What are sexually transmitted infections (STIs), and why are they important? This article will detail important points and reference important articles for providers to use to assist in the evaluation and treatment of patients that present with signs and symptoms related to sexually transmitted infections. Providers should use this article as a guide to further enhance their knowledge and provide a better encounter with their patients.
Sexually transmitted infections, also known as sexually transmitted diseases, involve the transmission of an organism between sexual partners through different routes of sexual contact, either oral, anal, or vaginal. STIs become a concern and burden on the healthcare systems, as many infections go untreated and lead to complications that will be discussed within this review article. We will discuss the natural history and patterns of the spread of the most common sexually transmitted infections. We will conclude with proper evaluation, treatment, and prevention.
Sexually transmitted infections (STIs) are a worldwide health problem and should be recognized by all health agencies in public sectors. We will explore the etiology of the most common STIs, including complications, physical, and the mental burden they place on infected persons. STIs go underrecognized and have a higher incidence in medically underserved populations. The presenting condition or disease depends on the specific organism, route, signs, and symptoms of the disease. Risk factors that increase transmission of STIs include having unprotected sexual contact with multiple partners, history of STIs, sexual assault, use of alcohol, use of recreational drugs, and intravenous drug use.
In an ideal world, healthcare providers would have a centralized data collection system to be able to analyze and fully assess the incidence and distribution of such sexually transmitted infections. As health providers, we use various published studies, an official government, or health organizations to assess STI's statistical importance, such as the incidence, distribution, and statistical data. Sexually transmitted diseases (STD) have a high incidence in most countries, especially between the ages of 15 to 50 years of age, including infants. The use of this data and information help clinicians better trend and treat STIs. Providers must recognize that most of all, STIs correlate with patient behavior and should also be addressed during clinical evaluation.
This article is to serve as a general presentation of sexually transmitted infections to include most common infections such as human immunodeficiency virus, gonorrhea, chlamydia, genital herpes, human papillomavirus, trichomoniasis, and syphilis. Pathophysiology is the analysis of the physiologic burden of a disease process within an infected person. Within this section, we will discuss the above most common and provide a link to further evaluate other STIs that may be of concern. Sexually transmitted infections can either be bacterial, viral, or parasites, which are transmitted through sexual activity with the exchange of bodily fluids from the infected partner. STIs invade the human body through microscopic abrasions within the mucosal membranes of the penis, vagina, anus, or any other mucosal surfaces. Transmission of STIs can include the use of intravenous drugs, exposure through the vagina during childbirth, or breastfeeding. Organisms invade normal cells and overburden the immune system creating typical signs and symptoms of the disease.
We will discuss basic symptomatology, including genital, extragenital, or disseminated with the use of a history and physical exam to assist with differential diagnosis and recommended treatments. We will review updated treatment regimens by the Center for Disease Control and Prevention and various data collections to have a general overview of sexually transmitted infections. As a provider in the frontlines of STI diagnosis, it is key to understand curable versus incurable sexually transmitted infections. We will cover the most common to be aware of as a provider and note other STI depending on region prevalence.
Human Immunodeficiency Virus(HIV) Acquired Immunodeficiency Syndrome (AIDS)
Human Papillomavirus (HPV)
Medical professionals are trained to communicate with patients, partners, and families to be able to understand their chief complaint and formulate a differential diagnosis effectively. At the same time, taking a detailed history is mandatory, whether it occurs in a primary clinic or the Emergency Department. Our role as a provider is to be able to communicate with the patient who presents with signs and symptoms of an undiagnosed sexually transmitted infection or infections. As a provider, you should be aware that all adolescents below the age of 18 have the right to an STI screening and treatment without parental consent. Further details should be investigated with individual state health care systems or reference the "Sexually transmitted disease treatment guidelines 2015" that was distributed by the CDC. While performing the sexual history collection, an easy pneumonic that can help guide your questions can be remembered as the "other 5 P's".
The physical exam should be guided by the presenting chief complaint and symptoms collected in the review of systems. Physical exam should be done in a private setting with a chaperone at the bedside who you can then document their name in your EHR. The physical exam, along with the history, will provide a concise differential diagnosis and guide the evaluation, treatment, and management plan of the suspected disease process. At the end of your exam, present the patient with an open-ended question to ensure that there is an open dialogue, and if the patient has any other details about their sexual practice, you as the provider should know.
The physical exam will be broken down by the most common signs and symptoms, the most common physical exam finding, and diagnosis.
Lymphogranuloma venereum (LGV)
This is a brief overview of the most common signs and symptoms, physical exam findings, and diagnosis of sexually transmitted infections that can be evaluated in an acute setting such as the emergency department or a routine visit with the patient's primary care provider. The information and references cited should be used for a more in-depth approach to the signs and symptoms of a sexually transmitted infection.
Screening recommendations can be found in a detailed presentation through “Sexually transmitted disease treatment guidelines 2015,” that was distributed by the CDC. The information provided will be extrapolated from the guidelines and should be used at the discretion of the provider in conjunction with the patient.
Depending on the clinical presentation of the patient and acuity, a patient with a primary complaint concerning a sexually transmitted infection should involve ruling out localized versus a systemic infection. Initial diagnostic testing will be guided by the presenting sexually transmitted infection concerning the CDC Sexually transmitted disease treatment guidelines that were updated in 2015.
Most common laboratory testing performed include:
When approaching treatment and management of a sexually transmitted infection (STI) previously termed as a sexually transmitted disease (STD). During the year 2013, the Center for Disease Control (CDC) and Prevention initiated a goal to update the Sexually Transmitted Treatment Guidelines 2015 with persons who are experts in the field. There are specific sections in this treatment guideline that direct specific care for select populations such as pregnant women, adolescents, persons in correctional facilities, men who have sex with men, women who have sex with women, and transgender men/women. These topics should be explored and reviewed on a case by case issue.
The treatment and management of the patient should be supported by the history and physical exam, whether the patient is evaluated in the Emergency Department or a primary care office. Primary treatments will be discussed, and further reference articles will be cited for further management options for providers. If the primary treatment is not tolerated or the patient is allergic, providers should consult their pharmacy department for further recommendations.
HIV: Primary treatment and management consist of establishing viral load, CD4 count, and starting a patient on highly active antiretroviral therapy (HAART).
Chlamydia: Primary treatment and management should be supported by history, the physical exam, and clinical presentation. Consideration of coinfections with the most common sexually transmitted infections should be considered and treated simultaneously.
Gonorrhea: Primary treatment and management should be supported by history, the physical exam, and the clinical presentation. Consideration of coinfections with the most common sexually transmitted infections should be considered and treated simultaneously.
Syphilis: Treatment and management of secondary, latent, and tertiary syphilis should be independent on the treatment of primary syphilis infection.
Genital Herpes: Treatment and management of a primary infection should include systemic infection followed by symptomatic treatment and starting antiviral medications. The provider and patient should discuss medication options, including the financial strain that may hinder appropriate treatment. Treatment of reactivation herpes infection should be treated with what medication works best for the patient.
Trichomoniasis: Treatment and management should be established with that patient after diagnosis.
Granuloma inguinale: Treatment and management should be guided by history, the physical exam, and clinical presentation as granuloma inguinale is not very common in the United States. 
LGV: Treatment and management should be guided by history, the physical exam, and clinical presentation as LGV is not very common in the United States.
Mycoplasma genitalium: Concern for an M. genitalium infection should be considered if the patient is suspected of a chlamydia or gonorrhea infection.
A broad differential should be approached when evaluating a patient, whether in an Emergency Department or a primary care setting. Sexually transmitted infections can be localized to the oropharynx, integumentary system, external and internal genitals depending is a male or female, perianal/perineal, and rectum. As the provider, you should establish primary concern and differentiate other diagnoses that may be present. A thorough history, the physical exam, and the clinical presentation should support the definitive diagnosis and also rule out your differential diagnosis.
When approaching a differential diagnosis specifically for sexually transmitted infections, the provider should evaluate each system i.e., cardiovascular, respiratory, gastrointestinal, genitourinary, central nervous system, musculoskeletal, and the integumentary system. By breaking it down into systems specifically for each sexually transmitted infection will help you as a provider to determine if it is the primary infectious process associated with the STI or a secondary associated symptom of a systemic infectious process. You should also recognize if there is a superimposed infection along with the primary sexually transmitted infection.
Differential STIs should be assessed by system and symptomatology: Each of the following systems can be affected by STIs, leading to direct or indirect involvement.
The use of different resources should be entertained to understand why a differential diagnosis is important and how to use the differential to better serve your patient population.
Throughout this article and literature reviewed, the prognosis depends on the diagnosis of the disease and the progression of the disease at the time of diagnosis. If the disease process is found in the acute phase and can be treated effectively with antivirals, antibiotics, or antifungals, the outcome is dependent on the treatment course. Medication adherence plays a primary role in the prognosis of an infection that is treatable or a chronic condition such as HIV, HSV-1/HSV-2, partially treated STIs, or asymptomatic STIs that continue untreated.
Sexually transmitted infections (STIs) that remain untreated lead to systemic infections leading to prolonged medical recovery also to include psychological, financial, and general health complications. STIs complications arise from partially treated or untreated infections. Medically underserved populations show an increase in undiagnosed untreated STIs due to the fact they have no attainable healthcare system. An increase of complications can be seen if resources are not allocated to the public sector, such as planned parenthood to provide needed resources to educate people of safe sex practices to included prevention, treatment, and health promotion.
There is a wide array of complications from STIs if left untreated. Females tend to be at higher risk for complications from STIs to include systemic infection from untreated PID, sterility, and infertility from complicated gonorrhea/chlamydial infections. Females, while pregnant, have a higher percentage of preterm labor if they are positive for certain STIs. Females and males have a risk of neoplasm secondary to certain HPV strain types. HIV infections, if not properly managed, will progress to AIDS, a fatal late complication of the infection secondary to a severely immunocompromised state.
Healthcare providers should understand the most common sexually transmitted diseases and should be comfortable with counseling patients on modifiable human behavior while providing a gold standard of care in line with the presenting disease process. Patients should be provided information on prevention, counseling, and proper treatment for their sexually transmitted infections.
Key pearls for sexually transmitted infections is to be able to have an open dialogue with your patients regarding their sexual history and current practices. Establishing a good relationship creates a neutral environment and optimizes the treatment course. Do not shame or judge a person's sexual history or sexual practices because this can lead to reservations by the patient to discuss their general and sexual health.
Whether a patient is seen in the emergency department or a primary care office the disposition of the patient should be determined on the clinical presentation. If the patient has a complicated systemic infection admission is most likely warranted but if they have a self-limiting complaint that can be easily treated with proper follow up the patient should be discharged home. Pitfalls a provider may encounter would most likely be limited education with the prevention, treatment, and limited resources for their patient population.
Sexually transmitted infections are a worldwide concern and issue as they go untreated patients succumb to their disastrous effects, including health, financial burden, psychological, and physical. Data collection for STIs is limited by area. Having access to a national data collection service can help with the prevalence and incidence of certain STIs to allocate resources directed towards prevention and treatment. Continued resources such as planned parenthood would include an interprofessional team and care coordinators to provide these services. Whether patients are seen in the emergency department or their primary care office, patient-centered care should remain the priority.
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