Sexually Transmitted Infections Nursing CE Course for APRNs

monly transmitted STIs and the cause of the majority of infection-related blindness globally. The WHO estimates that in 2020, there were 129 million new chlamydia infections among individuals aged 15 to 49. It is also the most commonly reported bacterial infection in the United States, with 1.65 million (492 cases per 100,000) chlamydia infections in 2023. The rate of urogenital infections is much higher in individuals assigned female at birth compared to those assigned male (3368 versus 610 cases per 100,000). Anyone sexually active can contract chlamydia; however, some factors increase the risk of infection. Individuals less than 25 years old tend to have the highest prevalence of chlamydia. The decline in prevalence after the age of 25 may be due to safer sex practices or partial immunity through periodic, repeated exposure. These young individuals may be at increased risk owing to multiple barriers to prevention, such as a lack of finances, a lack of transportation, and cultural/social stigma. Other risk factors include a new partner or multiple partners within the last 3 months, along with inconsistent use of barrier methods to prevent infection (e.g., condoms). Cervical ectopy (where cells from the endocervix are present on the ectocervix) may also increase risk. Male patients with multiple sexual partners, males who have sex with males (MSM), or those with a history of HIV are also at higher risk. A history of chlamydia is also a risk factor for reinfection. When chlamydia is left untreated, it can cause damage to the genital tract, making it easier for HIV to enter the body, increasing the risk of transmission (American College of Obstetricians and Gynecologists [ACOG], 2025; CDC, 2025a; Hsu, 2024b; Mohseni et al., 2023).

 

Screening and Prevention

Asymptomatic chlamydial infections are common among individuals assigned male and female at birth. According to the CDC’s 2021 guidelines on the treatment of STIs, all sexually active female patients less than 25 years of age should be screened annually for chlamydia. In addition, screening is recommended for female patients older than 25 with additional risk factors (new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI). Pregnant individuals should also be screened at their first prenatal visit if they are less than 25 years of age or over 25 years of age with an increased risk of chlamydia. If these individuals are deemed high risk for infection, they should be retested in the third trimester. Male patients should be screened as needed for chlamydia; however, if they are at higher risk, specifically MSM, they should be screened every 3 to 6 months. Individuals with HIV should be initially screened for chlamydia and then annually thereafter. Transgender individuals should be screened based on their anatomy at birth, sexual behaviors, and risk for exposure. Chlamydia can be prevented by avoiding anal, oral, or vaginal intercourse, correctly applying barrier methods (e.g., condoms) during each sexual encounter (refer to Table 1), or engaging in a monogamous relationship after both individuals have tested negative (CDC, 2025a; Ghanem & Tuddenham, 2025; Workowski et al., 2021).

 

Table 1

Correct Usage of Male Condoms

Do	Do Not
Apply a condom before penetration	Reuse condoms or apply more than one at a time
Read the package and check the expiration date	Use an expired condom
Check the condom before placement to assess for tears or defects	Use a condom with tears or defects
Place condoms in a cool, dry setting.	Place the condom in a wallet, as heat and friction will alter the integrity of the condom.
Use a latex or polyurethane condom	Use a condom made from a material to which either partner has an allergy
Pinch air out of the condom before placement	Use oil-based lubricants (e.g., baby oil, petroleum jelly)
Unroll the condom to the base of the penis	Use nonoxynol-9 due to potential skin irritation
Hold the condom in place after sexual intercourse and dispose of it
Perform hand hygiene

(CDC, 2024f; Rietmeijer, 2025)

                

If a condom is incorrectly placed, the risk of contracting an STI increases. Areas exposed and not covered by a condom may also result in transmission. Individuals at risk for not using condoms may include adolescents and those experiencing substance use, lower socioeconomic status, lower educational attainment, and a lack of access to condoms. Healthcare providers (HCPs) have a unique opportunity to assess and address all these factors through education and coordination of resources (CDC, 2024f; Goldenberg et al., 2020; Rietmeijer, 2025).

Signs and Symptoms

Individuals with chlamydia may or may not present with signs and symptoms; 70% of individuals assigned female at birth are asymptomatic. If symptoms occur, they tend to happen between weeks 1 and 3 following disease exposure. Individuals assigned female at birth may experience vaginal discharge, dysuria, frequency and urgency with urination, pelvic pain, and dyspareunia. They may also develop PID, characterized by fever and lower abdominal discomfort and tenderness on palpation of the abdomen, adnexa, and cervix. In addition, individuals assigned male at birth may experience pain and edema of the epididymis and testicles. They may also report dysuria, discomfort in the urethra, and clear to mucopurulent discharge. When the disease occurs in the rectum, patients may experience pain, discharge, and bleeding from the rectum. Although uncommon, the individual is usually asymptomatic if chlamydia occurs in the throat. The individual may develop conjunctivitis if the eyes come into contact with infected seminal or vaginal fluid. If left untreated, the patient can continue to transmit the disease (CDC, 2025a; Hsu, 2024a; Mohseni et al., 2023; Morris, 2023a).

 

Diagnosis

Chlamydia can be diagnosed through a health history, physical assessment, and laboratory testing. The health history can identify if the patient is at risk for contracting and transmitting the disease; the physical examination can assist the HCP in identifying any signs and symptoms of infection. All sexually active individuals with signs and symptoms, including cervicitis, urethritis, PID, epididymitis, and proctitis, should undergo diagnostic testing. In addition, any individuals determined to be at risk for infection should undergo testing since chlamydia infections can be asymptomatic. The gold standard for the diagnosis of urogenital chlamydia infections includes collecting a specimen for nucleic acid amplification testing (NAAT). Chlamydia cannot be cultured on artificial media and must be grown in tissue culture. NAAT can be performed on vaginal or cervical swabs (preferred method) or a first-void urine for individuals assigned female at birth. These specimens can be collected during a pelvic exam or can be self-collected without affecting sensitivity or specificity. For those assigned male at birth, testing can be performed on a first-void urine (preferred method) or urethral swab. NAATs may also be used for oropharyngeal or rectal specimen testing owing to enhanced sensitivity and specificity. Patients who test positive for chlamydia should be tested for other STIs, including gonorrhea, HIV, and syphilis. For patients with suspected PID, a complete blood count (CBC) should be collected (CDC, 2021, 2025a; Hsu, 2024a; Mohseni et al., 2023; Morris, 2023a; Workowski et al., 2021).

 

Treatment and Management

Treating individuals who test positive for chlamydia prevents adverse reproductive health complications and continued sexual transmission. Treating sexual partners can help prevent reinfection or transmission to other individuals. In addition, treating pregnant individuals can prevent transmission during birth. Individuals should be started on antibiotics to treat the infection. More specifically, adults and adolescents should be started on doxycycline (Monodox, preferred). A pregnancy test should be ordered for individuals assigned female at birth prior to treatment with doxycycline (Monodox). Alternative regimens include azithromycin (Zithromax) or levofloxacin (Levaquin; refer to Table 2 and Table 3). In addition to safe sex practices, the HCP should educate patients on completing the course of treatment (to prevent reinfection and antibiotic resistance) and abstaining from sex for 7 days following treatment. Any sexual partners within the last 60 days (or the most recent partner, even if more than 60 days) should be referred for treatment. Expedited partner therapy (EPT) should be offered where available if partner treatment is a concern. EPT is a strategy where HCPs give the patient medication or a prescription to treat their sexual partner or partners without requiring the partner to be seen by the HCP. Test of cure (at 4 weeks following treatment) is not required for nonpregnant individuals treated with one of the recommended regimens unless therapy adherence is a concern or symptoms persist. Follow-up testing at 3 months is recommended to reduce reinfection rates (CDC, 2024e, 2025a; Hsu, 2024c; Mohseni et al., 2023; Workowski et al., 2021).

 

Table 2

Medications to Treat Chlamydia

Patient Population	Medication	Alternative Medications
Adults and adolescents who are not pregnant	Doxycycline (Monodox) 100 mg orally (PO) twice daily (BID) for 7 days	Azithromycin (Zithromax) 1 g PO as a single dose OR Levofloxacin (Levaquin) 500 mg PO daily for 7 days
Adults and adolescents who are pregnant	Azithromycin (Zithromax) 1 gram PO as a single dose	Amoxicillin (Amoxil) 500 mg three times daily (TID) for 7 days

(Hsu, 2024c; Morris, 2023a; Workowski et al., 2021)

 

Table 3

Side Effects of Medications to Treat Chlamydia

Medication	Side Effects	Contraindications and Precautions
Doxycycline (Monodox)	Nausea, vomiting, diarrhea, hepatotoxicity, Stevens-Johnson syndrome, renal toxicity, urticaria, rash, hemolytic anemia, thrombocytopenia, and intracranial hypertension	Not to be used in patients with a tetracycline allergy Use of this medication may cause a fungal infection, including a super fungal infection Risk for exacerbation of lupus erythematosus and anaphylaxis
Azithromycin (Zithromax)	Nausea, vomiting, diarrhea, abdominal pain, bronchospasm, rash, and pruritus	Contraindicated in patients with hepatic dysfunction and hypersensitivity to azithromycin, erythromycin, any macrolide or ketolide drug Use with caution in patients with prolonged QT interval, altered liver function, risk of developing Clostridium difficile (C. difficile)-associated diarrhea, exacerbation of myasthenia gravis, and development of drug-resistant bacteria
Levofloxacin (Levaquin)	Dizziness, headache, insomnia, hyperglycemia, hypoglycemia, nausea, vomiting, constipation, diarrhea, dyspepsia, chest pain, and vaginitis	Contraindicated in patients with hypersensitivity to levofloxacin (Levaquin) or other quinolone antibiotics Risk for tendinopathy and tendon rupture, exacerbation of myasthenia gravis, hepatotoxicity, convulsions, increased intracranial pressure, prolonged QT interval, Stevens-Johnson syndrome, C. difficile-associated diarrhea
Amoxicillin (Amoxil)	Headache, nausea, vomiting, diarrhea, abdominal pain, and vulvovaginal mycotic infection	Risk for anaphylaxis and hypersensitivity in patients with penicillin allergy Risk for developing superinfections, C. difficile-associated diarrhea, drug-resistant bacteria, and false-positive urinary tests

(Woods, 2024)

 

Gonorrhea

Epidemiology and Pathophysiology

Gonorrhea is the second most common STI and is caused by the bacterium Neisseria gonorrhoeae (N. gonorrhoeae). The WHO estimates that there are 82.4 million new infections annually among individuals aged 15 to 49. In the United States, there are approximately 1.5 million new infections annually, with transmission rates of 22% during vaginal intercourse and 42% among MSM. The bacteria infect the mucus membranes along the reproductive tract, including the fallopian tubes, uterus, and cervix in individuals assigned female at birth, and the urethra, gastrointestinal tract (mouth, throat, rectum), and eyes of individuals assigned male or female at birth. Transmission of the disease during childbirth can lead to conjunctival infection in neonates. If it is not eradicated with antibiotics, patients are at risk for developing infertility, PID, scar tissue on the fallopian tubes, ectopic pregnancy, and abdominal/pelvic pain. Dissemination to the skin and joints can occur, causing lesions on the skin, fever, and migratory polyarthritis or pauciarticular septic arthritis (Bash & Connelly, 2024; CDC, 2025c; Morris, 2025a; WHO, 2024b).

 

Risk Factors and Protective Measures

Any sexually active individual is at risk of contracting gonorrhea. More specifically, those individuals younger than 25 and those with multiple sexual partners (or a new sexual partner) are at greater risk of contracting gonorrhea. Other risk factors include having a sexual partner with an STI or multiple concurrent partners, sporadic use of barrier methods (e.g., condoms), a prior or current history of another STI, and the use of sex to obtain drugs or money. MSM are at increased risk of infection if they engage in substance use or sex with multiple casual partners. Some underrepresented groups are also at increased risk of contracting gonorrhea, including those with lower education levels and lower socioeconomic status. Risk can be decreased when individuals practice safer sex (i.e., correctly and consistently apply condoms and minimize the number of sexual partners; Bash & Connelly, 2024; CDC, 2025c; Springer & Salen, 2023).

 

Screening and Prevention

Individuals assigned female at birth under the age of 25, as well as those who are over the age of 25 and deemed at high risk, should be tested annually for gonorrhea. If the individual contracts gonorrhea, retesting should be completed 3 months after treatment. If individuals are concerned about possible exposure to gonorrhea, they should be tested. Pregnant individuals should be tested if younger than 25 years or older than 25 and deemed at high risk; the same population of pregnant individuals should be retested in the third trimester. If the pregnant individual contracts gonorrhea, retesting should be completed 3 months after the completion of treatment. Screening of asymptomatic sexually active female patients over the age of 25 who are at average risk of exposure is not currently recommended. Currently, there are no clinical guidelines for screening asymptomatic sexually active heterosexual male patients who are at average risk of exposure to gonorrhea. MSM who engage in high-risk behaviors should be screened at all potential exposure sites every 3–6 months or annually if not engaging in high-risk behaviors. Transgender individuals should be screened according to their anatomic sex as assigned at birth. Individuals with HIV should be screened on initial diagnosis of HIV, then annually unless considered at-risk. If the individual is at-risk, screening frequency for gonorrhea should be determined based on the patient’s sexual behavior history (Ghanem & Tuddenham, 2025; Workowski et al., 2021).

 

Signs and Symptoms

Individuals with gonorrhea may be asymptomatic (especially individuals assigned female at birth), making screening essential. If symptoms are present, they may mimic a bladder or vaginal infection, including pain or burning sensation when urinating, increased vaginal discharge, and bleeding between menstrual cycles. Individuals assigned male at birth may experience pain or a burning sensation when urinating, white or purulent penile discharge, or painful or edematous testicles. If the individual has gonorrhea in the rectum, symptoms may include discharge, itching, soreness, painful defecation, and bleeding per rectum (CDC, 2025c; Ghanem, 2024; Morris, 2025a; Springer & Salen, 2023).

 

Diagnosis

Initially, a complete health history and physical exam should be conducted to assess patient risk and determine if diagnostic testing for gonorrhea is required. Diagnosis may be made through the bacterial analysis of a urine sample or swab of potentially infected areas: cervix, rectum, urethra, or throat. As with chlamydia discussed previously, NAAT is the most widely available option for genitourinary infections, although culture (for urethral, endocervical, rectal, oropharyngeal, and conjunctival infections) and point of care (POC) NAAT (i.e., GeneXpert [Cepheid] for genitourinary infections only) are also available. Urine samples, rectal swabs, and pharyngeal swabs can also be processed via NAAT and POC NAAT. Patient-collected samples can also be used with proper patient education/training. Culture and sensitivity testing should be performed in cases of suspected treatment failure. Urethral discharge can also be used for Gram staining in individuals assigned male at birth with reasonable sensitivity and specificity if polymorphonuclear leukocytes with intracellular gram-negative diplococci are observed. However, negative results should not be used to rule out infection. Additional testing for those diagnosed with gonorrhea should include HIV, chlamydia, and syphilis (Ghanem, 2024; Morris, 2025a; Springer & Salen, 2023; Workowski et al., 2021).

 

Treatment and Management

Treatment for gonorrhea consists of antibiotic administration (refer to Tables 4 and 5). Sexual abstinence is crucial until the entire course of treatment has been finished and the patient is asymptomatic; patients should be advised to avoid sexual intercourse for 7 days following the completion of treatment. Patients should be advised to complete the full course of antibiotics to prevent antibiotic resistance; antibiotic-resistant strains of gonorrhea are becoming increasingly prevalent. The CDC no longer recommends cefixime (Suprax) for gonorrhea treatment in the United States. Dual therapy with ceftriaxone (Rocephin) and azithromycin (Zithromax) was previously recommended to decrease antibiotic resistance rates, yet the consequences regarding microbiome health and impact on other pathogens have become evident. For this reason, only ceftriaxone (Rocephin) is recommended for treating gonococcal infections in patients who have tested negative for chlamydial infection. If chlamydial infection cannot be ruled out, dual therapy with doxycycline (Monodox), as described in Table 1, is still recommended. Gonococcal infection treatment should be done on-site, administered, and directly observed. Test-of-cure is only recommended for pharyngeal infections at 7–14 days. Any sexual partners within the last 60 days (or the most recent partner if more than 60 days) should be referred for treatment. EPT should be offered where available if partner treatment is a concern (CDC, 2025c; Workowski et al., 2021).

 

Table 4

Medications to Treat Gonorrhea

Preferred Medication

Alternative Medications

Ceftriaxone (Rocephin) 500 mg intramuscularly (IM) in a single dose for persons weighing < 150kg (1 g IM for persons weighing > 150 kg)

If cephalosporin allergy: Gentamicin (Garamycin) 240 mg IM in a single dose PLUS Azithromycin (Zithromax) 2 g PO in a single dose If ceftriaxone (Rocephin) is unavailable or not feasible but no allergy concerns: Cefixime (Suprax) 800 mg PO in a single dose If pharyngeal infection and unable to take/access ceftriaxone (Rocephin): No reliable treatment alternatives have been studied. Consult an infectious disease specialist.

(Morris, 2025a; Sena & Cohen, 2025; Springer & Salen, 2023; Workowski et al., 2021)

 

Table 5

Side Effects of Medications to Treat Gonorrhea

Medication	Side Effects	Contraindications and Precautions
Ceftriaxone (Rocephin)	Injection site: pain, phlebitis, tenderness Elevation of renal and hepatic lab function tests, nausea, vomiting, diarrhea, vaginitis, rash, pruritus, fever, and chills	Contraindications: patients with allergy to penicillin, cephalosporins, or beta-lactam antibiotics Use cautiously in patients taking calcium-containing products (do not place this in the same intravenous [IV] line); risk for neurologic events (encephalopathy, seizures, myoclonus), hemolysis, renal and pancreatic impairment, gallbladder precipitates, altered prothrombin time, development of drug-resistant bacteria, development of C. difficile-associated diarrhea
Gentamicin (Garamycin)	Respiratory depression, lethargy, confusion, depression, visual disturbances, decreased appetite, weight loss, hypotension, and hypertension; rash, itching, urticaria, generalized burning, laryngeal edema, anaphylactoid reactions, fever, and headache; nausea, vomiting, increased salivation, and stomatitis; purpura, pseudotumor cerebri, acute organic brain syndrome, pulmonary fibrosis, alopecia, joint pain, transient hepatomegaly, and splenomegaly Elevated liver function panel, decreased serum calcium, thrombocytopenia	Boxed warning: neurotoxicity, ototoxicity, nephrotoxicity
Azithromycin (Zithromax)	Nausea, vomiting, diarrhea, abdominal pain, bronchospasm, rash, and pruritus	Contraindicated in patients with hepatic dysfunction or hypersensitivity to azithromycin (Zithromax), erythromycin (Erythrocin), any macrolide, or any ketolide drug Precaution in patients with prolonged QT interval, altered liver function, infants with prolonged treatment (greater than 42 days); risk of developing C. difficile-associated diarrhea, exacerbation of myasthenia gravis, and development of drug-resistant bacteria
Cefixime (Suprax)	Diarrhea, flatulence, nausea, abdominal pain, and dyspepsia	Contraindicated in patients with a documented allergy to cefixime (Suprax) or other cephalosporins Precaution: Fall in prothrombin activity, C. difficile-associated diarrhea, development of drug-resistant bacteria

(Woods, 2024)

 

Genital Herpes

Epidemiology and Pathophysiology

Globally, an estimated 3.8 billion individuals (64% of the population) under the age of 50 have HSV. Among individuals aged 50 to 99, there are an additional 1.5 billion infections. The prevalence is highest among low- and middle-income countries. Approximately 1 in 5 individuals have HSV in the United States; however, many may be asymptomatic and not know they carry the disease. HSV is a viral STI with two strains, herpes simplex type 1 (HSV-1) and herpes simplex type 2 (HSV-2). These strains can cause sores on the mouth, genitals, or anal areas. Lesions around the mouth are known as cold sores or fever blisters and are typically associated with HSV-1. Genital warts are usually associated with HSV-2, although anogenital infections can be related to HSV-1. HSV infection during pregnancy carries a risk of negatively impacting the fetus, particularly if acquired in the first trimester. The disease may remain dormant for several years before a recurrence/outbreak, but the average incubation period is 4 days (Albrecht, 2024a; Kaye, 2023; Matthew & Sapra, 2024).

 

Risk Factors and Protective Measures

Risk factors for HSV mirror those of other STIs, including multiple sexual partners, age under 50, and individuals assigned female at birth. It is more commonly diagnosed in non-Hispanic Black individuals than in non-Hispanic White individuals. Consistent and appropriate use of a barrier method (e.g., condoms) most effectively decreases the risk of HSV transmission. It is more effective in limiting transmission from individuals assigned male at birth to those assigned female but less effective in decreasing transmission from individuals assigned female at birth to those assigned male. Circumcision for individuals assigned male at birth is still being investigated as a method for reducing transmission among adult heterosexual males. Antivirals cannot be used to prevent HSV transmission, although daily oral tenofovir/emtricitabine (TDF/FTC, Truvada) may decrease the risk of transmission in heterosexual partners. Recent HSV infection is a known risk factor for HIV transmission (Albrecht, 2024a; Kaye, 2023; Matthew & Sapra, 2024; Workowski et al., 2021).

 

Screening and Prevention

Routine screening for genital HSV infections is not recommended. Screening for HSV-1 and HSV-2 should be done in patients with multiple sexual partners and if they are newly diagnosed with another genital tract infection. Pregnant patients should be screened for HSV if they have multiple sexual partners or engage in high-risk behaviors. Condoms can prevent the spread of HSV (Albrecht, 2024a; Kaye, 2023; Matthew & Sapra, 2024; Workowski et al., 2021).

 

Signs and Symptoms

 

Initial Infection. The mean time between sexual contact and the first genital lesions in an initial infection is five days. After that, multiple lesions develop, and the typical progression begins with erythematous papules changing to 2–4 mm vesicles, which then develop into pustules. The vesicles are typically surrounded by erythema. Within three to five days, the pustules break and become painful ulcers that usually heal without scarring. Approximately one-third of patients also report headaches, fever, malaise, lymphadenopathy, dysuria, and myalgias. Vaginal or urethral discharge is common, and dysuria can occur if the lesions are near the urethra. For most patients, the signs and symptoms of an initial infection last an average of 19 days (Albrecht, 2024a; Corey, 2025; Kaye, 2023; Matthew & Sapra, 2024).

 

Recurrent Episodes. After the initial symptomatic episode, recurrent symptomatic episodes are pervasive, occurring in approximately 80%–90% of all individuals. It is unknown what causes recurrent symptomatic episodes, but fever, emotional stress, exposure to sunlight, and ultraviolet (UV) radiation can precipitate an episode. The number, frequency, and duration of recurrences vary from person to person. The average number of recurrences per year is four to five and typically decreases over time. Before a recurrence, the individual may report a prodromal syndrome characterized by local paresthesia in the buttocks, genitals, or perineum. Vesicular lesions appear, the individual has mild systemic symptoms like itching or pain, and recurrent episodes last about two to five days. The systemic effects resolve, and the lesions heal. Rarely, infection with genital HSV can cause encephalitis and acute and recurrent aseptic meningitis (Albrecht, 2024a; Corey, 2025; Kaye, 2023; Matthew & Sapra, 2024).

 

Diagnosis

NAAT or culture testing can be performed only when genital lesions are present. These virologic tests are type-specific, allowing for patient education and counseling based on which HSV subtype is identified. NAAT assays are the most sensitive (90.9%–100%) and can be used to diagnose genital or oral lesions. Alternatively, type-specific serologic testing based on the HSV-specific glycoprotein G2 and G1 (i.e., gG2 and gG1) can be performed during asymptomatic periods (no active lesions present). Their sensitivity ranges from 80%–98%. False-negative results are more common early, so negative tests can be repeated at 12 weeks to confirm. Confirmatory testing with Biokit or Western blot can also be beneficial in enzyme immunoassays (EIAs) with low specificity, such as the widely used HerpeSelect HSV-2. Polymerase chain reaction (PCR) testing of the blood should be considered for suspected systemic HSV infections (e.g., meningitis, encephalitis, hepatitis, or neonatal HSV). Viral culture is associated with low sensitivity but may be used when better options are unavailable. Negative NAAT or culture results should not rule out infection, as viral shedding is intermittent. Both Tzanck preparation to detect cellular changes related to HSV infection cytologically and direct immunofluorescence assay using fluorescein-labeled antibodies are unreliable owing to poor sensitivity and specificity. The risk for HIV is increased 2–3X in patients currently infected with HSV-2, so any patient diagnosed with an HSV-2 genital infection should also be tested for HIV (Albrecht, 2024a; Kaye, 2023; Matthew & Sapra, 2024; Workowski et al., 2021).

 

Treatment and Management

Being diagnosed with HSV can be stressful; patients should be advised of support groups and psychological services to help cope. In addition, patients should be educated that HSV can spread to their sexual partners even when active lesions are not present. Genital HSV is an incurable, lifelong viral infection, and no vaccine can prevent HSV infection, but there are approved medications that can treat infections via suppression (refer to Table 6). Antiviral medications treat/suppress initial and recurrent episodes; treatment goals do not include eradication of the infection. Topical therapies have minimal effect and are generally discouraged (Albrecht, 2024b; Corey, 2025; Matthew & Sapra, 2024; Workowski et al., 2021).

Antivirals for long-term suppression therapy have been shown to prevent and shorten recurrent episodes of genital HSV, reduce asymptomatic shedding to decrease transmission between partners, reduce the risk of complications, and improve quality of life. Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) have been shown to be similarly effective in treating recurrences. The choice of medication is based on convenience, cost, and the prescriber’s preference. Beginning treatment within 24 hours of the onset of symptoms will help shorten the duration of symptoms by 1 to 2 days. Although antiviral therapy effectively prevents, limits the duration, and decreases the severity of recurrent outbreaks, these beneficial effects only occur during active treatment with the medications. Episodic treatment can be used to shorten the duration of recurrent outbreaks, or suppressive therapy can be used to reduce the frequency of outbreaks by 70%–80% and decrease the risk of transmission. Famciclovir (Famvir) may be less effective in decreasing viral shedding, and once-daily dosing of valacyclovir (Valtrex) may be less effective for those with 10 or more outbreaks per year. Severe cases or complications requiring hospitalization are treated with IV acyclovir (Zovirax) dosed at 5–10 mg/kg every 8 hours until clinical improvement. Oral antivirals should follow this for a minimum of 10 days of total treatment (Albrecht, 2024b; Corey, 2025; Kaye, 2023; Matthew & Sapra, 2024; Workowski et al., 2021).

 

Table 6

Antiviral Therapy for Genital Herpes in Immunocompetent Patients

Initial Treatment	Episodic Recurrent Treatment	Suppressive Treatment
Acyclovir (Zovirax) 400 mg PO TID for 7–10 days OR Famciclovir (Famvir) 250 mg PO TID for 7–10 days OR Valacyclovir (Valtrex) 1 gm PO BID for 7–10  days	Acyclovir (Zovirax) 800 mg PO BID for 5 days or TID for 2 days OR Famciclovir (Famvir) 1 gm PO BID for 1 day or 500 mg once, then 250 mg PO BID for 2 days or 125 mg PO BID for 5 days OR Valacyclovir (Valtrex) 500 mg PO BID for 3 days or 1 gm PO daily for 5 days	Acyclovir (Zovirax) 400 mg PO BID OR Valacyclovir (Valtrex) 1 gm PO daily or 500 mg PO BID OR Famciclovir (Famvir) 250 mg PO BID

(Albrecht, 2024b; Matthew & Sapra, 2024; Workowski et al., 2021)

 

Human Papillomavirus

Epidemiology and Pathophysiology

Currently, HPV is one of the most common STIs in the United States and was identified in 42 million Americans; 13 million Americans are infected annually, including adolescents. Most sexually active individuals, whether male or female, will contract a genital HPV infection at some point in their lives. However, most of these infections will remain clinically silent, causing no symptoms, and resolve without treatment or complications. According to the CDC, by age 50, at least 4 out of 5 individuals assigned female at birth will have experienced an HPV infection, with the highest number of HPV infections among those ages 20 to 24. If the infection initially occurs after age 30, the person’s risk for cervical cancer increases. Globally, cervical cancer is the fourth most common type of cancer in individuals assigned female at birth and the second most common in those aged 15–44 years. Furthermore, each year, over 36,500 cases of cancer are linked to HPV in the United States. The direct annual cost of HPV is estimated at just over $9.01 billion (CDC, 2024a, 2024c, 2024d; Clay et al., 2023; Hinkle et al., 2021; National Cancer Institute, 2025; Norris, 2020; WHO, 2024a).

HPV can be transmitted via skin contact during vaginal, anal, and oral sexual intercourse. The virus comprises a family of small, double-stranded deoxyribonucleic acid (DNA) viruses that may cause lesions on the squamous epithelium. These benign lesions are visible condyloma acuminata (i.e., genital warts). The DNA replicates, causing the basal membrane to become occupied by the virus. In the early stages, low-grade intraepithelial lesions develop. These lesions are known and graded according to their neoplasia; thus, in their early stage, a low-grade intraepithelial lesion is referred to as cervical intraepithelial neoplasia (CIN), which involves one-third of the epithelium. CIN II covers two-thirds of the epithelium, and CIN III covers the entire epithelium. CIN I is low risk, whereas CIN II and CIN III demonstrate higher risk (Hoffman & Sullivan, 2020; Luria & Cardoza-Favarato, 2023; Meites et al., 2024).

HPV has over 200 types, affecting the genitals, mouth, and throat, which are differentiated according to their genomic sequence and the risk of cervical cancer development. Not all types of HPV will cause cervical cancer; low-risk types include 6, 11, 42, 43, 44, 54, 61, 70, and 72. 90% of HPV cases are deemed low-risk and present asymptomatically or with condyloma acuminata, infecting cutaneous epithelium and causing common warts. Benign or low-grade cervical abnormalities, anogenital warts, and respiratory tract papillomas can occur with types 6 and 11; these genital warts are visible and palpable on the vulva, vagina, cervix, and anus. Approximately 40 types infect the mucosal epithelium. The incubation period for HPV ranges from 3 weeks to 8 months to decades; the longer the incubation period is, the more likely it will correlate with a cervical cancer diagnosis (Hinkle et al., 2021; Hoffman & Sullivan, 2020; Luria & Cardoza-Favarato, 2023; Meites et al., 2024; Norris, 2020).

HPV types more frequently associated with cervical malignancy include 16, 18, 31, 33, 45, and 52. High-risk HPV types are detected in 99% of cervical precancers. CIN-specific subtypes, such as 16 and 18, place individuals at a greater risk of developing uncontrolled cervical dysplasia and cervical cancer. These types are evident in 70% of patients with cervical cancer. Type 16 accounts for 50% of all cervical cancers, and together with type 18, accounts for 66% of cervical cancers. In nearly all cases of cervical cancer, patients will test positive for infectious HPV. Cervical cancer typically develops within 3 to 7 years following changes in cervical cellular structure. Preventing HPV-related cervical cancer can occur through annual Papanicolaou (Pap) testing (ACOG, 2023; Hinkle et al., 2021; Hoffman & Sullivan, 2020; Luria & Cardoza-Favarato, 2023; Meites et al., 2024).

 

Risk Factors and Protective Measures

Individuals at greatest risk for developing HPV are young adults under age 25, individuals who are sexually active at a young age with a first partner at age 16 or younger, and those with multiple sex partners or a partner with multiple sex partners. In addition, lower socioeconomic status, smoking, poor nutrition, oral contraceptive use for more than five years, exposure to radiation and UV light, douching, and HSV-2 are other risk factors for HPV. Males are at risk of contracting HPV as well. HPV can contribute to the development of penile, anal, and oropharyngeal cancers in males. Immunocompromised individuals, including those with HIV, are at increased risk of developing cancer. In addition, individuals who receive anal sex are more likely to develop anal cancer (i.e., squamous cell carcinoma of the anus due to HPV-16). As a result, patient education in disease prevention is a critical nursing intervention, complemented by HPV immunization when appropriate. If an individual assigned female at birth contracts HPV, their risk for cervical cancer increases if they smoke, are immunosuppressed, or are exposed to hormone alterations (due to medications or pregnancy; CDC, 2024a; Donà et al., 2022; Hoffman & Sullivan, 2020; Luria & Cardoza-Favarato, 2023; Norris, 2020).

 

Screening and Prevention

In sexually active females, ages 21–29, recommendations for testing for HPV with cytology can vary based on the various guidelines (refer to Table 7). In patients with a cervix aged 30–65, screening should occur every 3 years with cytology or every 5 years with cytology and HPV testing (co-testing) or primary HPV testing. Pregnant individuals should be screened at the same frequency as nonpregnant individuals. MSM should be screened if at risk for anal cancer; transgender patients should be screened if at risk for cervical cancer. Individuals with HIV should be screened for HPV if at risk for cervical cancer. HPV vaccination is now the most effective method of prevention. Typically, HPV vaccination is administered at ages 11–12 in both males and females. However, the US Food and Drug Administration (FDA) expanded the use of Gardasil-9 in 2018 to include individuals aged 9 to 45. It prevents viral types 6, 11, 16, 18, 31, 33, 45, 52, and 58, which are attributed to the bulk of cervical cancer types. In patients between 9 and 14 years of age, the 2-dose series should be administered with 6–12 months between doses; in those 15 years and older, the 3-dose series is recommended at 0, 2, and 6 months. If children are sexually abused, have HIV, or are immunocompromised, HPV immunization is encouraged at age 9. A three-dose series is also recommended in those who did not wait the recommended 6 months between their first two doses or are immunocompromised. Pregnant individuals should not be given the vaccination. Preventing HPV and HPV-related cancers is also possible through proper condom use and sexual monogamy (ACOG, 2023; CDC, 2021; Cox & Palefsky, 2025; Workowski et al., 2021). For additional details on HPV vaccination, please refer to the Human Papillomavirus NursingCE Course.

 

Signs and Symptoms

Generally, HPV is asymptomatic and resolves without treatment within 2 years for 90% of patients. However, if an individual is immunocompromised or has specific subtypes of HPV, they are at risk for developing cervical dysplasia, genital warts, and cervical cancer. Genital warts on external surfaces tend to be small, flat, and flesh-colored, with a rough surface and a pedunculated appearance, affecting individuals of all genders. Internal genital warts (i.e., on the vagina, urethra, anus, or mouth) may have a cauliflower-like appearance. Symptomatic patients may experience itching, burning, or tenderness in affected areas (CDC, 2025b; Hoffman & Sullivan, 2020; Morris, 2025b; Norris, 2020).

 

Diagnosis

Since most subtypes of HPV are asymptomatic, screening for the virus is essential. HPV testing can be performed during Pap smears. A cervical swab sample is placed under a microscope to look for changes in cellular structure that demonstrate malignancy (cytology). Currently, HPV DNA can be identified using a hybridization solution. The testing confirms whether DNA for a high-risk HPV subtype is present. This testing can be performed alone or in conjunction with cytology, referred to as co-testing (Hoffman & Sullivan, 2020; Morris, 2025b; Norris, 2020). According to the American Cancer Society (ACS), all individuals assigned female at birth over 25 should receive HPV testing with their Pap smears. Testing for HPV is based on an assessment of age and risk (ACS, 2021, 2023, 2025). According to ACOG (2021) and the US Preventive Services Task Force, cervical cytology should begin earlier (age 21), with HPV testing incorporated later based on shared decision-making. Refer to Table 7 for recommendations from both groups.

 

Table 7

ACS 2020 Cervical Cancer Screening Guidelines Versus 2021 ACOG/USPSTF Guidelines

Age Range	2020 ACS Guidelines	2021 ACOG/USPSTF Guidelines
0–20	No screening recommended
21–24	No screening recommended	Cytology alone every 3 years
25–29	Three options: primary HPV testing every 5 years, OR co-test every 5 years OR cytology alone every 3 years	Cytology alone every 3 years, although primary HPV testing every 5 years may be considered in average-risk patients
30–65	Three options: primary HPV testing every 5 years, OR co-test every 5 years OR cytology alone every 3 years
65+	the decision to continue screening beyond 65 years depends on individual risk factors and past medical history who have undergone regular screening in the past 10 years with normal results and no history of CIN-2 or higher can stop screening once screening is stopped, it should not be started again
Patients who had a total hysterectomy with removal of the cervix	No screening is recommended unless it was performed to treat cervical precancer or cancer

(ACS, 2021; ACOG, 2021)

A colposcope—a low-power binocular microscope—allows visualization of the mucosal layers of the cervix and vagina. Acetic acid aids in the visualization of the columnar epithelium by removing mucus. Lugol’s solution is applied to examine the cervix and vagina during the procedure. The solution uses iodine, so patients should be assessed for an iodine allergy. Biopsies may be required if the tissue stained with the Lugol’s solution appears lighter in color than the surrounding healthy tissue (typically brown). For individuals assigned male at birth, HPV biopsy results may demonstrate intraepithelial neoplasia of the penis or anus. Neoplasia can result in penile or anal cancer. If HPV affects the throat, tongue, or tonsils, patients are also at risk for developing oropharyngeal cancer, so a visualization scope and biopsy may be required (CDC, 2024c; Hoffman & Sullivan, 2020; Norris, 2020).

 

Treatment and Management

Patients should be encouraged to maintain a healthy lifestyle to promote greater well-being through a balanced diet, smoking cessation, and limited alcohol intake. Patients may require psychosocial care to address anger and frustration related to developing warts or not knowing who infected them. Nurses can provide support by acknowledging the patient’s distress, educating them on preventing disease transmission, and coordinating care with social workers to address the patient’s psychosocial needs. Nurses should assess for pain and encourage patients to report any worsening pain or vaginal discharge (ACOG, 2023; Hinkle et al., 2021; Hoffman & Sullivan, 2020; Morris, 2025b; Norris, 2020).

If a patient has external genital warts, they may be prescribed a topical ointment of trichloroacetic acid (Tri-Chlor) or podophyllin (Podofin, Podocon). Patients may be prescribed topical products that can be self-administered at home, such as podofilox (Condylox) 0.5% gel or solution, imiquimod (Aldara) 5% cream, or sinecatechin (Veregen) 15% ointment. These agents work by collapsing the area surrounding the wart and encouraging an immune response. They may also require cryotherapy (thermal-induced cytolysis) or surgical removal of genital warts. Electrocautery or laser treatment may be warranted for abundant genital warts. While treatment for HPV is usually successful, the infection is viral, and treatments are not curative. They are designed to elicit an immune response. Given this, patients with weakened immune systems, those with diabetes, those who smoke, and pregnant individuals have an increased risk of pharmacologic resistance. Nurses should educate patients on the risk of local skin irritation and pain with topical applications. If a patient is experiencing pain, nurses should provide analgesia and reassess the treatment’s efficacy. Nurses should educate patients not to use over-the-counter wart removers for genital warts (ACOG, 2023; Carusi, 2025; Hinkle et al., 2021; Hoffman & Sullivan, 2020; Morris, 2025b).

If the tissue is high-grade neoplasia (CIN II or III), genital warts and the surrounding tissue should be extracted to assess for cervical cancer. Tissue can be removed by surgical ablation, excision, laser conization, or loop electrosurgical excision. Ablation utilizes temperature changes to remove the affected area through cryosurgery (freezing) or laser treatment. The impacted area may be excised using cold knife colonization (CKC). Using a laser, cervical tissue can be removed via laser conization. An electrosurgical excision uses a painless current to remove the tissue. If the tissue progresses to malignancy, then further resection, chemotherapy, and radiation may be required. Side effects of these therapies can include skin irritation, edema, blistering, and ulceration. These therapies may result in scarring or persistent hypo- or hyperpigmentation (Carusi, 2025; Hoffman & Sullivan, 2020; Luria & Cardoza-Favarato, 2023; Morris, 2025b).

 

Syphilis

Epidemiology and Pathophysiology

Syphilis is endemic in developing countries, particularly in areas that have limited access to health care. The WHO estimates that there are 7.1 million cases of syphilis annually worldwide, with the highest incidence occurring in Southeast Asia, Latin America, southern Africa, and the Caribbean. Additionally, the CDC estimates that the incidence of syphilis among adults in the United States has been on the rise, with 207,255 new cases in 2022, up from 88,042 cases in 2016. Syphilis is a multistaged bacterial disease caused by Treponema pallidum (T. pallidum). The disease is transmitted through direct contact with a chancre; a chancre is a visible but painless sore on the vagina, penis, rectum, lips, or mouth. Syphilis may also be transmitted vertically to a fetus. According to the CDC, the incidence of congenital syphilis in the United States has quadrupled from 2015 to 2019, with a rate of 78 cases/1,000 live births. Individuals with a stillborn delivered after 20 weeks should be screened for syphilis, as untreated syphilis has been found to contribute to 40% of fetal deaths (CDC, 2025d; de St. Maurice, 2025; Tudor et al., 2024; Workowski et al., 2021; WHO, 2025).

 

Risk Factors and Protective Measures

High-risk individuals include pregnant individuals (especially those not receiving prenatal care), those with multiple sexual partners, those engaged in active substance use, individuals who are incarcerated or have an incarcerated sexual partner, individuals experiencing homelessness, and MSM. Prevention can occur with proper use of condoms and being in a mutually monogamous relationship (CDC, 2025d; Ghanem & Tuddenham, 2025).

 

Screening Guidelines

Sexually active individuals who are deemed at risk should be screened for syphilis. Prenatal screening for syphilis should occur on the first prenatal visit. If the pregnant individual is found to be high-risk or has a new sexual partner since conception or the sexual partner tests positive for an STI, additional screening during week 28 of gestation is advised. Heterosexual male patients should be screened for syphilis if they are considered high-risk or have a history of syphilis infection. In MSM, screening should be conducted every 3–6 months if at increased risk; if sexually active but not at high risk, annual screening is recommended. If a patient is transgender, annual screening should be done based on sexual activity and potential exposure. For patients with HIV, syphilis should be tested for on initial diagnosis of HIV and annually after that (Ghanem & Tuddenham, 2025; Hicks & Clement, 2024a; Workowski et al., 2021).

 

Signs and Symptoms

The clinical course of syphilis has been divided into stages. These stages are unique in their clinical presentation as well as their recommended treatment (Hicks & Clement, 2023; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Primary Stage. The patient may present with a chancre or multiple chancres at the transmission site. Typically, the chancre is present for 3–6 weeks and heals without treatment. Patients need to be educated that a healed chancre does not mean the cessation of the disease. Without antibiotic treatment, syphilis will advance to the secondary stage and beyond (Hicks & Clement, 2023; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Secondary Stage. Like the primary stage, the second stage contains dermatologic alterations. The patient may demonstrate rashes at multiple sites on their body, including the transmission site. The rash may be present on the hands and feet and be painless, rough, red, or reddish-brown in appearance. Furthermore, the rash may appear faint, making it challenging to identify. Some patients may present with condylomas (white or gray bumps) in warm, moist areas such as the mouth, axilla, or groin. Patients may also present with hair loss and other systemic signs such as fever, lymphadenopathy, weight loss, fatigue, myalgia, headaches, and a sore throat. However, despite the resolution of systemic signs and symptoms, the disease will advance to the latent stage if not treated with antibiotics. Ocular syphilis occurs when the infection affects the visual system. It may present with panuveitis (inflammation of all components of the eye), conjunctivitis, optic neuropathy, retinal vasculitis, anterior uveitis, or posterior interstitial keratitis. Otosyphilis may cause hearing or balance dysfunction, such as vertigo, tinnitus, and hearing loss that is typically sudden in onset and rapidly progressive. Hearing or vision loss related to syphilis may be permanent (Hicks & Clement, 2023; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Latent Stage. Although this stage is asymptomatic, individuals are still capable of transmitting syphilis to others. This stage can last for years and may be classified as early (if within 12 months of exposure) or late (Hicks & Clement, 2023; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Tertiary Syphilis. If an individual does not obtain treatment, syphilis will go from the latent to the tertiary stage. To reach this final stage, the disease has been present in the body for 10–30 years. Tertiary syphilis causes significant multiorgan system damage and increases the risk of death in the individual. The disease can damage the brain, heart, blood vessels, liver, bones, joints, and skin. Of heightened concern is the risk of dysfunction in the nervous system. Neurosyphilis can cause loss of coordination, numbness, paralysis, severe headaches, cranial nerve dysfunction, meningitis, alterations in cognitive function, or stroke. Neurosyphilis can occur during any stage described here. All patients diagnosed with tertiary-stage disease should undergo cerebrospinal fluid (CSF) evaluation (Hicks & Clement, 2023; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Neonatal Onset. Neonates born with syphilis may be asymptomatic. However, the disease can overwhelm a neonate’s body and cause a cascade of future health problems, thus making early treatment imperative. If a neonate is not treated for syphilis within the first few weeks of life, they may experience seizures, developmental delays, or death. If the patient is treated with penicillin while pregnant, disease transmission is reduced (de St. Maurice, 2025; Morris, 2025c; Hicks & Clement, 2023; Workowski et al., 2021).

 

Diagnosis

The risk of syphilis can be assessed through a health history. A physical assessment and specimen collection to isolate the bacterium in the laboratory are then done to confirm a suspected diagnosis. There are no commercially available molecular NAATs for direct detection, although several labs have developed validated PCR tests available locally. Two serologic tests are used to confirm a syphilis diagnosis. The traditional algorithm utilizes an initial quantitative nontreponemal immunoassay with a titer (rapid plasma regain [RPR] or venereal disease research laboratory [VDRL]). If this is positive, the lab utilizes the same specimen for another immunoassay (treponemal test) for treponemal antibodies. This includes T. pallidum Particle Agglutination (TP-PA), EIAs, immunoblots, chemiluminescence immunoassays (CIA), and rapid treponemal assays. If this test identifies treponemal antibodies, the diagnosis of syphilis is confirmed. This process is required owing to a high rate of false positive results on the nontreponemal immunoassay related to pregnancy, certain vaccines, other infections (HIV), autoimmune disease, injection substance use, and increased age (Hicks & Clement, 2024a; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

Some labs will reverse the process, referred to as the reverse sequence algorithm. In this case, the serum sample is screened first using an automated treponemal immunoassay (EIA or CIA). If positive, the sample is immediately tested by the lab using a quantitative nontreponemal test with a titer (RPR or VDRL). If the nontreponemal test is positive, the diagnosis of syphilis is confirmed. If the nontreponemal test is negative, a second treponemal test is then run on the same sample by the same lab, preferably a TP-PA or assay based on a different antigen than the first test. If the second treponemal test is positive, the patient should be treated for syphilis (unless previously diagnosed and treated). If the second treponemal test is negative, and the risk/probability of syphilis is low, nothing further is indicated. Serial testing using a quantitative nontreponemal titer may be used to assess treatment response. However, the same test (preferably from the same manufacturer) should be used to avoid variation in results. Those with signs of neurosyphilis should undergo CSF analysis for cell count, protein, and VDRL reactivity. All patients diagnosed with syphilis should be tested for HIV and offered HIV pre-exposure prophylaxis (PrEP) if testing is negative (Hicks & Clement, 2024a; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

Neonates. If syphilis is suspected in a neonate, they may be subject to a battery of tests to confirm the presence of the disease. Suspicion of syphilis occurs when the pregnant patient tests positive for syphilis, as there is a concern for vertical transfer of the disease. Using infant serum, a quantitative nontreponemal test can be analyzed for congenital syphilis (RPR or VDRL). The HCP may also request further testing of bodily fluids from the placenta, umbilical cord, or other tissues. Treponemal tests (e.g., TP-PA, immunoassay-EIA, CIA, or microbead immunoassay) and commercially available immunoglobulin M (IgM) tests are not recommended; they are challenging to interpret owing to passive antibodies from the pregnant patient, which may remain for 15 months or longer. The testing may require the use of darkfield microscopy or PCR testing. In addition, testing may include a CBC with differential and platelets; analysis of CSF for VDRL, cell count, and protein; and long-bone radiographs (Hicks & Clement, 2024a; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Treatment and Management

Syphilis treatment includes antibiotics (refer to Table 8) and depends on the staging and patient population; penicillin is the primary medication used. The formulation, dose, and duration depend on the patient population and disease staging. Pregnant individuals with a penicillin allergy should undergo penicillin desensitization prior to treatment. If a pregnant individual misses a dose, they should repeat the entire course of treatment. Between 50% and 75% of patients with early syphilis develop the Jarisch–Herxheimer reaction from penicillin. The Jarisch–Herxheimer reaction begins within 24 hours after injection and is characterized by fever, headache, and myalgias. The response is short-lived, lasting approximately 24 hours, and resolves without sequelae; in pregnant individuals, it may precipitate early labor. Antipyretics can be used for symptomatic treatment (Hicks & Clement, 2024b; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Table 8

Medications to Treat Syphilis

Population	Medication	Alternative Medication
Nonpregnant: primary, secondary, early latent stages	Benzathine penicillin G (Bicillin L-A) 2.4 million units IM in a single dose (in infants and children: 50,000 units/kg IM in a single dose, max dose 2.4 million units)	Doxycycline (Monodox) 100 mg PO BID × 14 days OR Tetracycline (Sumycin) 500 mg PO four times daily (QID) × 14 days OR Ceftriaxone (Rocephin) 1 gram IM or IV daily × 10-14 days
Nonpregnant: late latent stage, tertiary stage (with no involvement in cerebral spinal fluid)	Benzathine penicillin G (Bicillin L-A) 7.2 million units administered as three doses of 2.4 million units IM each at 1-week intervals	Doxycycline (Monodox) 100 mg PO BID × 28 days OR Tetracycline (Sumycin) 500 mg PO QID × 28 days
Neurosyphilis, ocular syphilis, or otosyphilis	Aqueous crystalline penicillin G (Pfizerpen), 18–24 million units daily, administered continuously or 3–4 million units IV Q4H × 10–14 days	Procaine penicillin G 2.4 million units IM daily × 10-14 days PLUS Probenecid 500 mg PO QID × 10–14 days OR In the setting of severe penicillin allergy: Ceftriaxone 1–2 gm IM or IV daily × 10–14 days
Pregnant: primary, secondary, or early latent stage	Benzathine penicillin G (Bicillin L-A) 2.4 million units IM as a single dose	None
Pregnant: late latent stage or tertiary syphilis (with normal CSF)	Benzathine penicillin G (Bicillin L-A) 7.2 million units administered in three doses of 2.4 million units IM each, at 1-week intervals	None
Neonates	Aqueous crystalline penicillin G (Pfizerpen) 100,000–150,000 units/kg/day, administered 50,000 units/kg IV Q12H × 7 days, then Q8H × 3 days	Procaine penicillin G 50,000 units/kg IM daily × 10 days

(Hicks & Clement, 2024b; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021)

Patients should be advised not to have sexual intercourse until the chancres are completely healed. Furthermore, patients should be counseled to inform their partners and advise them to seek treatment to prevent reinfection. Sexual partners within the last 90 days can be treated for syphilis presumptively. Those exposed more than 90 days prior should be tested but may be treated presumptively if testing results are delayed, or follow-up is tenuous. Patients should be educated on proper condom application and limiting the number of sexual partners to prevent recurrence. Clinical and serologic follow-up (typically with repeat quantitative nontreponemal titer, expected to decrease fourfold in 12 months) is recommended at 6 and 12 months following treatment. Those diagnosed with latent disease should follow up at 6, 12, and 24 months (Hicks & Clement, 2024b; Morris, 2025c; Tudor et al., 2024; Workowski et al., 2021).

 

Trichomoniasis

Epidemiology and Pathophysiology

Trichomoniasis is the most common nonviral STI worldwide, with over 150 million new cases annually. It occurs more commonly in individuals assigned female at birth compared to those assigned male (5.3% vs. 0.6%). The CDC estimates 2 million new cases of trichomoniasis annually in the United States. Trichomoniasis is a parasitic infection; Trichomonas vaginalis (T. vaginalis) is a protozoan that attacks the lower genital reproductive tract in individuals assigned female at birth and the urethra in those assigned male at birth during sexual intercourse. The disease can be transmitted during vaginal, oral, or anal sex or genital touching. Trichomoniasis is the size of a white blood cell, with at least four flagella that provide undulating motility. While in the urogenital tract, the organism releases cytotoxic proteins that destroy the epithelial lining (CDC, 2025e; Schumann & Plasner, 2023; Sobel & Mitchell, 2023; Workowski et al., 2021).

 

Risk Factors and Protective Measures

Trichomoniasis is more common in individuals assigned female at birth compared to those assigned male. In addition, infection is found equally as often in those over the age of 24 as in those under. The condition is more common in Black individuals assigned female at birth than in White or Hispanic individuals assigned female at birth. Individuals assigned male at birth experience fewer signs and symptoms and are therefore less likely to know they are infected, not seek treatment, and unknowingly transmit the disease to their partner. Rates of trichomoniasis are higher in those previously incarcerated or with two or more sexual partners in the previous 12 months. Other risk factors include individuals with less than a high school education and living below the national poverty level. Bacterial vaginosis, although not an STI, increases the risk of trichomoniasis infection, as does vaginal douching. Condom use is the best method of prevention (CDC, 2025e; Schumann & Plasner, 2023; Sobel & Mitchell, 2023; Workowski et al., 2021).

 

Screening and Prevention

Although there are no formal screening recommendations, the CDC recommends consideration of annual screening for at-risk female patients, which includes those who are being cared for in a setting with high prevalence (i.e., correctional facilities and STI clinics), those with multiple sexual partners, a history of obtaining money for sex, substance use, or a prior history of an STI. Sexually active asymptomatic individuals assigned female at birth with HIV should be screened annually. Individuals assigned female at birth seeking evaluation for vaginal discharge should be screened. Owing to the inflammation caused by the infection, patients with trichomoniasis are at a greater risk of contracting HIV, so the CDC recommends annual HIV testing in patients with trichomoniasis. Disease prevention can occur through the correct application of condoms, testing, communication of STI results with a sexual partner, monogamy, not douching, and not misusing drugs or alcohol due to risky lifestyle behaviors (CDC, 2025e; Schumann & Plasner, 2023; Sobel & Mitchell, 2023; Workowski et al., 2021).

 

Signs and Symptoms

Approximately 70%–85% of patients with trichomoniasis do not experience symptoms but can still carry and transmit the infection. If signs and symptoms are present, patients experience them in the genital tract, which may occur 5 to 28 days after exposure to the disease. Individuals assigned female at birth may notice itching, redness, burning, or soreness in their genitals; discomfort during urination; and vaginal discharge that may appear clear, white, yellow, or green with a fish-smelling odor. The discharge may be thin or increased in frequency. Although rare, individuals assigned female at birth may experience lower abdominal pain. If pregnant, individuals are at risk for premature delivery and having a neonate with low birth weight. Individuals assigned male at birth may experience itching or irritation in the penis, discharge from the penis, and a burning sensation after urinating or ejaculating. Sexual intercourse may be uncomfortable, and signs and symptoms may be transient in individuals assigned male or female at birth (CDC, 2025e; Schumann & Plasner, 2023; Sobel & Mitchell, 2023; Workowski et al., 2021).

 

Diagnosis

A health history, a physical assessment, and laboratory testing assist in testing and diagnosing a patient with trichomoniasis. Testing should be completed when a patient experiences any discharge from the genitals. During the pelvic exam, the HCP collects an endocervical or vaginal swab; the sample is placed under a microscope and examined for the presence of trichomonads. Wet mount microscopy is inexpensive and immediate. The sensitivity of microscopy is low (44%–68%). Slides should be examined immediately to improve detection rates. In addition, NAATs, DNA testing, or fluid culture may be utilized to enhance sensitivity. Urine specimens and liquid Pap smear specimens may also be used for some assays, such as the Aptima T. vaginalis assay by Hologic. The probe Tec TV Q Amplified DNA Assay and Max CTGCTV2 assay by Beckton both allow for the use of patient-collected vaginal swabs. Cultures must be incubated and examined a week after collection to assess for the presence of the parasite. Patients who test positive for trichomoniasis should be tested for other STIs, such as HIV, gonorrhea, syphilis, and chlamydia (CDC, 2025e; Schumann & Plasner, 2023; Sobel & Mitchell, 2023; Workowski et al., 2021).

 

Treatment

If not treated, trichomoniasis infection may persist for months to years. Patients should be prescribed metronidazole (Flagyl) or tinidazole (Tindamax) for treatment and be advised to complete the entire course of treatment to promote disease eradication and prevention of reinfection (refer to Tables 9 and 10). Follow-up testing should occur 3 months after the completion of treatment (Schumann & Plasner, 2023; Sobel & Mitchell, 2024; Workowski et al., 2021).

 

Table 9

Medications to Treat Trichomoniasis

Population	Medication	Alternative Medication
Individuals assigned female at birth	Metronidazole (Flagyl) 500 mg BID × 7 days	Tinidazole (Tindamax) 2 g PO in a single dose
Individuals assigned male at birth	Metronidazole (Flagyl) 2 g PO in a single dose

(Schumann & Plasner, 2023; Sobel & Mitchell, 2024; Workowski et al., 2021)

 

Table 10

Side Effects of Medications to Treat Trichomoniasis

Medication	Side Effects	Contraindications and Precautions
Metronidazole (Flagyl)	Seizures, encephalopathy, vertigo, headaches, nausea, vomiting, diarrhea, glossitis, metallic taste, furry tongue, pruritus, rash, neutropenia and thrombocytopenia, Stevens–Johnson’s syndrome, mouth dryness, fever, polyuria, darkened urine, and hepatotoxicity	An allergist should approve this medication if the patient is known to have an IgE-mediated response Defer breastfeeding for 12–24 hours after the dosage Precautions: hepatic and renal impairment, risk of fungal superinfection, caution with a patient history of blood dyscrasias, avoid alcohol, risk of potentiating warfarin (Coumadin) anticoagulant effect, elevated serum lithium levels, prolonged QT interval (caution with other medications that prolong QT interval)
Tinidazole (Tindamax)	Headaches, convulsions, transient neuropathy, stomatitis, diarrhea, hypersensitivity (ranging from urticaria to angioedema), cardiac palpitations, darkened urine, transient neutropenia, candida overgrowth, elevated hepatic serum tests (transaminase level)	An allergist should approve this medication if the patient is known to have an IgE-mediated response History of hypersensitivity to tinidazole (Tindamax) or other nitroimidazole derivatives due to severe reactions (urticaria to Stevens–Johnson’s syndrome) Precaution: patients with blood dyscrasias, antibiotic drug resistance History of Cockayne syndrome: risk of hepatotoxicity

(Schumann & Plasner, 2023; Sobel & Mitchell, 2024; Workowski et al., 2021)

Approximately 1 in 5 patients experience reinfection within 3 months of treatment; this can be prevented by educating patients on sexual abstinence during treatment and avoiding sexual intercourse with someone with trichomoniasis. To avoid reinfection, sexual partners should be treated simultaneously, and sexual intercourse should be avoided until treatment has been completed and symptoms have resolved in both partners. Patients should be encouraged to apply condoms before sexual intercourse (Schumann & Plasner, 2023; Sobel & Mitchell, 2024; Workowski et al., 2021).

Nonpharmacologic Care for STIs

Patients may require psychosocial care for anger and frustration related to developing an STI or not knowing who infected them. HCPs can provide support by acknowledging the patient’s distress, educating on transmission prevention, and coordinating care with social workers to tend to the patient’s psychosocial needs. Creating a clinical environment that is welcoming is essential when caring for patients who have concerns about STIs. Establishing the patient’s preferred name and pronouns, as well as sexual orientation and gender identity, is critical to establishing a trusting and supportive relationship. Training in trauma-informed care can help HCPs apply patient-centered, sensitive care (Hinkle et al., 2021; Hoffman & Sullivan, 2020).

References

Albrecht, M. A. (2024a). Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection. UpToDate. Retrieved August 10, 2025, from https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-genital-herpes-simplex-virus-infection

Albrecht, M. A. (2024b). Treatment of genital herpes simplex virus infection. UpToDate. Retrieved August 10, 2025, from https://www.uptodate.com/contents/treatment-of-genital-herpes-simplex-virus-infection

American Cancer Society. (2021). The American Cancer Society guidelines for the prevention and early detection of cervical cancer. https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/cervical-cancer-screening-guidelines.html

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