Chapter 34 Sexually Transmitted Infections

Sexually transmitted infections (STIs) are a major public health care concern. Women as well as infants are at a great risk of bearing the long-term consequences of STIs. The effective assessment and management of these diseases are key in the emergency department (ED). The emergency nurse must be able to assess and provide care for this population as they present to the ED.¹^–³ This chapter places a primary focus on female patients who present to the ED seeking treatment for gynecological problems.

The adolescent population has the highest reported incidence of STIs.³ Adolescence is a time of sexual exploration through experimentation. Therefore the emergency nurse must learn to establish a trusting relationship rapidly to garner information pertinent to the care of adolescents. This is accomplished by being nonjudgmental and allowing for confidentiality as well as respect.^1,³

Patient History and Assessment

An accurate history is essential when dealing with the potential diagnosis of an STI. Key issues to ask about are:

• Sexual orientation

• Sexual activity

• The potential of sexual abuse or assault

• Number of partners

• Previous STIs

• Possibility of pregnancy

• Type of contraceptive practices being used

• Use of condoms ³

Additional information to obtain:

• Menstrual history

• Medication use

• Pain: time of onset, quality, what makes it better or worse, treatment prior to arrival

• Vaginal discharge

• Obstetrical history

• Last Papanicolaou (Pap) test ⁴

If the patient presents with a gynecological complaint, the emergency nurse should:

• Perform a general assessment as well as a focused assessment of the abdomen and genital area

• Prepare for a pelvic exam

• If STI is suspected, prepare for specimen collection

All female patients of childbearing age should have at least a urine pregnancy test performed.

Selected Emergencies

Human Papillomavirus

Human papillomavirus (HPV) is the most prevalent STI in both adolescents and adult women. HPV is usually asymptomatic but can cause benign warts or certain types of cancer.^5,⁶ There are more than 40 types of HPV that can infect both men and women.

Signs and Symptoms

• Often asymptomatic

• Genital warts (Condylomata acuminata): can occur on the vulva, perianal area, vaginal walls, and cervix (Fig. 34-1); can also occur in male patients

Fig. 34-1 Genital warts.

(Reproduced with permission from Emergency Nurses Association. [2009]. Sheehy’s emergency nursing: Principles and practice [6th ed.]. St. Louis, MO: Mosby.)

Therapeutic Interventions

• In the absence of genital warts no treatment is recommended.

• Topical medication (Podofilox 0.5% gel or Imiquimod 5% cream) as ordered if external warts are identified.

• Educate patient on treatment and prevention related to spreading the virus.

• HPV vaccine starting at age 11 or 12 years.

• Series of three injections; the second and third injections are given 2 and 6 months after the first injection.

• The vaccine can be given to females 13 to 26 years of age who have not previously been immunized.

• Research is ongoing to determine the effectiveness of the vaccine in boys and young men.⁷

• Research is ongoing to determine the effectiveness of the vaccine in females older than 26 years.⁸

• Consistent use of condoms.

• Instruct patient to notify her obstetrician of HPV if pregnant, as HPV can worsen during pregnancy.

• Encourage routine Pap testing; HPV is associated with cervical dysplasia.

Herpes Simplex Virus

Herpes simplex virus (HSV) is a viral illness that is transmitted through oral, vaginal, and rectal intercourse. HSV is a chronic infection with remissions and exacerbations. It has been estimated that up to 70% of people with HSV are asymptomatic.^2,⁶

Gonorrhea

Gonorrhea, the second most common STI in the United States, is caused by Neisseria gonorrhoeae, a gram-negative diplococcus. Women under the age of 25 years are at greatest risk.⁶ Gonorrhea is the leading cause of cervicitis and pelvic inflammatory disease (PID) in female patients and of urethritis in male patients.⁶ Men will present symptomatically whereas women can remain asymptomatic. Untreated gonorrhea can lead to infertility, ectopic pregnancy, and chronic pelvic pain.^6,¹⁰