antibiotics as ordered Administer vasopressor such as Dopamine (Intropin) as ordered to increase BP Instruct aeg to avoid the use of tampons or to only use tampons made of natural materials such as cotton

TRICHOMONIASISS Trichomoniasis is a sexually transmitted protozoal infection caused by Trichomonas vaginalis. Pathophysiology T. vaginalis inhabits the vaginal and urethral tissues. In women, T. vaginalis is isolated from the vagina, cervix, urethra, bladder, and Bartholin and Skene glands. In men, the organism is isolated from the anterior urethra, external genitalia, prostate, epididymis, and semen. The protozoal pathogen causes direct damage to the epithelium, leading to microulcerations. Epidemiology Co-exist with other conditions: gonorrhea, bacterial vaginitis Suspect sexual abuse if (+) in pre-pubertal child Mode of Transmission Primarily sexual Incubation Period 4-28days Signs and Symptoms May be asymptomatic Yellowish to greenish, frothy, mucopurulent, copious, malodorous vaginal discharge Diagnosis Elevated vaginal pH (5.5+) Treatment Metronidazole (Flagyl) Nursing Interventions Instruct aeg to douche with vinegar to acidify the vagina Medications as ordered Sexual partner may need to be treated Inform aeg that Flagyl may turn the urine brown

Phil stat: 2.1/100,000 population Concurrent infection with Chlamydia trachomatis is common Incubation Period 2-7days Mode of Transmission Direct contact with vaginal secretions of mother during childbirth Sexual intercourse Suspect sexual abuse if (+) in pre-pubertal child Signs and Symptoms Male: purulent discharge after 2-7days of exposure; rectal infection: tenesmus, pruritus, discharge Female: initially asymptomatic; endometritis; salpingitis; pelvic peritonitis; infertility Diagnosis U/A: inc WBC; (+) urine culture Treatment Penicillin; Ceftriaxone; Ciprofloxacin; Cefixime Nursing Interventions Medications as ordered Instruct aeg to avoid multiple sex partners SYPHILIS Also Lues, The Pox, Bad Blood, is an infectious disease caused by the spirochete Treponema pallidum. Has a myriad of presentations and can mimic many other infections and immune-mediated processes in advanced stages. Hence, it has earned the nickname "the great imposter." The complex and variable manifestations of the disease. Pathophysiology T. pallidum penetrates abraded skin or intact mucous membranes easily and disseminates rapidly, although asymptomatically, via the blood vessels and lymphatics. The prominent histologic features of the human response to the presence of T pallidum are vascular changes with associated periarteritis. Additionally, chronic infection can result in granulomatous lesions called gummas. Mode of Transmission Transplacental or perinatal for congenital syphilis Direct contact with primary lesions Contact with body fluids or secretions Incubation Period 10-90days Signs and Symptoms Primary: painless chancre Secondary: alopecia areata patchy alopecia, affects eyebrows; condylomata lata- highly infectious lesions at perianal, vulva, scrotum, inner thighs, axilla, undersides of breasts Latent: Gumma diffuse solitary lesions; meningeal syphilis brain and spinal cord Congenital syphilis: may lead to abortion, still birth, pneumonia Early: obstructed nasal breathing w/ bloody nasal discharges, condylomata

GONORRHEA Is a purulent inflammation of mucous membrane surfaces (GUT, rectum,pharynx) caused by a sexually transmitted microorganism, Neisseria gonorrhoeae. In the developed world, where prophylaxis for neonatal eye infection is standard, the vast majority of infections follow genitourinary mucosal exposure. Locally known as tulo. Pathophysiology Infection of the lower genital tract, the most common clinical presentation, primarily manifests as male urethritis and female endocervicitis. Infection of the pharynx, rectum, and female urethra occur frequently but are more likely to be asymptomatic or minimally symptomatic. Retrograde spread of the organisms occurs in as many as 20% of women with cervicitis, often resulting in pelvic inflammatory disease (PID), with salpingitis, endometritis, and/or tubo-ovarian abscess. Retrograde spread can lead to frank abdominal peritonitis and to a perihepatitis known as Fitz-Hugh-Curtis syndrome. Epididymitis or epididymo-orchitis may occur in men after gonococcal urethritis. Epidemiology

 Late: interstitial keratitis to blindness; saddle nose; cleft palate/cleft lip Tertiary syphilis (the final stage of syphilis): characterized by brain or central nervous system involvement (neurosyphilis), cardiovascular involvement with inflammation of the aorta (aortitis or aneurysms), and gummatous syphilis (destructive lesions of the skin and bones). Diagnosis Darkfield microscopy Symptomatic Serology Treatment Penicillin IM/IV Nursing Interventions Medicationss as ordered Avoid multiple partners Safe sex

Treatment Acyclovir (topical or PO) Nursing Interventions/Considerations Supportive care Isolation of aeg If mother is infected, CS delivery

GENITAL WARTS Are an epidermal manifestation attributed to the epidermotropic human papillomavirus (HPV). Approximately 90% of all genital warts are related to HPV types 6 and 11 (HPV-6, HPV-11). Pathophysiology HPV invades cells of the basal layer of the epidermis, penetrating skin and mucosal microabrasions in the genital area. A latency period of months to years may ensue. Following that period, viral DNA, capsids, and particles are produced. Host cells become infected and develop the morphologic atypical koilocytosis (a condition of certain cells characterized by perinuclear vacuolation) of genital warts. Epidemiology Mortality is secondary to malignant transformation to a carcinoma. HPV infection appears to be more common and worse in patients with various types of immunologic deficiencies. Mode of Transmission Sexual contact Signs and Symptoms Painless bumps; pruritus; discharge Diagnosis PE Biopsy Treatment Keratolytic agents: Podofilox (Condylox), topical Cryotherapy/cryosurgery (freezing with liquid nitrogen); electrodessication; surgical excision Prevention Gardasil IM Nursing Interventions Aeg teaching

GENITAL HERPES Herpesvirus hominis, or herpes simplex virus (HSV), is one of the most common agents infecting humans of all ages. Genital HSV infection (HSV-2) in older adolescents and adults is a major public health problem, having markedly increased in prevalence in the last 3 decades. This increased prevalence of genital HSV infections poses major threats to newborns because most infections in neonates are acquired perinatally. Neonatal HSV infection is a disease with high morbidity and mortality rates. Pathophysiology After direct exposure to infectious material (i.e., genital secretions), initial viral replication occurs at the entry site in the mucous membrane. The biologic properties of HSV that control the course of infection are neuroinvasiveness (the ability of the virus to invade the brain), its neurotoxicity (its ability to multiply and destroy the brain), and its latency (its ability to remain in a nonreplicating form in the dorsal root ganglia of the CNS). After retrograde axonal flow from neurons at the viral point of entry and local replication, the viral genome becomes latent. A stimulus (e.g., physical or emotional stress, fever, ultraviolet light) reactivates the virus in the form of skin vesicles or mucosal ulcers, with symptoms less severe than those of the primary infection Epidemiology Premature infants at high risk Humans are the primary hosts for infection. Incubation Period 2-12days Mode of Transmission Sexual contact Signs and Symptoms Vesicular or ulcerative lesions in genitalia Diagnosis Isolation of virus from secretions ELISA; PCR Pap smear less sensitive than isolation

HIV/AIDS Clinically apparent human immunodeficiency virus (HIV) infection first was recognized in 1981 in homosexual men in New York City who presented with evidence of a profound acquired immune deficiency syndrome (AIDS). We now appreciate that HIV infection is a worldwide health problem that affects millions of men and women. HIV has the capability to affect every organ system in the body by direct damage by the virus or by rendering the host susceptible to opportunistic infections. AIDS is technically the end stage of HIV infection. HIV is found in blood, semen, vaginal secretions, and breast milk

 The most common opportunistic is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 mos. Pathophysiology HIV is a Lentivirus, a subgroup of retroviruses. This family of viruses is known for latency, persistent viremia, infection of the nervous system, and weak host immune responses. HIV has high affinity for CD4 T lymphocytes and monocytes. HIV binds to CD4 cells and becomes internalized. The virus replicates itself by generating a DNA copy by reverse transcriptase. Viral DNA becomes incorporated into the host DNA, enabling further replication. Progressive immune deficiency increases the risk for opportunistic infections Epidemiology Humans are the only known reservoir. Isolated in blood, CSF, pleural fluid, breast milk, semen, cervical secretions, saliva, urine, tears. Only blood, cervical secretions, semen, breast milk implicated epidemiologically in transmission. Incubation Period 6months-5years Mode of Transmission Sexual contact (vaginal, anal, oral) Percutaneous Vertical, breastfeeding Signs and Symptoms In children: Chronic cough Chronic or recurrent diarrhea Hepatosplenomegaly Lymphadenopathy Malaise and fatigue Night sweats Oral candidiasis Parotitis Weight loss In adults: Malaise, fever, anorexia, wt loss, flu-like sx Lymphadenopathy for at least 3 mos Leukopenia Diarrhea Fatigue Night sweats P. jiroveci infx (major source of mortality) Neoplasms ( Kaposis sarcoma: purplishred lesions of internal organs and skin, B cell non-Hodgkins lymphoma, cervical CA) Fungal infx (candidiasis, histoplasmosis) Viral infx (cytomegalovirus, herpes simplex) Bacterial infx Diagnosis ELISA for screening Western blot: usual confirmatory test for ELISA PCR: ID virus CD4+ T cell counts (N: 500-1600 cells/L) Viral culture Treatment The goals in the use of antivirals are to shorten clinical course, prevent complications, prevent development of latency and/or subsequent recurrences, decrease transmission, and eliminate established latency Reverse Transcriptase Inhibitors

Abacavir (Ziagen) Lamivudine (Epivir) Zidovudine (Retrovir, Azidothymidine) Protease Inhibitors Atazanavir (Reyataz) Ritonavir (Norvir) Saquinavir (Invirase) Nursing Interventions Standard/universal or blood and body fluids precautions Provide meticulous skin care Admin oxygen and respiratory tx as prescribed Maintain F & E balance Nutritional rehab Avoid direct unprotected contact with body fluids Do not share eating utensils Treatment of opportunistic infection Clean up body fluid spills with a bleach solution (10:1 ratio of water to bleach) 5 Ps: Promote homeostasis; Promote comfort; Prevent infection; Psychological support; Provide information/education