Sexual infections have carried a significant social stigma throughout the ages; various acts of legislation, such as the Contagious Diseases Act 1864, confirmed abhorrence of these infections and sought to ‘blame’ individuals (usually women) for their spread (Cooper & Reid 2007). In the wake of an upsurge in sexual infections during the First World War, a different approach was adopted. In 1916 the Public Health (Venereal Diseases) Regulations heralded free and confidential SAI clinics for all (Clutterbuck 2008). As a result, gonorrhoea and syphilis became less common in the UK, compared with industrialised countries that still stigmatised these infections. The advent of penicillin was a major breakthrough in the treatment of SAIs. Treatment availability, along with the advent of the oral contraceptive pill, may have contributed to sexual freedom. Unfortunately the oral contraceptive pill led to a reduction in condom use and consequential rise in the incidence of SAIs experienced in the 1960s. Since this time, HIV has appeared on the scene. Faced once more with a potentially fatal and incurable SAI, society has looked for scapegoats, often incorrectly blaming those on the periphery of society.

The current trends in SAIs show that cases are still rising despite public health programmes and the ready, and often free, availability of barrier contraceptives such as condoms. Those most at risk of acquiring SAI include: young, single people; those who have multiple sexual partners; those who do not use barrier contraceptives; and those who live in metropolitan areas. Structural gender inequality, where women are forced into having unsafe sex as a byproduct of social, economic and gender disparity, is an additional factor (Gupta et al 2008). The number of all episodes of SAIs continues to increase in the UK.

Of all the SAIs, HIV has the most significant impact and it is on HIV that much of this chapter is focused. HIV is a global pandemic and has had a devastating effect on the developing world, in particular sub-Saharan Africa, which bears the greatest burden. The World Health Organization (WHO) estimated that in December 2007 over 33 million people worldwide were living with HIV, of whom two thirds live in sub-Saharan Africa, which also bears the brunt of new infections and death from acquired immune deficiency syndrome – AIDS (WHO 2008). In the UK, although there is a relatively low incidence when compared to many countries in the developing world, HIV continues to be a growing problem. In 2007 the Health Protection Agency (HPA) estimated that 77 400 people were living with HIV, of whom 7734 were newly diagnosed, and an increasing percentage (23%) were heterosexually acquired cases originating within the UK (HPA 2008b).

The role of the nurse

The role of the nurse in a sexual health setting involves several key concepts, irrespective of the infection with which patients present. A diagnosis of any SAI can raise significant anxieties, not only from the diagnosis but also from the need for health care professionals to know the type of sexual act involved. It is also essential to provide open, non-judgemental care, responding to the needs of the patients. Counselling services and sexual health education are still seen as important for patient support, particularly when patients are deciding whether to have a test for HIV. However, with the advent of better treatment options for HIV, there is increased pressure that testing should be ‘normalised’ with less emphasis placed upon pre- and post-test counselling. Whatever changes are made in approaching the screening for SAIs, sexual health centres maintain a policy of confidentiality that often allows previously undisclosed sexual expression from the patient or client.

Partner notification

One of the most important aspects of nursing patients in a sexual health setting is the provision of partner notification (Trelle et al 2007). Health advisors attached to sexual health clinics organise partner notification. Only by encouraging patients to contact their partners to inform them of the chance of infection and then screening and treating those partners before further sexual activity, can the cycle of infection and re-infection be broken. In order to do this successfully, an accurate sexual history is of fundamental importance. Without a comprehensive and accurate history it can prove impossible to contact, screen and treat all affected parties. Although it is more effective if partner notification is performed by the patients themselves, health advisors may act in lieu of their patients and contact the patient’s sexual partners on their behalf.

The common sexually acquired/transmitted infections are discussed below, with some generalised treatment strategies; however, since this field of health care is evolving (particularly so with HIV), the drugs indicated are a rough guide rather than fixed treatment regimens, since in this dynamic area therapies often change. The British Association for Sexual Health and HIV (www.bashh.org/guidelines) provides information on the latest treatment trends.

Taking a sexual history

Before examining the various SAIs in more detail, it is necessary to consider the patient’s sexual history. This is an essential first step prior to screening a patient for SAIs. Obtaining a sexual history in the context of a sexual health centre is easier than with a general practitioner or family doctor. In the sexual health centre the patient is expecting to discuss sexual problems and infections. In a general practitioner or family doctor surgery, the patient might wish to discuss an embarrassing sexual problem but not know how to introduce it into the conversation. ‘I have a little problem down below’ can mean anything from genital warts to a prolapsed rectum. Conversely the patient attending a general practitioner or family doctor with a body rash might not understand why the doctor may wish to discuss their sexual history. This can be particularly uncomfortable if the doctor is seen as a family friend and may mean that the practice nurse needs to work in a more facilitative way and give the patient ‘permission’ to talk about intimate and possibly embarrassing issues. Also, the doctor’s or nurse’s own embarrassment may present an obstacle in identifying, treating and educating their patient about STIs (Box 35.1).

The term ‘confidentiality’ implies that only the client and the providers involved in direct care have access to the client’s personal information. If there are any limitations to the boundaries of confidentiality, these should be disclosed clearly at the outset, for example, issues relating to child protection.

The environment is important when taking a sexual history. Ideally the discussion should take place in a soundproof room, preferably away from clinical areas, so that people can talk freely. The room should be comfortable and not harshly lit. Arrange comfortable seating, so that interviewer and patient are at an angle facing each other, not face on. Use the same type of chair as the patient to try and ensure a sense of equality and not of a power relationship of professional and patient. Remember, attending a sexual health clinic can be awkward and embarrassing.

Be aware of a patient’s body language, it hints at their state of mind. The patient might be attending for a wide-ranging set of conditions ranging from Candida to erectile dysfunction. They can be under enormous stress. When taking a sexual history, it is important to be non-coercive, non-judgemental and non-punitive. Use language appropriately and make sure the patient is not confused by the use of technical terms or jargon. Take into account the patient’s potential embarrassment, but make sure your meaning is clear.

History taking

Human sexuality is complex and presumptions are often wrong. Do not assume that the patient is gay or straight; it is important to ask. Use open, inclusive questions when discussing the patient’s sexual activities. History taking needs to be systematic, incorporating questions appropriate for ascertaining risks and then provision of appropriate care. Consequently, whilst taking into account the individual patient, a sexual history should include the following questions (French 2007):

• When did you last have sex?

• Was it with a man or a woman?

• Was it with a regular partner?

• What kind of intercourse was it?

• Were barrier contraceptives (condoms or femidoms) used?

• Do you or your partner/s have any symptoms?

• Have you had any other partner in the past 12 weeks? (If so, double-check partner’s gender.)

• Do you have pain during or after intercourse?

• Have you ever had a sexually transmitted infection before?

• Have you ever had a sexual health screen before? (If not, explain and reassure.)

• Have you ever been screened for hepatitis, syphilis or HIV before? (If not, explain that a blood test is involved.) It is important to reassure patients that their blood will not be tested for HIV without their informed consent. Anonymous and random testing for HIV is carried out in some clinical areas including sexual health centres; this is generally done to collect data for government health departments to measure the spread of the virus within the population and enable planning for future health care provision. There is usually an ability to ‘opt out’ if the patient is concerned but it is important to reassure the patient that they cannot be identified.

• Have you been vaccinated against hepatitis B? (If not, assess risk and offer vaccination if required.)

Parasitical infections

Common parasitical infections that may affect the genital area include scabies and lice. In addition Trichomonis vaginalis and Candida will be discussed. Strictly speaking, Candida is an opportunistic fungal infection, which does not sit clearly within the classic ‘trinity’ (parasitical, bacterial and viral infections) found in SAIs. It is normally grouped with the parasitical sexual infections.

Scabies

The parasite Sarcoptes scabiei is a tiny skin mite that is almost impossible to see without a microscope. It causes a fiercely itchy skin condition known as scabies. Dermatologists estimate that more than 300 million cases of scabies occur worldwide every year. The disease can strike anyone of any race or age, poverty and over-crowding being more associated with the transmission of scabies than personal hygiene (McCarthy et al 2004).

The mite is a tiny eight-legged creature with a round body that burrows under the surface of the skin, forming shallow burrows of up to 4 mm in length. The normal colony is made up of 10–50 mites. The scabies mite is an arachnid 0.4 mm in length which tunnels approximately 2 mm a day. The burrows are 1–4 mm in length and contain 10–25 eggs plus the mites’ waste products. The larvae take 3–4 days to hatch. The human body develops a reaction to the mite that results in severe itching that is often intense enough to keep sufferers awake at night, and frequently leads to skin infections.

Transmission

Human scabies is almost always contracted from close personal contact with someone who is already infested. Amongst adults the most common source of infection is a sexual partner (Walton & Currie 2007). Some people react more severely than others, and rarely an infected person may hardly itch at all. The mite is attracted to the warmth and odour of the body. The female mite is drawn to a new host, making a burrow, laying eggs and producing secretions that cause an allergic reaction. Larvae hatch from the eggs and travel to the skin surface, lying in shallow pockets where they will develop into adult mites. It may be 4–6 weeks before a newly infected person will notice the itching or swelling that can indicate the presence of scabies. In cases of reinfestation, established hypersensitivity may lead to symptoms within 1–3 days (Chosidow 2006).

Clinical presentation

The earliest and most common symptom of scabies is itching, particularly at night. An early scabies rash will present as little red bumps, like hives, tiny bites or pimples. In more advanced cases, the skin may be crusty or scaly. Scabies will usually begin in the folds and crevices of the body, particularly between the fingers, under the arms, on the wrists, buttocks or belt line and on the penis. Mites also tend to hide in, or on, the skin under rings, bracelets or watchbands or under the nails. The head and face are not affected, except in children or those with a compromised immune system.

Diagnosis of scabies is usually by means of direct examination of skin scrapings, epiluminescence microscopy, identification of the burrows or epidemiological diagnosis. An epidemiological diagnosis is one where all signs and symptoms point to a specific cause, but as yet there has been no laboratory confirmation.

Nursing management and health promotion: scabies

The patient’s household contacts and sexual contacts during the month prior to diagnosis will require treatment. All household contacts will be required to take treatment at the same time.

Two treatments are available:

• permethrin 5% dermal cream applied to the whole of the body below the neck and washed off after 8–24 h, according to the manufacturer’s instructions

• malathion 0.5% in an aqueous lotion applied to the whole body below the neck and washed off after 24 h.

The cure rate is 95% with one application; however, it is important to warn patients that the intense itching might continue for several weeks. This is because proteins from the dead mites and the faecal waste left behind in their burrows can continue to trigger an immune response, even though the infestation has been successfully treated. Practitioners need to monitor treatment compliance, but should resist the automatic assumption of re-infestation and thus unnecessary re-treatment. Potentially contaminated clothing and bedding should be washed at a temperature of over 50°C as it is thought that mites may survive for up to 72 h when separated from their human host.

Crusted (Norwegian) scabies

Crusted or Norwegian scabies is caused by exactly the same mite as found in standard infestations, the main difference being simply the number of mites present on an infected person. In regular scabies, the number of mites on a host at any one time is, on average, 10–15 (with a range of 3–50). Persons with crusted scabies, on the other hand, will have thousands to millions of mites. Consequently their skin manifestations are much more severe, with thick, hyperkeratotic crusts that can occur on almost any area of the body. This form of scabies affects frail elderly people, often those in residential care, and patients who are immunosuppressed, such as those who are HIV positive (Johnston & Sladden 2005).

Nursing management and health promotion: crusted (Norwegian) scabies

As with all types of scabies, the patient’s household contacts and sexual contacts during the month prior to diagnosis will require treating. All household contacts will be required to take treatment at the same time. Crusted scabies can be treated with two doses of oral ivermectin, 2 weeks apart. The actual dosage required is dependent on body weight (Johnston & Sladden 2005).

Pediculosis

The most common parasitic infection pediculosis is an infestation by Pthirus pubis, otherwise known as the pubic louse or crab louse. The pubic or crab louse is quite distinct in appearance; it has pincer-like claws resembling those of sea crabs. These claws on their legs are adapted for feeding and clinging to hair or clothing. Lice are blood-sucking insects that move freely and quickly, which explains their ease of transmission. The eggs (nits) are attached to the hair shaft, close to the skin surface, where the temperature is optimal for incubation. The eggs hatch in about 8–10 days. Nits are cemented to the hair shaft and are very difficult to remove. The eggs themselves are encased in an armoured material known as chitin and are well protected.

Clinical presentation

Pubic lice may be found on the short hairs of the body, areolar hair (around the nipple), axillary hair, beard, scalp margins, eyebrows and eyelashes, in addition to pubic hair. Pubic lice are spread through sexual activity but can also be passed on through contact with infested clothing or objects, such as bedding, combs or hats. Pubic lice can only live for a short period of time away from their natural habitat, coarse body hair. Those found on bedding or clothing are often physically damaged and have lost their ability to grip. However, they can remain viable and active for several hours whilst off the host’s body. Pubic lice cause the infected person to itch as the lice suck blood. The lice do not produce a rash, but constantly scratching the skin could cause irritation. In addition, some people have an inflammatory skin reaction to the louse’s bite. The insect is about 2 mm in diameter and has a 30 day lifespan, feeding approximately 12 times a day. It lays up to 10 eggs per day. The chitinous envelope that makes up the egg casing is known as the nit. Larvae take 8–10 days to hatch and the larvae take another week to mature fully into adult lice.

The lice can be seen by the naked eye upon close inspection, and with a magnifying lens the eggs or nits can be seen; these are usually attached near to the base of the pubic hairs.

Nursing management and health promotion: pediculosis

Infestation with Pthirus pubis is on the whole a sexually transmitted infection, and 30% of these patients have a second STI. Therefore the nurse needs to bear in mind the need for a full sexual health screen (Varela et al 2003). If a patient has been infested with pubic lice they often feel ‘unclean’, particularly as the parasites are visible. The nurse needs to reassure the patient that the infestation, although easily acquired, is readily treatable and eradicable. It is important to remember that sexual partner(s) require treatment.

Pubic lice can be treated and destroyed with one application of a prescription medication or over-the-counter shampoo.

• Malathion 1% in a shampoo base (Derbac-M) is applied to pubic hair and body hair other than the scalp. It should be left on for 5 min and then rinsed. Application is repeated after 7 days.

• Permethrin 1% cream rinse in an alcohol base (Lyclear) is applied to pubic hair and body hair other than the scalp. It should be left on for 10 min and then rinsed and dried.

In the case of pediculosis of the eyelashes, treatment is with occlusive ophthalmic ointment, which is applied to the eyelid margins twice a day for 10 days. Occlusive ointment works by occluding or blocking the breathing holes found in the mites’ skin, thus suffocating them.

Candidiasis (vaginal thrush)

The causative organism is usually Candida albicans. Most women will have an episode in their lifetime. The yeast normally lives in the gut, mouth and genital tract, thriving in warm, moist and dark environments. The vagina can be considered an ideal environment for growth of this infection, since semen, menstrual blood, pregnancy and feminine hygiene products can all change the pH of the vagina. Some cultures resort to vaginal douches with home-made or proprietary preparations immediately after penetrative intercourse, in an attempt to prevent conception or infection. They are also used as a means of ‘improving’ feminine hygiene. This practice should be discouraged as it adversely affects the pH values of the vagina. Changes in pH create an imbalance that predisposes to the development of thrush. Additional risk factors include diabetes mellitus, hormone replacement therapy (HRT), the oral contraceptive, antibiotic therapy and immunodeficiency (Barousse et al 2004).

Transmission can be by sexual intercourse, during foreplay and by oral–genital contact. Men are more likely to acquire the infection during sexual activity, whereas women are more likely to acquire it as a result of the factors identified above. The incubation period is between 2 and 5 days.

Clinical presentation

Signs and symptoms include intense pruritus (itching) that is often worse at night, vaginal soreness, white patches on the vulva/vagina, sometimes dysuria (pain when passing urine), creamy white vaginal discharge and balanitis (inflammation of the glans penis) in men, although these signs are non-specific. Diagnosis is by examination and microbiological investigation.

Nursing management and health promotion: candidiasis

Antifungal drugs such as clotrimazole, miconazole and nystatin are commonly used as creams and pessaries in the management of this condition. Systemic treatment by fluconazole capsules may be necessary if symptoms persist. Sexual partners with symptoms should also be treated as they may cause re-infection. Some patients prefer to use one of the many traditional and alternative therapies, e.g. oral garlic supplements and dietary changes.

Trichomoniasis

Trichomonas vaginalis (a protozoon) causes trichomoniasis and is exclusively a sexually acquired disease in adults. This is a very common infection. Trichomonas causes disease in the genital tract, affecting the vagina and urethra. Transmission is by contact with vaginal or seminal fluid; the protozoa can last for several hours outside the body.

Clinical presentation

The signs and symptoms include profuse vaginal discharge (offensive, yellow, thin, frothy and irritating), dysuria, vulval soreness and lower abdominal pain, although men can remain asymptomatic. The incubation period can be up to 4 weeks, although this can be dependent on the menstrual cycle. It can be difficult to diagnose in men due to the lack of distinct symptoms, and although there are difficulties, it is vital to trace sexual partners.

Nursing management and health promotion: trichomoniasis

Diagnosis is by examination (the vaginal walls and cervix may be inflamed). A high vaginal swab is taken for culture, microscopy or, where available, a screening test known as latex agglutination (Adu-Sarkodie et al 2004). Treatment options include the antibiotic metronidazole, given to both partners over 5 days. This should be taken with food, and alcohol and sexual activity should be avoided during the treatment programme.

Bacterial sexually acquired infection

Sexually acquired bacterial infections can range from the relatively innocuous to the life threatening. They encompass a wide range of symptoms and may even be symptom free. If they have been screened for and detected, most bacterial infections can be successfully treated.

Bacterial vaginosis

This is a condition caused by overgrowth of the vaginal commensal microorganisms, associated with changes in the normal pH values of the vagina. If the mildly acidic environment of the vagina is subject to disturbance, the normal acid-producing lactobacilli of the vagina are supplanted by anaerobic bacteria. This initiates an increase in vaginal discharge and an increase in the pH of the vagina to above 4.5. Bacterial vaginosis (BV) may or may not be sexually transmitted; its aetiology remains unclear (Wilson 2004). The bacterium most associated with BV is Gardnerella vaginalis although it is suspected that several other organisms may be implicated. The presence of Gardnerella vaginalis does not necessarily mean the woman will be symptomatic (Smart et al 2004).

Clinical presentation

Women complain of a thin, grey-white vaginal discharge that has a ‘fishy’ odour. The nature of the discharge can be very distressing and women are embarrassed and acutely aware of the associated odour. The odour is caused by the release of amines, a product caused by changes in the pH value of the vagina and which releases the distinct smell of ammonia.

Nursing management and health promotion: bacterial vaginosis

On microscopic examination of vaginal secretions, characteristic clue cells can be seen. These are epithelial cells covered in a profusion of mixed bacteria which obscures the outline of the normally clearly delineated cell wall. In conjunction with the distinctive smell of BV, a raised vaginal pH value and the presence of the offensive discharge, clue cells help diagnose the presence of BV (Keane et al 2005).

The causes of BV are not known for certain. The pH value of the vagina can be disturbed by the presence of seminal fluid. Similar untoward disturbances can be caused by the use of strongly scented soaps and feminine hygiene products. The practice of douching (washing out the vagina after penetrative sex), common in some cultures, should be discouraged by the nurse as this appears to alter vaginal pH balance.

There are potentially serious complications of BV. Its presence has been implicated in an increase in risk of acquiring and transmitting HIV as well as other SAIs such as Trichomonas vaginalis and chlamydia (Livengood 2009).

Treatment of BV is straightforward and consists of metronidazole for 5 days. Alcohol must be avoided during treatment, as should sexual intercourse.

Chlamydia

Chlamydia is caused by the bacterium Chlamydia trachomatis. It is the most common sexually acquired infection in the UK (HPA 2009). It is particularly common in young, sexually active women (16–19 years). It is thought that younger women tend to have more sexual partners than older women and perhaps lack the skills and experience to negotiate safer sex, making them more vulnerable to infection. In men, the highest incidence of chlamydia is between the ages of 19 and 24.

Chlamydia is a potentially serious infection and has a number of complications; therefore early detection and treatment are important. However, many patients are asymptomatic (see below) making early investigation and detection less likely.

Testing for chlamydia now involves the use of molecular biological tests to detect chlamydial DNA in urine and vaginal, cervical and vulval swabs. A national screening service for chlamydial infection was introduced in the UK during 2002 to 2003. This offers screening in non-traditional venues, in an effort to increase the number of participants. The screening programme has adopted non-invasive or self-administered tests involving urine samples and vaginal swabs (LaMontagne et al 2004).

Clinical presentation

Many patients with chlamydia (80% of women and 50% of men) are asymptomatic. However, women may present with:

• postcoital or intermenstrual bleeding

• purulent vaginal discharge

• lower abdominal pain

• proctitis (inflammation of the rectum).

The presentation in men includes:

• urethral discharge

• dysuria

• testicular/epididymal pain

• proctitis.

Chlamydial infection leads to a number of major complications in women. These include pelvic inflammatory disease (PID), which can be defined as infection and resultant inflammation of the upper genital tract that may ascend to the fallopian tubes, ovaries and surrounding structures (Ross 2001). Commencing sexual activity under the age of 20, non-white ethnicity, and not having had children all increase the chances of developing PID (Simms et al 2006). PID can cause chronic pelvic pain and significantly increases the risk of ectopic pregnancy and infertility. Specific aspects of PID can include endometritis (infection of the lining of the womb) and even salpingitis (inflammation/infection affecting the uterine tubes). This is a consequence of ascending infection as described above and can cause acute abdominal pain. Long-term damage to pelvic organs can result, causing infertility.

In men, chlamydial infection can spread to the upper genital tract causing inflammation of the epididymis and testes (epididymo-orchitis) (Fenton et al 2001).

Nursing management and health promotion: chlamydia

Sexual intercourse should be abstained from during the treatment programme. Antibiotics such as doxycycline can be used provided the patient is not breast feeding or at risk of pregnancy. A single dose of azithromycin is becoming a popular mode of treatment; giving a single dose of an antibiotic avoids the problems with patient compliance frequently experienced with treatment involving a week of doxycycline. An alternative treatment is erythromycin.

Partner notification must be discussed with patients. It is essential that all recent (previous 3 months or previous partner if longer) and current sexual partners should be informed and advised to attend for assessment. Without treatment the reproductive system of both sexes can be severely damaged, in addition to the continued transmission of the infection.

Non-specific urethritis (NSU)

This condition only affects men. It is an inflammation of the urethra and is called ‘non-specific’ because there are a range of different causes, of which chlamydia is the most common. Other sexually transmitted infections may be implicated; there is increasing evidence that Mycoplasma genitalium is associated with this condition (Moi et al 2009). Urine and/or bladder infection may cause NSU, but this is quite unusual, particularly in younger men. Another cause is injury during sexual activity; the urethra is delicate and may be damaged during vigorous sexual activity, leading to NSU.

Clinical presentation

Many men notice a clear (sometimes cloudy) discharge coming from the end of their penis which is associated with pain, irritation or discomfort on passing urine.

Nursing management and health promotion: NSU

NSU can usually be successfully treated with doxycycline. It is important to ensure that sexual partners are also seen and examined and treated as necessary to prevent re-infection. Damage to the urethra takes a few weeks to heal and therefore it is best for patients to avoid sexual intercourse until there is no sign of the infection and sexual partners have also been treated.

Anxious patients should be discouraged from over-examination of their genitals following a diagnosis of NSU. Squeezing the penis or, for example, using disinfectants when worried about an unresolved infection might cause further inflammation of the urethra.

Gonorrhoea

Gonorrhoea is caused by the bacterium Neisseria gonorrhoeae, which infects the mucosal surfaces of the genital tract, rectum and oropharynx. The infection is always transmitted by sexual contact; however, eye infections can occur in infants during birth, and gonococcal vulvovaginitis in young girls can result from sexual abuse. The incubation period is around 24 h. Gonorrhoea is usually symptomatic within 3 days but can take up to 5 days. It is highly infectious. Currently gonorrhoea is most commonly seen in minority ethnic groups, homosexuals, women aged 16–19 and men aged 20–24. Uncomplicated gonorrhoea is the second most common bacterial SAI (HPA 2009).

Clinical presentation

The signs and symptoms of gonorrhoea depend on the site of infection but include urethritis (causing dysuria and purulent discharge), cervicitis (inflammation of the cervix causing vaginal discharge), proctitis with discharge and pharyngitis. However, many patients, especially women with uncomplicated infection, are asymptomatic. It is important to note that:

• 85% of men with urethral infection develop symptoms within 2 weeks

• rectal infection may be asymptomatic

• pharyngeal infection may be asymptomatic

• cervical infection in women is often asymptomatic.

Complications of gonorrhoea in men include formation of abscess, epididymitis, prostatitis and urethral strictures (see Ch. 8). Women may develop endometritis, ovarian abscesses, salpingitis and infertility, and bartholinitis (see Ch. 7). Gonorrhoea is diagnosed by microbiological examination of a swab of the discharge to identify the microorganism. In addition, patients should be screened for concurrent SAIs, especially chlamydia and trichomoniasis.

Nursing management and health promotion: gonorrhoea

In the past Neisseria gonorrhoeae proved sensitive to penicillin. However, as resistant strains of gonorrhoea have become more common, treatment options have evolved. A single dose of intramuscular ceftriaxone or oral cefixime is the treatment of choice (British Association for Sexual Health and HIV Clinical Effectiveness Group [BASHH] 2005). Single-dose treatments are used wherever possible as they overcome problems of non-compliance with medication regimens. Patients are asked to abstain from sexual activity until a second test confirms that treatment has been effective. The opportunity should be taken to advise patients about the use of condoms in preventing the spread of SAIs.

Contact tracing with partner notification must be discussed with patients but it is essential that all recent (previous 2 weeks or previous partner if longer) and current sexual partners should be informed and advised to attend for assessment. After treatment, patients should be encouraged to return to clinic for a test of cure some 3–5 days after completing treatment.

Lymphogranuloma venereum (LGV)

LGV is caused by specific sub-types of Chlamydia trachomatis that attack regional lymph nodes rather than mucocutaneous tissue, which is more usual. Until recent years, LGV was an almost forgotten infection in the industrially developed world. However, it remained endemic in Africa, the Caribbean and parts of Asia. Since 2004 there has been an increase of LGV in the industrialised West, in particular, although not exclusively, amongst men who have sex with men (MSM) (Ward & Miller 2009).

Clinical presentation

LGV is normally associated with inflammation of the inguinal lymph nodes with possible abscess formation. In the current resurgence of LGV amongst MSM, proctitis (an inflammation of the rectal mucosa) is often the presenting condition. Currently, in the Western world, LGV diagnosis appears to be closely associated with co-infection by HIV and other SAIs (Sethi et al 2009). If left untreated LGV may cause inguinal bubo (a highly inflamed, infected lymph node) with fistula formation and significant scarring.

Nursing management and health promotion: LGV

Nurses will need to ensure that patients understand the need to complete treatment, as a rather lengthy course (3 weeks) of oral doxycycline twice daily is required. Alternatively erythromycin may be used if a patient is allergic to doxycycline or pregnant (Klausner & Hook 2007). If a patient is diagnosed with LGV, it would be appropriate for the nurse to discuss HIV screening, given the association between the two infections.

Syphilis

Syphilis is a potentially lethal infection if left untreated and has a complex pattern of development (Box 35.2). Once thought to be in decline in industrialised countries, syphilis diagnoses have increased in recent years, generating concern (Simms et al 2005, Kerani et al 2007).

Box 35.2 Information

(from Brooker & Nicol 2003)

The stages of syphilis – clinical presentation

Primary

Two to four weeks after exposure, a papule develops (at the site of infection) and ulcerates, becoming a hard, painless ulcer known as a chancre. There is swelling of local lymph nodes. The ulcer is highly infectious. It usually heals within a few weeks.

Secondary

A few months after the ulcer has healed, there may be a generalised ’flu-like illness with fever, sore throat and non-specific pain. Clinical signs of secondary syphilis may be present and include generalised lymph node enlargement, skin rashes, warty areas (condylomata lata) in the perianal and other moist body sites, and mucosal ulcers in the mouth/external genitalia (also called ‘snail-track’ ulcers).

Latent

The person is well but serological tests for syphilis are positive. This stage may last for years.

The causative organism is Treponema pallidum, a corkscrew-shaped motile bacterium that is transmitted sexually and vertically (in utero). Treponema pallidum enters the body via skin and mucous membranes through macroscopic and microscopic abrasions during sexual contact. The spirochaete, a bacterium, disseminates itself by travelling via the lymphatic system to regional lymph nodes and then throughout the body via the bloodstream.

Tertiary (late) syphilis disease progression

Approximately 30% of untreated patients progress to the tertiary stage within 1–20 years. Clinically, this final stage may manifest as encapsulated, necrotic lesions known as gummata. Gummata are found in soft tissue or viscera and can also erode bony surfaces. As well as involving the skin and bones, tertiary syphilis may also attack the cardiac and central nervous systems causing cardiovascular and cerebral vascular damage (Box 35.3). Cardiovascular syphilis often involves the aortic arch, causing aortic incompetence or a saccular aortic aneurysm. The usual period in untreated syphilis from primary infection to development of the aneurysm is 10–15 years (Bossert et al 2004). Neurological manifestations of syphilis include meningovascular damage leading to strokes. In addition there may be the development of tabes dorsalis, a form of ataxia caused by syphilis attacking the neurological system, and possibly the development of general paresis (Goh 2005).

Congenital syphilis

Transmission to the fetus can occur during any stage of syphilis, but the risk is much higher during pregnancy with primary and secondary syphilis. Fetal infection can occur during any trimester of the pregnancy. Treatment of the mother during the last month of pregnancy cannot be considered adequate treatment for the fetus.

The manifestation of early lesions in infants less than 2 years old is usually inflammatory and may involve the development of blisters on the skin, mucous membranes and bones. In addition the spleen and lymph glands may be inflamed. Haematological abnormalities may include thrombocytopenia and anaemia (see Ch. 11). The manifestation of late lesions in infants older than 2 years tends to be immunological and destructive. A chronic inflammation of the middle layers of the cornea known as interstitial keratitis may occur. Less commonly nerve deafness or developmental abnormalities of the teeth and long bones may be found.

Diagnosing syphilis

Given the complexity of syphilis, a close examination and a careful medical history is required. Confirmation of diagnosis is dependent on serological tests that are used to detect the presence of antibodies. The tests include the fluorescent treponemal antibody absorbed test (specific test) and the rapid plasma reagin test (non-specific test). Primary syphilis may be diagnosed by confirmation of the presence of the microorganism in exudates obtained from the ulcer (chancre). This requires a nurse or technician who is familiar with dark ground microscopy.

Interaction between syphilis and HIV

The lesions associated with syphilis allow easier transmission of HIV. Syphilis and HIV infections commonly coexist and, in general, the clinical course is similar to non-HIV-infected patients. However, it has been suggested that in cases of co-infection with both syphilis and HIV, there is likely to be a higher viral load of HIV and a lower CD4 count (Buchacz et al 2004). The reasons why this should be are not fully understood; however, it has been demonstrated that successful treatment of syphilis is followed by a decrease in HIV viral load and a rise in the patient’s CD4 count (Kofoed et al 2006). In addition, in cases of co-infection the chancre of primary syphilis may be multiple and deeper than the classic presentation (painless and solitary) (Zetola et al 2007). Some research notes that the symptoms of secondary syphilis are on occasion more severe and neurosyphilis more likely (Lynn & Lightman 2004). In the vast majority of patients serological tests for syphilis are equally sensitive in both HIV-infected and non-infected persons. However, if clinical suspicion is high for syphilis and the serological tests are negative, biopsy of the lesion or rash is recommended.

Nursing management and health promotion: syphilis

In cases of co-infection, conventional therapy as given in syphilis alone is usually effective. However, some investigators believe in cases of co-infection, patients are more likely to present with or develop neurosyphilis and require a more intensive course of antibiotics (Goh 2005). The antibiotic chosen and duration of treatment depend on the disease stage: intramuscular procaine penicillin (or oral erythromycin if allergic to penicillin) or oral doxycycline and oxytetracycline are used. Patients having penicillin should be warned about the possibility of experiencing a Jarisch–Herxheimer reaction. This is characterised by fever, chills, nausea, muscle pain, dizziness and headache and is thought to be caused by toxins released when the microorganisms are destroyed (Pound & May 2005). The reaction occurs within a few hours of having the penicillin and is usually short-lived.

Patients should also abstain from sexual activity during antibiotic treatment and continue to use a barrier method (i.e. condoms) at least until blood tests show that the infection has passed. However, the benefits of condom use in preventing further infection should be stressed. As with all sexually acquired infections, patients found to be positive for syphilis require screening for other SAIs and should be encouraged to undergo screening for HIV.

Viral sexually acquired infections

As in the case of bacterial sexually acquired infections, viral infections can range from the relatively innocuous to the life threatening. However, in the case of viral infections our ability to cure is restricted. For most viral sexually acquired infections, at best we can ameliorate symptoms for what often becomes a chronic condition.

Genital herpes

This highly contagious viral disease is transmitted through close physical or sexual contact and is caused by the herpes simplex virus (HSV). Once acquired, HSV remains in the body, lying dormant within nerve roots. In most patients the virus intermittently works its way along the nerve root to the surface of the skin, where it may cause symptoms. There are two types of HSV, both of which infect the skin and mucous membranes: HSV-1 commonly causes cold sores, and HSV-2 infects the genital areas. In addition, HSV-1 is frequently the cause of genital herpetic lesions. If a person contracts HSV, they may be subject to repeated symptomatic episodes (Sen & Barton 2007).

Genital herpes is often asymptomatic; in fact, most cases are transmitted when the partner with HSV is symptom free (Box 35.4). The virus remains latent indefinitely and reactivation can be precipitated by multiple known and unknown factors which then induce viral replication. The efficiency of sexual transmission is greater from men to women than from women to men, although it is thought that the likelihood of transmission to others declines with increased duration of infection. The incubation period after acquisition is 2–12 days although the average is 4 days. Genital HSV infection will increase the risk of both acquisition and transmission of HIV infection.

Box 35.4 Reflection