forensic nurse - Clinical Update - Sexually Transmitted Diseases: An Overview for the SANE

Sexually transmitted diseases (STDs) is a broad term for more than 50 diseases or syndromes that may be sexually transmitted. Sexually transmitted diseases are transmitted through the exchange of blood and body fluids such as semen, vaginal fluid and saliva.

If the patient has a pre-existing STD, it may have bearing on a legal case. This is important information to pass on to the detective investigating the case. The detective may have the suspect evaluated for the same STD. Some sexual assault nurse examiner (SANE) programs elect to treat prophylactically and not obtain cultures on the adult population. By doing this you may be missing important evidence in a case. While this may not be conclusive evidence, it could be circumstantial evidence or a link to the case.

This article will discuss the most common STDs the SANE may encounter in the adult sexually assaulted population; the clinical symptoms, modes of transmission and treatment modalities of the most common STDs. It will also discuss cross contamination and disinfection. In most states, STDs must be reported to the health department. It is strongly recommended if there are any questions regarding transmission or treatment of an STD, that you contact a specialist in this field.

Chlamydia trichomatis is the most common curable STD in the United States. It is easily left untreated because it is often asymptomatic. If untreated, Chlamydia can lead to infertility, pelvic inflammatory disease or Fitz-Hugh Curtis Syndrome. If symptoms are present they may include: discharge from the genital area, burning with urination and pelvic pain. Women may also experience bleeding after intercourse or between periods. Symptoms of an infection usually appear from one to three weeks from the time of transmission.

Chlamydia is transmitted by direct contact with the affected area, whether or not the person is symptomatic. This can be mouth to genitals or anus, genital-to-genital contact and/or genital-to-anal contact. Because Chlamydia is a live virus it cannot be transmitted by casual contact. This includes toilet seats, hot tubs, etc. When used properly, condoms can help prevent transmission.

Chlamydia is easily treated with antibiotics. The Centers for Disease Control and Prevention (CDC) recommends for adults: usually Doxycycline 100 mg by mouth for seven days, or a single dose of Zithromax 1 gram by mouth. The treatment for pregnant women is usually Erythromyocin 500 mg four times daily for seven days. Treatment also includes abstaining from sexual contact for one week following antibiotic therapy. Both partners must be treated to prevent reoccurrence of the infection. In most cases, it is not necessary to be tested after treatment unless symptoms persist or reinfection is suspected. After an acute sexual assault, the patient is instructed to follow up in two to four weeks for testing.

Neisseria Gonorrhoeae, also known as "the clap," is a bacterial infection transmitted by direct contact with an affected person, whether or not the person is symptomatic. Although gonorrhea cannot be contracted by kissing, gonorrhea can live in the throat. This is more commonly seen in women or men who have performed oral sex on a male that is infected. It is less likely to contract gonorrhea from oral sex on the genitals of a female, but it is possible. Recent literature suggests that patients who have gonorrhea are more susceptible to HIV infections. Gonorrhea is the only STD that is conclusive for sexual contact. Symptoms of gonorrhea include: vaginal or penile discharge, often yellow in color, pain or burning with urination. In women, pain and/or bleeding after intercourse and between periods are common symptoms. The infection usually starts in the cervix of females and in the urethra of males. If left untreated, gonorrhea can cause pelvic pain in females and epididymitis in males, which may interfere with fertility. Symptoms can occur two to 10 days from the time of exposure.

Gonorrhea cannot be transmitted by contact with inanimate objects such as toilet seats or towels. Condoms, if used correctly, can prevent transmission of gonorrhea. Gonorrhea can be completely effective when treated with antibiotics. The CDC-recommended treatment for adults is: Cefixime 400 mg orally in a single dose or Ceftriaxone 125 mg IM in a single dose, or Ciprofloxin 500 mg orally in a single dose, or Ofloxacin 400 mg orally in a single dose or Levofloxin 250 mg orally in a single dose. All partners need to be treated to prevent reinfection. Use of a condom, spermicide and nonoxynol-9 will help to decrease the transmission of gonorrhea. Follow up testing is recommended.

Herpes Simplex Virus is considered an extremely common viral infection (1 in 4 adults in the U.S. are infected). Herpes is an incurable viral disease with two serotypes, HSV-1 and HSV-2. HSV-1 usually causes oral infections and HSV-2 usually causes genital/anal infections, although HSV-1 can occur in the genital/anal area and HSV-2 can occur around the mouth. Almost all cases of recurrent genital herpes are caused by HSV-2. Most HSV-2 infected persons have not received a diagnosis of genital herpes; such persons have mild or unrecognized infections and shed the virus intermittently in the genital tract.

Symptoms caused by HSV-1 include redness, bumps or blisters on the outside of the lips. The blisters can be found on the roof of the mouth, the gums and in the throat. They are commonly known as cold sores. Symptoms associated with HSV-2 vary. The symptoms can range in some persons from subtle itching, redness or tingling in the infected area, to classic, red pimple-like bumps, blisters, ulcers and tiny slits or scratches to the infected area(s). First infections of HSV usually cause more severe symptoms than re-occurrences. This may be accompanied by a vaginal discharge, white to yellow in color and painful intercourse.

Lesions that appear on mucosal surfaces such as the lips, vaginal and anal areas will not scab as they heal. Lesions that appear on skin surfaces such as the face, penis, buttocks and outer genital areas in men and women will usually scab before they heal. An evaluation for syphilis should also be performed if lesions are present. Some persons infected may experience lymph node swelling in the groin, back or leg pain, stiff neck, sore throat, or a tired and achy feeling all over similar to symptoms of the flu.

Outbreaks of symptoms can be seen from two to seven days from the time of initial contact with an infected person. Symptoms can last about two weeks with the first outbreak of either HSV-1 or HSV-2; if left untreated, symptoms can last up to six weeks.

Reoccurrence varies from person to person, but averages about four to eight outbreaks per year. Men usually have more outbreaks than women. Outbreaks can be brought on by increased stress, foods, fatigue, illness and exposure to sunlight. Herpes lesions will usually spontaneously resolve whether or not they are treated, but the infection is not gone and can reoccur.

Transmission of HSV-1 and HSV-2 is by direct contact with the infected area(s). The most common area to contract the virus is the mucosal surfaces coming in contact with semen, vaginal secretions and/or saliva. Women are more likely to contract herpes because of the greater amount of mucosal surface in the genital area. Because herpes is a live virus, it cannot be transmitted from inanimate objects such as drinking glasses, towels and toilet seats or in the water of hot tubs and swimming pools, but it can be transmitted with the use of shared sex toys if they are immediately exchanged between partners.

Treatment includes antiviral therapy and counseling. Antiviral medications will decrease the symptoms a person can experience and reduce outbreaks, but there is no cure for herpes. Use of condoms can decrease chances of transmission if used properly. Testing should be done for presence of HSV as well as typing of the lesion(s) to differentiate between HSV 1 and 2. If the testing of the herpes lesion returns negative, you can still draw blood for antibodies. The antibody testing has to be done at least three weeks after the first outbreak.

The CDC recommendations for treatment for HSV are as follows: For the first clinical episode of genital herpes, Acyclovir 400 mg orally three times a day for seven to 10 days, or Acyclovir 200 mg orally five times a day for seven to10 days, or Famciclovir 250 mg orally three times a day for seven to 10 days, or Valacyclovir 1 gm orally twice a day for seven to 10 days.

Episodic therapy for recurrent genital herpes is Acyclovir 400 mg orally three times a day for five days or Acyclovir 200 mg orally five times a day for five days or Acyclovir 800 mg orally twice daily for five days or Famciclovir 125 mg orally twice a day for five days or Valacyclovir 500 mg orally twice a day for three to five days or Valacyclovir 1 gm orally once a day for five days. Suppressive therapy includes Acyclovir 400 mg orally twice a day or Famciclovir 250 mg orally twice a day, or Valacyclovir 500 mg orally once a day or Valacyclovir 1 gm orally once a day.

Human Papillomavirus (HPV) is the virus that causes genital warts, and it is the most common sexually transmitted infection that brings people to the physician. There are more than 20 types of HPV that can infect the genital area. HPV types 6 and 11 usually cause visible warts. Genital warts are generally asymptomatic, but itching can be an associated symptom. Because genital warts are asymptomatic it is not uncommon to be infected with them and not know it. There can be a lag time between infection and development of visible warts. Visible symptoms may either resolve on their own or with treatment. HPV can be treated, but there is no cure. They can appear flat or have a cauliflower-like appearance. They can appear spontaneously or slowly grow over time, usually in three to six months.

Transmission of HPV is from direct skin-to-skin contact with an infected person. HPV cannot be transmitted through blood or body secretions. Transmission from the genital/anal area to the oral region is rarely seen. There is also a small possibility that the virus may be transmitted through inanimate objects, such as towels. The virus can be transmitted during childbirth. The treatment for genital warts is removal, but the HPV will remain in the body’s system.

Warts can be frozen with liquid nitrogen, removed by surgery or topical medication such as Podophyllin resin 10 percent to 25 percent, Trichloracetic acid can be applied by the physician in the office. Medications such as Podofilox 0.5 percent gel or Imiquimod 5 percent cream can be applied by the patient at home while under a physician’s care. Follow-up evaluation with a physician is recommended after home therapy to evaluate the effectiveness of the treatment. Certain types of HPV are more cancer prone than others. The use of condoms, may reduce risk, but does not eliminate the risk of transmission to uninfected persons, even when used properly.

Syphilis is a common bacterial infection transmitted during sexual contact. The bacteria can infect multiple-organ systems and cause a full range of symptoms. Since the development of penicillin the number of cases of syphilis have decreased dramatically. Those infected in the U.S. are usually poor, immigrants, those who use drugs or engage in sex for drugs.

Symptoms of syphilis vary because any organ can be affected. Syphilis is divided into early and late stages. The early stages are primary, secondary and early intent syphilis. Late stages include tertiary and neurosyphilis. Symptoms of primary syphilis can appear 10 to 90 days from the time of contact with an infected parson. The first symptom is usually a chancre at the site where the infection took place, any area of the skin or mucous membrane. The lesion can be, but is rarely painful. Often the person is unaware they have been infected. The lesion usually resolves on its own without treatment, but syphilis is still present.Testing should be done if HSV lesions are present. Associated symptoms can include swelling of the lymph nodes in the area of infection.

Symptoms of secondary syphilis appear several months later after the bacteria has entered into the bloodstream. Secondary syphilis carries a wide variety of symptoms that may include: red, flat, non-itching rash all over the body, fever, sore throat, joint pain, headaches and wart-like lesions in the genital area. These symptoms can easily be mistaken for other medical problems such as the flu. If untreated, symptoms of tertiary or latent syphilis appear.

Symptoms of tertiary or latent syphilis include internal destruction of organs and tissue. This stage is rarely seen today. If the infection progresses to the brain it is called neurosyphilis.

Syphilis is transmitted through direct sexual contact or intimate contact with an infected person. Blood, semen and vaginal secretions are all contagious. Common routes of non-sexual transmission are through small breaks in the skin. Syphilis is most contagious during the primary and secondary stages. The chancres and rash are very infectious.

Diagnosis of syphilis is done easily by a blood test. The tests used are a VDRL or RPR An infected person can take up to three months to test positive. All patients that test positive for syphilis should be tested for HIV.

The CDC-recommended treatment of syphilis is dependent upon the stage. For primary, secondary syphilis and early latent syphilis the recommended regimen for adults is Benzathine Penicillin G 2.4 million units IM in a single dose. For tertiary syphilis, late latent syphilis or latent syphilis of unknown duration the recommended regimen is Benzathine Penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at one-week intervals. For neuorsyphilis the recommended regimen is Aqueous Crystalline Penicillin G 18-24 million units every day, administered as 3-4 million units IV every four hours or as a continuous infusion for 10 to 14 days. Penicillin (with the exception of neurosyphilis) must be given by injection. Follow-up titers of VDRL and/or RPR need to be drawn to assess treatment therapies.

Trichomonas Vaginalis is caused by a protozoan and it is the most common STD in the world. Trichomoniasis infections are found exclusively in the genital areas; they do not occur in the mouth or anal area.

Symptoms of trichomoniasis in women include: a yellow-green frothy discharge, itching, irritation, redness and a strong fishy odor. Women may also experience lymph node swelling in the groin, painful intercourse and burning with urination. Trichomoniasis is diagnosed by microscopy of vaginal secretions. Men usually do not experience symptoms with trichomoniasis, but can have burning with urination and a penile discharge. Trichomoniasis is acquired through direct sexual contact with a partner that is infected. It is not transmitted by the use of towels or toilet seats.

Trichomoniasis can be treated and cured with antibiotics. The CDC-recommended regimen in adults is Metronidazole 2 gms orally in a single dose. Alternatively, Metronidazole 500 mg can be given twice daily for seven days. Both partners should do antibiotic treatment. Abstinence for one week is recommended. Condoms when used properly can prevent transmission of trichomoniasis. Follow-up is only necessary if symptoms have not resolved or if reinfection is suspected.

This can occur when touching lesions and then touching yourself or equipment without proper handwashing or cleansing techniques. Do not wash your hands with gloves on and then continue with the examination. Washing gloved hands with soap may cause the latex to break down, thus triggering micro-leaks into the gloves and possibly contaminating the patient and the nurse.

Always wash, or change lab coats or jackets between procedures to prevent infecting the next patient. Try not to place contaminated objects, including linen, onto upholstered furniture. The following is a list of tips to prevent or decrease cross/self contamination during a procedure: