Hey guys it's Dr. Baker Townsend and I'm going to talk to you about sexually transmitted infections. This is on page 145 to 165 of your book in chapter 7. So here's some learning objectives that you can kind of go through and it just talks about the STIs that we're going to talk about today. So primary prevention for STIs, that means never acquiring the STI in the first place. So how do you do that? You have the patient use a condom or some type of barrier method.
Condom is the best. Or you can use abstinence. Abstinence is strong. 100% effective in preventing STDs or STIs.
Secondary prevention, so what we do is we identify populations that are at high risk and we screen them and we take the those patients and we then, through the screening measure, find out who's positive and then we can do more sophisticated testing if we need to. So we usually test everybody under the age of 24 who's sexually active, is their high risk group or any high risk groups, people who are having multiple sexual partners, that would be another high risk group. So we screen them. We want proper diagnosis and treatment so that we can prevent that STI.
which causes inflammation we can prevent that from causing inflammation of the cervix of the uterus of the fallopian tubes of the ovary we don't want that chronic inflammation because that can cause scarring and it can decrease fertility also secondary prevention we want to identify the people who do have an STI so we can treat them or advise them that they have a viral STI and prevent the spread of the disease to another person. So how do we further risk reduction measures? Know your partner.
Of course, random hookups are notable for STI acquisition. Reducing the number of partners, low-risk sex. that would be with a single partner and use of barrier protection. Avoid exchange of body fluids and of course vaccination for like hepatitis B which is viral or HPV. So other measures, of course physical barriers are great, condoms, chemical barriers, noxanol-9 which is a spermicide, it actually helps to kill some of the viruses.
Communication of coercion want to talk to the person and make sure that you know their sexual history, they know yours, and that you're both tested, attention to their response. And then the nurse is responsible for educating the woman that use of the... condom is her choice that she can avoid having sex with someone if they don't want to use a condom so you have to like kind of empower her and help her to understand that she needs to communicate that and then again vaccination all right so chlamydia this is the one we see most often sadly chlamydia trachomatis so it's the most common and fastest spreading sti sadly it can be very silent In the last five or seven years, I've done so many exams on women that I did not see them have any discharge at all, no irritation, no cervical irritation, nothing. And then they come back positive for chlamydia, which is really scary because that whole time there's inflammation that's just causing damage to the tissues and could cause scarring, which can lead to infertility.
So this is why we screen for it for everybody sexually active under the age of 24, somebody with a new sexual partner. screening and diagnosis we always we always screen people who are asymptomatic and pregnant women if they're sexually active up to the age of 24 and then all pregnant women because we definitely do not want inflammation of the cervix of the uterus because we know that can cause a preterm delivery So how are we going to treat them? We can give them doxycycline or azithromycin.
Of course, we want their partners treated. In Jacksonville, we really don't, well, we encourage the partner to go get tested and treated so it's documented. So we don't treat their partner at the same time. Some people come into the health clinics wanting their partner to have treatment without an exam and a lot of times we do not do that. We don't do that but a lot of places will not do that.
Of course we want to get rid of the chlamydia. and so what we'll do is we'll tell them okay so here's your treatment and we'll it's a one-time dose with azithromycin with doxycycline however it can be a seven-day course and we tell them that they need to get your treatment and then their partner needs to go get assessed and treated because they can have additional STIs we just don't know that's what we want them to be assessed they need to get treated but they should not have intercourse until they are both treated and it's seven days from the last partner's treatment so say for instance she came in and got treated today and Bill comes in and gets treated on Friday he takes this one gram of it or his two grams of the zithromycin he takes the one-time treatment um then he should they should wait a week from friday to become sexually active again because we want to make sure that the bacteria is dead next one is gonorrhea um gram nocative diplococci Oldest communicable disease in the U.S., second to chlamydia in reported cases. Of course, it can be spread very quickly.
Jacksonville is notorious for bacterial or antibiotic resistant. gonorrhea which was really scary and many times women can be asymptomatic. Chlamydia and gonorrhea are best friends.
Wherever gonorrhea goes chlamydia likes to hang around so a lot of times you will see them together on diagnosis. So we want to screen everyone for gonorrhea that's in the high risk group of course under the age of 24 or if they have a new partner or if you're at risk at all. testing should be performed for pregnancy in the first trimester, like we already know. And then, of course, at 36 weeks, because we know that if the neonate is exposed to gonorrhea and the vaginal canal, this can result in blindness.
So we definitely want to treat her before the delivery. And of course, it's a reportable disease. So what is the management? Rocephin or ceftriaxone.
And so if you get treated for gonorrhea, you're also going to get treated for chlamydia because they are best friends. If you get treated for chlamydia and you test negative for gonorrhea, you're only going to be treated for chlamydia. And then we've already talked about the perinatal complications that can result. Next one is syphilis and it's caused by trypanema palladium.
It's a spirochete. It's this little round spirochete that looks like this and it causes massive inflammation all through the genital tract. It was very early described STI. Transmission enters through the tissue and microscopic abrasions.
transmitted through kissing, biting, and oral genital sex. Transplacental transmission can occur and that is very scary. In Jacksonville we've had eight deaths in two months over the last little while here so it's It's terrible because if you get it in early pregnancy, the spirochete can damage the developing tissues. And so these deaths are unacceptable.
These women did not have prenatal care, but they did have death of their children just simply from an STI, which we did not like, especially because it could have been treated. okay so I want to show you about syphilis because it's a very interesting STI it can lead to system systemic disease and death if you don't treat it so it's interesting that during the initial stages when someone first gets it and I know these are different because this is from the CDC and this was from your book but stage one is from three to five days to 90 days after exposure and all they get is a painless shanker it It looks like a cigarette burn, but you guys, they have no pain with it. And it just is this ulcerated, you know, awful looking lesion. And then it goes away. Secondary is six weeks to six months.
And you can see the CDC says four weeks to 10 weeks after initial infection. And so you guys, this is gone. This painless shanker is gone. And then they develop a rash. It's usually on their hands, on their palms, and on their feet.
It can be in different parts of their body as well. Very scary that once this goes away, then it affects all the internal organs. You can have cardiac disease, liver, neuro.
any of these diseases because it just lies there and causes damage to the internal organs. Here's the initial lesion and then here's one on the penis because I wanted to show you a good picture. It looks punched out. It's painless and derated, raised border, smooth. It really doesn't have a lot of secretion.
So we're going to screen women, of course, anybody who's in a high risk, of course all pregnant women. And we're going to do an RPR or rapid protein reagent or a VDRL, which is a veneer-realtor- research laboratories that is only a screening test so if that comes back positive then we're going to do a confirmatory diagnostic test because we have a lot of false positives with this screening test if you have lupus or any major autoimmune disease you can have a false positive result and so we don't want to treat a false positive if it's a if it's a positive on the screen again we're going to do it we're going to send it for a diagnostic to make sure what is the management how do we take care of it penicillin of course we want sexual abstinence during the treatment and up to one week after both partners have been treated pelvic inflammatory disease is when any of these infections just continue to irritate all the tissues and you can have lesions you can have scarring all Inside of the cervix, inside of the uterus, inside the fallopian tubes, inside of the ovaries. You can have it in the urinary system, in the bladder, in the ureters, and it can go up into the kidneys as well. So who's at risk? Risk factors, young age, never had a baby, multiple partners, a lot of new sexual partners, history of STIs, and previous pelvic inflammatory disease.
People who have had pelvic... inflammatory disease or at risk for ectopic pregnancies? Well, that's because there's more scar tissue. There was inflammation, let's just say in your fallopian tube. So there was a lot of inflammation there that created scarring and damage to that fallopian tube.
When there is fertilization in the fallopian tube and then the cilia and the peristalsis is diminished due to the scar tissue that replaced it from the inflammation the fertilized ova may sit in the fallopian tube and start to develop instead of coming down and dropping into the uterus of course infertility in chronic pelvic pain because you have all this scarring there And here's just another picture of it. So you can see all this inflammation inside the cervix, inside the uterus. You can have abscesses in the fallopian tube, in the, oh my goodness, like in the ovary.
I mean, this is painful. It can cause massive infection and scarring. So our goal is to identify the people who are at risk for STIs, screen them, treat them before it ever develops into public inflammatory disease.
So depending on the type of infection, if it's acute and you're pregnant, you're going in the hospital because we know that it is a serious risk for premature delivery. Subacute would be it's not as pronounced, although you have it, it's not as pronounced. We can do a regimen that is outpatient, but if you're febrile with flank pain, and uterine tenderness, cervical motion tenderness, and again, you're female, we may go ahead and admit you to the hospital. Chronic is you just continue to get it back. We keep screening and doing outpatient regimens.
It's just really sad to see these chronic cases because they get cleared up and keep coming back, and we know they have a lot of inflammation, infection. So screening and diagnosis, we look at their history, number of partners, previous STIs, and then CDC has a... a criteria for screening for PIDs based on the number of times they've had it.
Management prevention, of course, hospitalization. if they're febrile and then education on how to prevent it from happening again. HPV, the human papillomavirus, it's very very common.
80% of all people have it. It can produce condyloma accumulata which are venereal warts and that's what you see around. here.
It affects more than 20 million Americans. It's the most prevalent STI that we see. It used to be called genital warts or venereal warts and we do see a lot of it in pregnant women.
because pregnancy lowers your immunity and with every viral infection I'm sorry, my printer is printing. It's a wireless printer and one of my family members has sent a print job to the printer So I apologize for that noise that you're hearing But pregnant women We know that they have a decreased immunity during pregnancy and so these nasty viral STIs can raise their ugly head so human papillomavirus we screen people we if they have a known exposure if they say they've had intercourse with somebody with warts then we know that it can be a serious risk that they have it physical inspection we look and then we do a pap smear pap smear is actually the tests for HPV that's cervical cytology and then we have a separate HPV test that we can do as well for women 30 years and over so we start screening so we know that the human papillomavirus there is 16 and 18 are the most notable types of the human papillomavirus that produce cervical oral anal rectal esophageal and vaginal cancers those are the most two prevalent ones but But 31, 33, 45, 52, and 58 can also produce cancer, and they're oncogenic. So we really worry about these people coming into contact sexually with these particular types, and then it causing changes to the cervix. So then we do a pap smear, which is simply getting a scrape of the cervix to see if we see any precancerous changes or any cancerous changes.
changes. Gardasil also added numbers 6 and 11. HVP type 6 and 11 produced 90% of all genital warts. So not only is it a cancer vaccine, but it's a vaccine to prevent disfigurement for for you know especially teenagers with body image issues at risk. for warts because sadly we have to you know do treatments for warts people come in we can give them medications that they can do at home but it takes 12 to 16 weeks for these medications to work we can freeze them we can use acid on the genital warts and people just don't like it and they hate the way they look.
So, I mean, I always encourage everyone to get a cancer vaccine, which is Gardasil, and then you have the benefit. of not getting the vaginal warts. 90% of the vaginal warts accompanied.
I do want to say one thing that there's a lot in the media and in the lay community that Gardasil is the scorable vaccine. It is not. There's no evidence to support claims that the cheerleader walked backwards and that there were, you know, a lot of deaths and all these things.
The bottom line is with any vaccine, there are risks and benefits. And so if you have a history of Guillain-Barre, if you have a history of any type of autoimmune problem, seizures, anything that has come about as a result of a vaccine, which it can come as a result of any type of infection. I mean, a vaccine really protects you, but, you know, you can have seizures that are brought on by infection. You can have seizures brought on by infection.
on by viruses so if you have those history you may want to think twice about getting any vaccines i'm a big proponent of all vaccines but there are people who should not get vaccines you know people who are allergic to them people who have autoimmune disorders that it's not recommended some people with egg allergies and you know so you just got to be super careful but the majority of people have no problems with most vaccines and especially this one. It's just really the uneducated I could say the uneducated conspiracy community really did a number on this one. This is certainly a cancer vaccine.
And we've talked about all of these, removal, medications, and then counseling. We want to talk to patients about the spread. Herpes, HSV. one and hsv2 herpes one and two um we always think of herpes one um being on your face or lips and herpes two being in your genitals unfortunately you can get herpes two in your region with oral sex and you can and same thing with herpes type 2 you can get in the oral regions with oral sex so regardless it's the herpes simplex virus and we treat it just the same we don't even type them we don't want it we don't care if it's type 1 or 2 it doesn't matter the treatments the same and it can cause the same kind of problems most people when they initially get exposed to the herpes virus they get primary herpes herpes, which is a terrible, makes them feel awful. They have, um, the initial infection causes, um, painful, a lot of painful lesions, fevers, chills, malaise, and severe dysuria.
I mean, they feel so bad. They feel like they got a really bad, bad flu and plus they have this outbreak that is really bad so after primary herpes usually they never have that level of infection again they'll just have a lesion so it can be chronic and reoccurring there's no cure so we give antivirals we you know most notably talk about a Valtrex and a Cyclovir for these infections what we do is if we know a mother has a history of herpes type 1 or 2 we're going to start her and especially in the genital area we're going to start her on valtrex or acyclovir at 36 weeks just to prevent an outbreak because we know that moms transmit the virus during the viral shedding phase when there's not actually a lesion seen and we do not want a baby to get herpetic meningitis. Neonatal herpes is the most severe complication and most mothers lack the history of HSV. So what's really sad is they could have gotten one lesion. They may never have had primary outbreak.
They didn't have all the malaise, the fever. a lot of lesions they can have had one lesion and then since they're at a state of altered immunity during pregnancy they had another outbreak they just feel a tingle in their genital area and that can transmit it to the baby and they had no clue that they even had it so that can be very upsetting and deathly to the baby hepatitis a infection of the liver fecal oral route um You can get this sexually. Flu-like symptoms, malaise, anorexia, nausea, itching, fever, right upper quadriplegian, of course, because that's your liver. And usually it goes away. Hepatitis B, of course, we can get in blood, sexually transmitted infection as well.
Very threatening to the life of a mom and a neonate. We know that babies are exposed to hep B. Some of them do not live past eight years old. Thank you.
can be very very devastating for babies liver can be silent transmitted parentally perinatally orally and of course we have the vaccination we have that because we can be exposed to it so recover is usually spontaneous within three to sixteen weeks but you can have you know you still will have the virus but you may not be infectious hep C blood we know that this like very bad in america the baby boomers have a lot of it just a low-lying infection of the liver there are many treatments and they have a brand new treatment very very expensive but the effectiveness of treatment varies depending on how sick the patient is hiv and i know you've talked about this in med surg there's so many new cases each year heterosexual transmission is over the top because we for so long just said that it was in high-risk homosexual men and so we really dropped the ball on making sure that women knew and so we've had a lot of new infections in women of course HIV can be transmitted through body fluids so you know HIV is the precursor to AIDS symptoms fever headache So it's malaise lymphadenopathy, swollen lymph nodes, malaysia, nausea, diarrhea, weight loss, sore throat, and rash. So of course we do the testing for HIV, then we retest. We definitely are going to test early in pregnancy. We know that we can give her medications, antivirals, and get the load down so that we can prevent perinatal transmission. Always do pre-test and post-test counseling and let the patient know their result.
Patients with HIV, of course we need to consult with the doctor. consult now our treatments are so good we consider it a chronic disease um because we have we are so good at treating it um with the medication but we also want to refer them for death and dying suicide prevention financial assistance very expensive legal advocacy and prevention of transmission we don't have a cure yet they're working on a vaccine and hopefully we'll have a cure one day um so hiv counseling and testing should be offered to all pregnant women and on prenatal care entry without exception if we can get them on medication we can decrease transmissions to one to two percent which is amazing um and cesarean birth is recommended so that the baby does not come into contact with the maternal blood system sti and pregnancy of course you know it's bad so it can cause all this inflammation in your uterus it can cause premature rupture membranes because the chorion and the amnion and the placenta are all infected premature labor postpartum sepsis because we have tissue damage and then the STI gets into the blood system dystocia because of the swelling the baby can't come out and then of course miscarriage can happen as well um other torch infections and we know that these can cross the placenta herpes cytomegalovirus rubella hepatitis hiv and toxoplasmosis but the ones for STI really hepatitis hiv and hs be we are part of that torch family it's actually torches zika's along with that so we just need to get ask the history do the exam do the test find out what's going on um expect of clan of clear expected plan of care is we want to identify them and treat them and talk about how to not get this infection again Infection control, they're reportable. So we have to report it to State of Florida, gonorrhea, syphilis, chancroid, lymphogranuloma venerum, and granuloma inguinal. You don't really see these last two very much, but they are reportable.
Also trichomoniasis as well. Chlamydia and Trichomoniasis are both reportable to you. So these are just some key points we just don't want to transmit it to the baby. HPV is the most common viral STI.
Syphilis has reemerged as a common one, and it is terrible with people not seeking prenatal care. And a lot of people do not seek prenatal care due to the opioid problem. heroin use and then they're getting syphilis and not knowing it and then their babies are getting it and are dying. Um, comity is the most common.
Viral hepatitis is several forms. Um, we need kids to practice safe sex because they're at greatest risk because they're experimenting and changing partners. Um, they're responsible for substantial mortality, morbidity with economic impact and STI and vaginitis are biologic events, which all individuals have the right to expect.
Objective, compassionate, effective health care. We do not label people, so we're very happy when they get care and come to us. Thank you so much. Take your quiz.
I enjoyed talking to you today.