Part 11: The “Social Diseases” Gonorrhea and Syphilis L INDA K. H U X A L L , R N , BSN

Gonorrhea is the No. 1 reported communicable disease in the United States. T h e Department of Health, Education and Welfare’s Center for Disease Control (CDC) reported 809,681 new cases of gonorrhea during July 1972 through July 1973-a 12.7% rise from the preceding year. T h e CDC estimates that the total figures are much higher, close to 2.5 million new cases.I Many cases are not reported and many people do not seek medical help because of past experience with unempathetic health professionals. Lastly, many people have few, if any, symptoms. Syphilis is the most serious of the treponemal diseases, which include yaws, endemic syphilis, and pinta. Among adults it is transmitted almost exclusively by sexual contact with a person who has an open lesion containing Treponema pallidurn. T h e spirochetes can be transmitted transplacentally to a fetus. Syphilis is the number four reported communicable disease in the United States. From July 1972 through July 1973, 25,080 new cases (4.5% increase over the previous year) were reported. T h e actual number is estimated a t 85,000-90,000.1

GONORRHEA Factors Contributing to Spread

T h e increased use of oral contraceptives and IUD’s is often blamed for the current epidemic. It is not their use but the decreased use of mechanical barriers such as the condom that contributes t o the spread of gonorrhea. Condoms, while not 100% effective, do decrease the probability of infection. Contraceptive foam may offer some protection against gonococci (and trichomonas) ;2 therefore, we recommend that patients with IUD’s or taking oral contraceptives use one or both products when there is any possibility that the sexual partner is infected. Although failure to take prescribed medication and reinfection significantly advance the spread of gonorrhea, antibiotic resistance is a primary cause of treatment failure. Neisseria gonorrhoeae has become increasingly resistant to penicillin, so much so that the presently recommended dosage of penicillin is eight times greater than it was before 1960. Multiple resistant mutations of gonorrhea develop after gonococcus is exposed to multiple antibiotics at different times; the organism acquires resistance to each drug.3 16

In parts of the United States and Europe, resistant strains are increasing. In Africa and Southeast Asia, the problem is far worse. Self-administration of black market penicillin of low quality has led to a very resistant form, the so-called Vietnam Rose.4 Seaport cities in this country have been among the first to report extremely resistant strains. With the return of men and women from Vietnam and the increased population mobility throughout the world, a rising incidence of resistant strains can be expected. Physicians in this country also contribute to the problem via misdiagnosis, inappropriate choice of antibiotic or too low a treatment dose. A gonorrheal attack confers no immunity to subsequent reinfection. “Ping-pong” gonorrhea-reinfection (usually by an asymptomatic carrier), successful treatment, and repetition of the cycle-is common. Therefore, treating patients who have positive cultures o r symptoms is not sufficient to bring this disease under control. All known sexual contacts with an infected person should be given adequate prophylactic therapy before culture results are known. Failure to do this will perpetuate the losing game of “ping-pong” gonorrhea. Symptoms and Complications

T h e two most constant presenting symptoms in the gonorrheal female are dysuria and an increased vaginal discharge. T h e gonorrheal discharge may not be thick and yellowish-green, since trichomonas vaginalis is also present in almost 50% of cases of gonorrhea. There is no typical picture when vaginitis is superimposed. The patient may also complain of frequent micturition, mild low backache, and lower abdominal discomfort. T h e frightening fact is that 60 to 90% of women with acute uncomplicated gonorrhea are asymptomatic. When symptoms are present, they are often attributed to urinary tract infections or to a coexisting vaginitis. T h e message is clear. Cultures for gonorrhea should be a routine part of all pelvic examinations. In the male, acute gonorrhea involving the anterior and posterior urethra is symptomized by acute dysuria, frequent urination, and a thick purulent discharge. In 10 to 12% of men, symptoms are so mild they go unnoticed.6 Complications of acute gonorrhea in the female include bartholinitis, skenitis, cystitis, salpingitis, proctitis, and peritonitis. Salpingitis may mimic disorders January/February 1975 JOGN Nursing

such as appendicitis, ectopic pregnancy, ovarian cyst and fibroids. About half of women with gonorrhea will have positive rectal cultures. Rectal gonorrhea results from anal intercourse or is spread from the vaginal area. Usually asymptomatic, it is diagnosed solely on the bases of rectal examination and a positive culture. Symptoms-rectal discharge, painful defecation, rectal bleeding-are frequently attributed to hemorrhoids. T h e incidence of systemic (metastatic) gonorrhea is growing. Gonococcemia may occur without prior symptoms of genital gonorrhea. Cutaneous lesions may mimic those of meningococcemia. Systemic manifestations with severe malaise, hyperpyrexia and tachycardia may result. Arthritis or arthralgia are the most common extragenital complications of gonococcemia. The arthritis may be monarticular or polyarticular. Unless gonococcal arthritis is considered in the differential diagnosis and in cultures taken from the genital area, the inflamed joint, and the blood, the true diagnosis may be missed; inadequate treatment can lead to permanent damage of the joint(s). Rare systemic complications are endocarditis, myocarditis, pericarditis, meningitis and anterior u v e i t i ~ . ~ Some states no longer require the treatment of neonates’ eyes with silver nitrate or penicillin to prevent ophthalmis neonatorum; they are under the illusion that this prophylaxis has become unnecessary. This simple, inexpensive procedure should be routine after every delivery. In addition, pregnant women should be recultured one to two weeks before expected delivery. Gonoccal conjunctivitis in older children and adults usually results from direct contamination of the eye with gonoccal pus b y fingers. Inform patients of this possibility and instruct them in proper hygiene. W e also recommend using two gloves during all pelvic examinations. Diagnostic Tests T h e best site for a routine culture in women is the endocervical canal. After removing surface mucus with a cotton ball, insert a sterile cotton-tipped swab into the canal and rotate for at least 15 seconds t o allow for absorption of organisms. Unless the swab contains Stuart’s holding medium, immediately inoculate the specimen on Thayer-Martin culture plates or in a Transgrow bottle. A delay of even seconds will result in false negative cultures. Take urethral cultures from males with a bacteriologic wire loop or a synthetic swab (Calgiswab) that is inserted about onehalf inch into the urethra. Rectal, throat, and vaginal cultures should be taken when indicated by symptoms or history, and from all posthysterectomy patients. Contact the Center for Disease Control, Atlanta, Georgia, if you have questions regarding your culture January/February 1975 ]OGN Nursing

Do you have a question about VD? Other nurses probably have the same question. We’ll help you find the answer. Address your question to the authors of this article, care of JOGN Nursing, Suite 2700, One East Wacker Drive, Chicago, IL 60601. Questions and answers about sexually transmitted diseases will be published in a later issue of JOGN Nursing.

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methodology. It is common practice to postpone taking a culture when a woman is menstruating. Actually, menstruation is the ideal time for culturing, since the infected woman is shedding a large number of organisms. T h e use of gram-stained or fluorescent-antibodystained smears is not recommended for the diagnosis of gonorrhea in women, because gram-negative organisms are normally present in the vagina. Microscopic demonstration of the typical gram-negative, intracellular diplococci from urethral exudate in men is sufficient evidence of gonorrhea. If no exudate is present or the gram-stain is questionable, obtain a culture. Neither gram-stained nor fluorescent antibody smears are recommended as tests-of-cure in either men or women.7 Treatment Schedules

T h e treatment for uncomplicated gonorrhea for both men and women is 4.8 million units of aqueous procaine penicillin G, divided into two doses and injected at different body sites at one visit. One gram of oral probenecid (Benemidm) should be given a t least 30 minutes before the injections. Probenecid blocks renal excretion of penicillin, thus increasing the peak blood level of the penicillin and, thereby, the cure rate.* Alternate antibiotics are: a) Oral ampicillin, 3.5 grams; administer 1 gram of probenecid simultaneously. b ) Tetracycline HCI, 1.5 grams given orally as an initial dose when penicillin is contraindicated; follow b y 0.5 grams q.i.d. for 4 additional days for a total of 9 grams. c ) Spectinomycin: 2 grams for men in one injection; 4 grams, divided into two doses and injected at different body sites at one visit for women. Obtain follow-up cultures no later than a week after treatment for a test-of-cure, and always consider the possibility of reinfection when a follow-up culture is positive. All gonorrhea patients should have a serologic test for syphilis (STS) at the time of diagnosis. Patients receiving the recommended parenteral penicillin to treat gonorrhea do not need follow-up serologic tests if the initial test is negative. However, if an antibiotic ‘7

other than penicillin is used, an STS should be taken monthly for four months to detect syphilis that may be masked by the antibiotic.'

SYPHILIS Factors Contributing to Spread

Syphilis goes undiagnosed for many reasons. I t produces symptoms similar to dozens of other diseases. Since syphilis is systemic from the onset, a diagnostic examination limited to the sexual organs is insufficient. Unfortunately, in too many facilities, including V D clinics, patients do not receive a basic physical. Stages

Syphilis is usually described as having three stages: primary, secondary, and latent. T h e transmission stages, primary and secondary (up to two years of infection) are often grouped and known as early or infectious syphilis. Noninfectious stages are called tote syphilis and include continuation of the latent stage beyond two years, as well as much later manifestations of the disease.

A . Primary Syphilis T h e average incubation period is 20 to 30 days, with a span of 10 to 90 days. T h e chancre of primary syphilis may be found anywhere since spirochetes can penetrate intact skin, but most chancres are found in the genital and mouth areas. Usually only one appears but multiple chancres are possible where genital parts touch, such as on the labia or the underside of the penis and scrotum. The typical chancre is an ovel-shaped sore or ulcer. It is usually smaller than a quarter, has a raised border with a base that does not bleed easily, and is painless unless secondarily infected. O n palpation it feels hard like a button under the skin. Nearby lymphatic glands swell painlessly a few days after the chancre appears.1° Many primary chancres are not noticed by the patient or, if noticed, are treated with a variety of creams or ointments. Ointments kill the surface organisms and change the characteristic appearance of the lesion. Antibiotics used for other disorders change the appearance of the chancre and also the lesions of secondary syphilis. A differential diagnosis of primary chancre includes the venereal diseases chancroid, granuloma inguinale, lymphogranuloma venereum, and herpes genitalis. Nonvenereal conditions include trauma, cancer, seborrhea, psoriasis, and the sore that heralds pityriasis rosea.11 B. Secondary Syphilis Even if untreated, the chancre heals within five 18

weeks. For awhile, the infected person has no symptoms. However, the disease continues to develop, and the person is infectious. About six weeks (as early as two weeks or as late as six months) after the primary chancre appears, syphilis enters into the secondary stage. I t is manifest as a macular, maculo-papular, papular, or pustular skin rash or as mucus membrane sores or as lesions known as condylomata lata. T h e skin rash is extremely variable; the only factor common to most cases is lack of itching or pain. On white skin the rash turns from cherry or ham-colored to coppery. O n black skin the rash is greyish-blue. A flat dusky-red rash on the palms of the hands and soles of the feet is almost diagnostic since few other diseases cause rashes in these areas. Loss (patchy alopecia) of scalp and eyebrow hair is common.ll Mucous patches may be present in the mouth. They appear greyish-white encircled by dull red. A mildly sore throat and a husky voice are common. Moist lesions known as condylomata lata may develop on any warm, moist area of the body-most commonly on the anus, labia, or corners of the mouth. T h e greyish-white, flat-topped, fleshy-looking masses, are the most infectious lesions of secondary syphilis. Condylomata lata should not be confused with condylomata accuminata (venereal warts). In about 25% of cases of secondary syphilis, there is general ill health displayed by frequent nocturnal headaches; anorexia; nausea; constipation; pain in long bones, muscles and joints; and a low, persisting fever. Differential diagnosis of secondary syphilis encompasses at least 40 skin diseases, over 20 mouth lesions, and a t least 16 genital lesions.12 C . Latent Syphilis Even without treatment, all symptoms of secondary syphilis disappear within two to six weeks, sometimes longer, of their first appearance. This misleads people into believing that they have recovered. Actually, the disease then enters a more dangerous latent stage that, in 75% of people, is asymptomatic for months to years. T h e other 25% of untreated people experience relapses of primary and secondary symptoms during the first two years of the latent stage. A chancre may reappear at its original site and rashes may redevelop. These symptoms may disappear after a few weeks, and the disease either resumes its completely hidden nature o r secondary complications may incapacitate o r kill. About two-thirds of untreated people live the rest of their lives without any further damage from their disease. T h e remaining third develop the complications of late syphilis. Some develop painful gummas I

January/February 1975 JOGN Nursing

SCREENING AND TREATMENT OF OBSTETRIC PATIENTS FOR SYPHILIS

Categories o f patients t o be screened:

1 . Initial visit 2. Last trimester (6 weeks

Patients under 1 6 weeks o f pregnancy

Patients over 16 weeks o f pregnancy

before term) 3. Patients w i t h gonorrhea 4. V D contacts

1. VDRL

1. V D R L 2. Darkfield if indicated a. Chancre b. Mucosal ulcerations c. Condyloma latum

2. Darkfield i f indicated a. Chancre b. Mucosal ulcerations c. Condyloma latum

L

Perform FTA-ABS only if results available and treatment can be

I

Repeat an. nually or as indicated

Spinal tap w i t h 1. V D R L 2. Spinal fluid analysis

P Positive spinal fluid

Positive VDRL; negative FTA-ABS

1

c Repeat annually or as indicated above

Negative spinal

el

systemic diseases, e.g.,

r

spinal fluid

spinal

r

Treat w i t h aqueous procaine penicillin G 2.4 M U q 2 days XlO. Give 1.2 M U i n each buttock; total dosage 2.4 M U

Treat w i t h 2.4 M U I.M. benzathine penicillin G 1.2 M U i n each buttock ( R .O. pen ici Ili n sensitivity)

Treat w i t h aqueous procaine penicillin G 2.4 M U q 2 days x6. Give 1.2 M U i n each buttock. Total dosage 14.4 M U

L----7r

Follow V D R L every 4-6 weeks throughout gestation I

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Cord blood serology Refer t o pediatrician

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Alternate forms of treatment of syphilis in pregnancy when penicillin is contraindicated Under 16 weeks‘ gestation: Erythromycin base or estolate given 2 g per day in four

divided doses for total o f 30 t o 40 g Over 1 6 weeks’ gestation: Cephaloridine

a. Early syphilis - 1 g daily I.M. XlO days b. Late syphilis - 1 g daily I.M. x 2 0 days From “Diagnosis and Treatment of Syphilis,” a Technical Bulletin of The American College of Obstetricians and Gynecologists, prepared by the College’s Special Interest Committee on Community Health.

January/February 197.5 JOGN Nursing

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SCREENING A N D T R E A T M E N T OF GYNECOLOGIC PATIENTS FOR SYPHILIS

Categories of patients t o be screened :

1. N e w patients

2. Annual revisits 3. Patients w i t h gonorrhea

Suspicious lesions: 1 . Chancre 2. Mucosal ulcerations 3. Condyloma l a t u m

No suggestive

4. VD contacts 5. High-risk for VD

history o r physical findings

I

RF] Positive

negative results w i t h cancre)

biopsy

biopsy

Negative

I

Repeat annually o r as indicated above

Do VDRL in 6 weeks

r

I

1

Negative

Positive

VDRL

VDRL

Repeat annually or as indicated above

i-----l Positive

Positive

positive

negative

Spinal tap w i t h

2. Spinal f l u i d

Consider other systemic diseases,

analysis

r

Treat w i t h 2.4 M U benzathine penicillin G. 1.2 M U I.M. in each b u t t o c k (R.O. penicillin sensitivity)

Recheck VDRL at 1 , 3 ,and 12 m o n t h s 1 . Falling t i t r e indicates successful treatment 2. Rising t i t r e indicates a. Reinfection

1 Aqueous procaine peniclllln G :

2.4 M U q 2 days XI0 Total dose; 24 MU ( R .O. penicillin sensitivity)

Alternate forms of treatment o f syphilis when penicillin is contraindicated: 1 . Tetracycline hydrochloride 0.5 g orally q.i.d. f o r 20 t o 30 days. ( T o t a l dose i n early syphilis, 40 g; in late or neurosyphillis, 60 9.) 2. E r y t h r o m y c i n base or estolate 0.5 g orally q.i.d. f o r 20 t o 30 days

From "Diagnosis and Treatment of Syphilis," a Technical Bulletin of The American College of Obstetricians and Gynecologists, prepared by the College's Special Interest Committee on Community Health.

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January/February 1975 JOGN Nursing

(granulomatous, destructive lesions) in skin, bone, nervous and cardiovascular systems. Others manifest the extremely destructive cardiovascular syphilis or neurosyphilis.12 Transmission in Pregnancy and Congenital Syphilis

Treponemu pallidurn is transmitted to the fetus via the placenta. If syphilis is treated before the placenta is well developed ( 16-1 8 weeks LMP/ 16 weeks of gestation), the organisms cannot cross it and the child will not contract the disease. If the mother’s infection is not treated, the probability of premature stillbirth increases fourfold, the probability of infant death almost doubles, and almost 20% of surviving children suffer from congenital syphilis.12 Sy mptoms of secondary . syphilis are usually less noticeable In pregnancy since the incubation period of the disease is 1 to 90 days. It is advisable to repeat a STS towards 36 to 38 weeks’ gestation. Indications for treatment of the neonate are maternal infection shortly before birth, a cord blood titer higher than the maternal titer, o r evidence of early congenital syphilis. Early congenital syphilis manifests as vesicular/bullous cutaneous lesions, pseudoparalysis and hepatosplenomeglia. T h e neonate may be asymptomatic and still have congenital syphilis. Diagnostic Tests When a lesion is present, a darkfield microscopic examination may be done for the corkscrew-shaped spirochetes of Treponerna pallidurn. Rub the surface of the lesion with a gauze pad moistened with saline, then place the thick, clear fluid on a glass slide. If testing facilities are not at hand, draw fluid up into a capillarv tube, seal the tube at both ends with wax, and mah it in a special container. Darkfield examination must be done only b y an expert because other spirochetes in the oral and genital area can be confused with T . pallidurn. All of the available blood tests for syphilis work b y detecting antibodies formed to T. pallidurn. Since yaws, endemic syphilis, and pinta are caused b y the same organism, they cannot be distinguished by blood tests. T h e three most common tests for syphilis are:

1. VDRL test (Venereal Disease Research Laboratory test) detects 7 5 % of primary syphilis at six weeks, and 100% of secondary syphilis. False-positives may occur in people wh o have recently had measles, chicken-pox, mononucleosis, infectious hepatitis, systemic lupus erythematosus, o r rheumatoid arthritis. Sixty percent of heroin addicts have false-positives. 2 . F T A - A B S test (Fluorescent treponemal antibody January/February 1975 JOGN Nursing

absorption test) detects 85% of primary syphilis. Good to use when exposure is less than four weeks. Falsepositives are less common than with VDRL but the test is more expensive. 3 . T P I ( T r e p o n e m u pallidurn immobilization test) has very few false-positives. Expensive and difficult to perform, but useful for special problem cases.4 Most currently used serologic tests for syphilis become positive within ten and always within 30 days after the chancre appears. If the patient is treated before the serology becomes positive, he will likely remain seronegative. If the antibody titer is alreadv elevated, the titer gradually becomes negative 6 to 12 months after primary syphilis is successfully treated and 1 2 to 18 months after secondary syphilis is cured. After treatment, follow-up examinations for latent syphilis must be more extensive but negative serology can be expected in about two years. When a VDRL test is positive in the absence of symptoms, the FTA-ABS test should be done and should be repeated if reactive in order to eliminate error in reporting or performance. Treatment

People with primary and secondary syphilis should not have sexual intercourse for one month after receiving treatment and while skin lesions are present. (Condoms are of little value and only give a false sense of security.) After one year of latent syphilis, the person is no longer infectious, with one exception: a pregnant woman may infect her unborn child. Drug therapy is as follows (except for pregnancy over 16 weeks; see accompanying charts for recommended treatment of pregnant patients and for more comprehensive treatment of others) :

Primary -Benzathine penicillin G: 2.4 million U (treatment of choice) or -PAM: 2.4 million U initially, then 1.2 million U q 3 days for a total of 4.8 million U or -Erythromycin: 20-30 grams over 10-15 days or -Tetracycline: 30-40 grams over 10-1 5 days Secondary -Same as primary Latent -Same as primary if spinal fluid serology is nonreactive. Otherwise, 6 to 9 million units of benzathine penicillin G , is given in doses of 3 million units a t 7 day intervals.12 21

Epidemiologic Treatment T r e a t m e n t of all sexual c o n t a c t s of patients with early infectious syphilis is recommended, e v e n if they a r e a s y m p t o m a t i c a n d serologically negative. All contacts should be treated for syphilis ( r a t h e r t h a n for incubating syphilis) with 2.4 million units of benza-

thine penicillin G .

REFERENCES 1. “Syphilis Incidence Shows Slight Decline,’’ Am Nurs 74(6) : 1148, 1974 2 . Bolch, Oscar H., and James C . Warren: “In Vitro Effects of Eniko on Neisseria Gonorrhoeae and Trichomonas Vaginalis.” Am 1 Obstet Gynecol 115(8):1145-1148, 1973

. . . Why,” in Venereal Disease. Pfizer. Inc., MEDCOM. Inc.. Publishers, 15-18, 1972 4. Cherniak, Donna and ,411an Feingold: V D Handbook. Montreal. Handbook Collective. 1972 5. “Gonorrhea-Treatment in’ the Female.” ACOG Tech Bull No. 16, Feb 1972 6. Schroeter, Arnold: “Detecting Asymptomatic Gonorrhea,” in Ortho Panel 12. Ortho Pharmaceutical Corp., pp 6-10, 3. Sparling, P. Frederick: “Antibiotic Resistance

1972 7. “Critcria and Techniques for the Diagnosis of Gonorrhea,” Center for Disease Control, Venereal Disease Branch, Atlanta, Georgia, Dcpt. of H E W , Publishers, 1973 I). Holnies, et al.: “Single-Dose Aqueous Procaine Penicillin G Therapy for Gonorrhea: Use of Probenecid and Cause of Treatment Failure.” 1 Infect Dis 127(4):455-460, 1973

9. Rosebury, Theodore: Microbes and Morals. New York, The Viking Press, New York, 67-82, 1971

Venereal Diseases: Treatment and Nursing. Baltimore, Williams and Wilkins Company,

10. Elliott, Hazel and Kurt Ryz:

1972 11. Pariser, )Marry: “Syphilis,” in Venereal Disease. Pfizer, Inc., MEDCOM, Inc., Publishers, pp 45-53, 1972 12. Aiman, J.: “Syphilis,” Grand Rounds Presentation, Apr 1970

Address reprint requests to Mrs. Barbara Quirk, RN, h4N, 6725 Belinder, Mission Hills, KS 66208.

Linda Huxall is ma O B - G Y N Nurse Practitioner and an instructor in the Department of Gynecology and Obstetrics, University of Kansas Medical Center, School of Health Care Sciences, at Kansas City. T h e author also coordinates tbe U S A F Nurse Practitioner Training Program. Miss Huxall received her BSN f r o m the University of Kansas i n 1967 and is working toward a master’s degree in maternalchild nursing. She has worked in pediatrics, and as a consultant in sex education for the Life Cycle Center, Kimberly Clark Corporation. She is a menibe?. of N A A C O G , A N A , Siecus and Sigma Theta T a u .

INFECTION CONTROL CONFERENCE IN CHICAGO T h e Association for Practitioners in Infection Control will hold its first National A P I C Conference, April 27-30, 1975, a t the Sheraton Chicago Hotel, Chicago, Illinois. T h e A P I C is an interdisciplinary g r o u p which includes physicians, surgeons, nurse epidemiologists and microbiologists. For further information on the conference, contact: Julia K . Rowan, RN, 3324 Craig Drive, Hammond, IN 46323.

PERINATAL WORKSHOPS THROUGHOUT TEXAS T h e problem pregnancy and the early identification and care of the high-risk neonate will b e covered in one or two-day workshops that are being presented in 3 3 different Texas cities through J u n e 1975. T h e Regional Medical Program of Texas is cosponsoring the workshops with various state institutions.

For details, interested nursing and paramedical personnel should write to John Dombroski, Texas Regional Medical Program, 4200 N o r t h Lamar, Suite 200, Austin, T X 78756.

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January/February 1975 J O G N Nursing