Sexually Transmitted Disease Ceu Course for Nurses

Upon successful completion of this course the healthcare professional will be able to:

Sexually transmitted diseases (STDs), once called venereal diseases, are among the most common infectious diseases in the United States today. More than 20 STDs have now been identified, and they affect more than 13 million men and women in this country each year. The annual comprehensive cost of STDs in the United States is estimated to be well in excess of $10 billion.

Understanding the basic facts about STDs – the ways in which they are spread, their common symptoms, and how they can be treated– is the first step toward prevention. It is important to understand at least five key points about all STDs in this country today:

1. STDs affect men and women of all backgrounds and economic levels. They are most prevalent among teenagers and young adults. Nearly two-thirds of all STDs occur in people younger than 25 years of age.

2. The incidence of STDs is rising, in part because in the last few decades, young people have become sexually active earlier yet are marrying later. In addition, divorce is more common. The net result is that sexually active people today are more likely to have multiple sex partners during their lives and are potentially at risk for developing STDs.

3. Most of the time, STDs cause no symptoms, particularly in women. When and if symptoms develop, they may be confused with those of other diseases not transmitted through sexual contact. Even when an STD causes no symptoms, however, a person who is infected may be able to pass the disease on to a sex partner. That is why many doctors recommend periodic testing or screening for people who have more than one sex partner.

4. Health problems caused by STDs tend to be more severe and more frequent for women than for men, in part because the frequency of asymptomatic infection means that many women do not seek care until serious problems have developed.

Some STDs can spread into the uterus (womb) and fallopian tubes to cause pelvic inflammatory disease, which in turn is a major cause of both infertility and ectopic (tubal) pregnancy. The latter can be fatal.
STDs in women also may be associated with cervical cancer and other genital cancers.
STDs can be passed from a mother to her baby before, during, or immediately after birth; some of these infections of the newborn can be cured easily, but others may cause a baby to be permanently disabled or even die.

5. When diagnosed and treated early, many STDs can be treated effectively. Some infections have become resistant to the drugs used to treat them and now require newer types of antibiotics. Experts believe that having STDs other than AIDS increases one's risk for becoming infected with the AIDS virus.

AIDS (acquired immunodeficiency syndrome) was first reported in the United States in 1981. It is caused by the human immunodeficiency virus (HIV), a virus that destroys the body's ability to fight off infection. An estimated 900,000 people in the United States are currently infected with HIV. People who have AIDS are very susceptible to many life-threatening diseases, called opportunistic infections, and to certain forms of cancer. Transmission of the virus primarily occurs during sexual activity and by sharing needles used to inject intravenous drugs.

This infection is now the most common of all bacterial STDs, with an estimated 4 to 8 million new cases occurring each year. In both men and women, chlamydial infection may cause an abnormal genital discharge and burning with urination. In women, untreated chlamydial infection may lead to pelvic inflammatory disease, one of the most common causes of ectopic pregnancy and infertility in women. Many people with chlamydial infection, however, have few or no symptoms of infection. Once diagnosed with chlamydial infection, a person can be treated with an antibiotic.

Chlamydial ("kla-MID-ee-uhl") infection is a curable sexually transmitted disease (STD), which is caused by a bacterium called Chlamydia trachomatis. You can get genital chlamydial infection during oral, vaginal, or anal sexual contact with an infected partner. It can cause serious problems in men and women as well as in newborn babies of infected mothers.

Chlamydial infection is one of the most widespread bacterial STDs in the United States. The U.S. Centers for Disease Control and Prevention (CDC) estimates that more than 4 million people are infected each year. Health economists estimate that chlamydial infections and the other problems they cause cost Americans more than $2 billion a year.

Because chlamydial infection does not make most people sick, you can have it and not know it. Those who do have symptoms may have an abnormal discharge (mucus or pus) from the vagina or penis or pain while urinating. These early symptoms may be very mild. Symptoms usually appear within one to three weeks after being infected. Because the symptoms may be mild or not exist at all, a person might not seek care and get treated.

The infection may move inside the body if it is not treated. There, it can cause pelvic inflammatory disease (PID) in women and epidydimitis in men, two very serious illnesses. Trachomatis can cause inflamed rectum and inflammation of the lining of the eye ("pink eye"). The bacteria also can infect the throat from oral sexual contact with an infected partner.

Chlamydial infection is easily confused with gonorrhea because the symptoms of both diseases are similar and the diseases can occur together, though rarely.

The most reliable ways to find out whether the infection is chlamydial are through laboratory tests. Usually, a doctor or other health care worker will send a sample of pus from the vagina or penis to a laboratory that will look for the bacteria.

The urine test does not require a pelvic exam or swabbing of the penis. Results from the urine test are available within 24 hours.

If a person is infected with C. trachomatis, a doctor or other health care worker will probably give a prescription for an antibiotic such as azithromycin (taken for one day only) or doxycycline (taken for seven days) to treat people with chlamydial infection. Or, a person infected might get a prescription for another antibiotic such as erythromycin or ofloxacin.

Doctors may treat pregnant women with azithromycin or erythromycin, or sometimes, with amoxicillin. Penicillin, which doctors often use to treat some other STDs, won't cure chlamydial infections. It is very important for the infected person to tell their sex partners that they have chlamydial infection so that they can be tested and treated.

In women, untreated chlamydial infections can lead to PID. In men, untreated chlamydial infections may lead to pain or swelling in the scrotal area, which is a sign of inflammation of a part of the male reproductive system located near the testicles known as the epididymis. Left untreated, these complications can prevent people from having children.

Each year up to 1 million women in the United States develop PID, a serious infection of the reproductive organs. As many as half of all cases of PID may be due to chlamydial infection, and many of these don't have symptoms. PID can cause scarring of the fallopian tubes, which can block the tubes and prevent fertilization from taking place. Researchers estimate that 100,000 women each year become infertile because of PID.

In other cases, scarring may interfere with the passage of the fertilized egg to the uterus during pregnancy. When this happens, the egg may attach itself to the fallopian tube. This is called ectopic or tubal pregnancy. This very serious condition results in a miscarriage and can cause death of the mother.

A baby who is exposed to C. trachomatis in the birth canal during delivery may develop an eye infection or pneumonia. Symptoms of conjunctivitis or "pink eye," which include discharge andswollen eyelids, usually develop within the first 10 days of life.

Symptoms of pneumonia, including a cough that gets steadily worse and congestion, most often develop within three to six weeks of birth. Doctors can treat both conditions successfully with antibiotics. Because of these risks to the newborn, many doctors recommend that all pregnant women get tested for chlamydial infection.

If a person is infected but has no symptoms, they may pass the bacteria to their sex partners without knowing it. Therefore, many doctors recommend that anyone who has more than one sex partner, especially women under 25 years of age, be tested for chlamydial infection regularly, even if they don't have symptoms.

Genital herpes affects an estimated 60 million Americans. Approximately 500,000 new cases of this incurable viral infection develop annually. Herpes infections are caused by herpes simplex virus (HSV). The major symptoms of herpes infection are painful blisters or open sores in the genital area. These may be preceded by a tingling or burning sensation in the legs, buttocks, or genital region. The herpes sores usually disappear within two to three weeks, but the virus remains in the body for life and the lesions may recur from time to time. Severe or frequently recurrent genital herpes is treated with one of several antiviral drugs that are available by prescription. These drugs help control the symptoms but do not eliminate the herpes virus from the body. Suppressive antiviral therapy can be used to prevent occurrences and perhaps transmission. Women who acquire genital herpes during pregnancy can transmit the virus to their babies. Untreated HSV infection in newborns can result in mental retardation and death.

Genital herpes is an infection caused by the herpes simplex virus or HSV. There are two types of HSV, and both can cause genital herpes. HSV type 1 most commonly infects the lips, causing sores known as fever blisters or cold sores, but it also can infect the genital area and produce sores. HSV type 2 is the usual cause of genital herpes, but it also can infect the mouth. A person who has genital herpes infection can easily pass or transmit the virus to an uninfected person during sex.

Both HSV 1 and 2 can produce sores (also called lesions) in and around the vaginal area, on the penis, around the anal opening, and on the buttocks or thighs. Occasionally, sores also appear on other parts of the body where the virus has entered through broken skin. HSV remains in certain nerve cells of the body for life, and can produce symptoms off and on in some infected people.

According to the U.S. Centers for Disease Control and Prevention, 45 million people in the United States ages 12 and older, or 1 out of 5 of the total adolescent and adult population, are infected with HSV-2.

Nationwide, since the late 1970s, the number of people with genital herpes infection has increased 30 percent. The largest increase is occurring in young teens. HSV-2 infection is more common in three of the youngest age groups which include people aged 12 to 39 years.

Most people get genital herpes by having sex with someone who is having a herpes “outbreak.” This outbreak means that HSV is active. When active, the virus usually causes visible lesions in the genital area. The lesions shed (cast off) viruses that can infect another person. Sometimes, however, a person can have an outbreak and have no visible sores at all. People often get genital herpes by having sexual contact with others who don’t know they are infected or who are having outbreaks of herpes without any sores. A person with genital herpes also can infect a sexual partner during oral sex. The virus is spread only rarely, if at all, by touching objects such as a toilet seat or hot tub.

Unfortunately, most people who have genital herpes don’t know it because they never have any symptoms, or they do not recognize any symptoms they might have. When there are symptoms, they can be different in each person. Most often, when a person becomes infected with herpes for the first time, the symptoms will appear within 2 to 10 days. These first episodes of symptoms usually last 2 to 3 weeks.

Within a few days, sores appear near where the virus has entered the body, such as on the mouth, penis, or vagina. They also can occur inside the vagina and on the cervix in women, or in the urinary passage of women and men. Small red bumps appear first, develop into blisters, and then become painful open sores. Over several days, the sores become crusty and then heal without leaving a scar.

Other symptoms that may go with the first episode of genital herpes are fever, headache, muscle aches, painful or difficult urination, vaginal discharge, and swollen glands in the groin area.

If a person has been infected by HSV 1 and/or 2, they will probably have symptoms or outbreaks from time to time. After the virus has finished being active, it will then travel to the nerves at the end of the spine where it stays for a while. Even after the lesions are gone, the virus stays inside the nerve cells in a still and hidden state, which means that it’s inactive.

In most people, the virus can become active several times a year. This is called a recurrence. But scientists do not yet know why this happens. When it becomes active again, it travels along the nerves to the skin, where it makes more viruses near the site of the very first infection. That is where new sores usually will appear.

Sometimes, the virus can become active but not cause any sores that can be seen. At these times, small amounts of the virus may be shed at or near places of the first infection, in fluids from the mouth, penis, or vagina, or from barely noticeable sores. An infected person may not notice this shedding because it often does not cause any pain or feel uncomfortable. Even though one might not be aware of the shedding, it still can infect a sex partner during this time.

After the first outbreak, any future outbreaks are usually mild and last only about a week. An infected person may know that an outbreak is about to happen by a tingling feeling or itching in the genital area, or pain in the buttocks or down the leg. For some people, these early symptoms can be the most painful and annoying part of an episode. Sometimes, only the tingling and itching are present and no visible sores develop. At other times, blisters appear that may be very small and barely noticeable, or they may break into open sores that crust over and then disappear.

The frequency and severity of recurrent episodes vary greatly. While some people have only one or two outbreaks in a lifetime, others may have several outbreaks a year. The number and pattern of repeat outbreaks often change over time for a person. Scientists do not know what causes the virus to become active again. Although some people with herpes report that their outbreaks are brought on by another illness, stress, or having a menstrual period, outbreaks often are not predictable. In some cases, outbreaks may be connected to exposure to sunlight.

Because the genital herpes sores may not be visible to the naked eye, a doctor or other health care worker may have to do several laboratory tests to try to prove that symptoms are caused by the herpes virus. A person may still have genital herpes, however, even if the laboratory tests do not show the virus in the body.

A blood test cannot show whether a person can infect another with the herpes virus. A blood test, however, can show if a person has been infected at any time with HSV. There are also newer blood tests that can tell whether a person has been infected with HSV 1 and/or

Recently, the Food and Drug Administration approved Valtrex for use in preventing transmission of genital herpes.

During an active herpes episode, whether the first episode or a repeat one, an infected person should follow a few simple steps to speed healing and avoid spreading the infection to other places on the body or to other people.

• Keep the infected area clean and dry to prevent other infections from developing.

• Avoiding sexual contact from the time they first feel any symptoms until the sores are completely healed, that is, the scab has fallen off and new skin has formed where the sore was.

Although there is no cure for genital herpes, a health care worker might prescribe one of three medicines to treat it as well as to help prevent future episodes.

Acyclovir (Zovirax)
Famciclovir (Famvir)
Valacyclovir (Valtrex)

Usually, genital herpes infections do not cause major problems in healthy adults. In some people whose immune systems do not work properly, genital herpes episodes can last a long time and be unusually severe. (The body’s immune system fights off foreign invaders such as viruses.)

If a woman has her first episode of genital herpes while she is pregnant, she can pass the virus to her unborn child and may deliver a premature baby. Half of the babies infected with herpes either die or suffer from damage to their nerves. A baby born with herpes can develop serious problems that may affect the brain, the skin, or the eyes. If babies born with herpes are treated immediately with acyclovir, their chances of being healthy are increased.

If a pregnant woman has an outbreak, which is not the first episode, her baby’s risk of being infected during delivery is very low. If a woman is having an outbreak during labor and delivery and there are herpes lesions in or near the birth canal, the doctor will do a cesarean section to protect the baby. Most women with genital herpes, however, do not have signs of active infection with the virus during this time, and can have a normal delivery.

Genital herpes, like other genital diseases that produce lesions, increases a person’s risk of getting HIV, the virus that causes AIDS. Also, prior to better treatments for AIDS, persons infected with HIV had severe herpes outbreaks, which may have helped them pass both genital herpes and HIV infection to others.

Genital warts (also called venereal warts or condylomata acuminata) are caused by human papillomavirus, a virus related to the virus that causes common skin warts. Genital warts usually first appear as small, hard painless bumps in the vaginal area, on the penis, or around the anus. If untreated, they may grow and develop a fleshy, cauliflower-like appearance. Genital warts infect an estimated 1 million Americans each year. In addition to genital warts, certain high-risk types of HPV cause cervical cancer and other genital cancers. Genital warts are treated with a topical drug (applied to the skin), by freezing, or if they recur, with injections of a type of interferon. If the warts are very large, they can be removed by surgery.

Genital warts (condylomata acuminata or venereal warts) are the most easily recognized sign of genital HPV infection. Many people, however, have a genital HPV infection without genital warts.

Some types of HPV cause common skin warts, such as those found on the hands and soles of the feet. These types of HPV do not cause genital warts.

Genital warts are very contagious and are spread during oral, genital, or anal sex with an infected partner. About two-thirds of people who have sexual contact with a partner with genital warts will develop warts, usually within three months of contact.

In women, the warts occur on the outside and inside of the vagina, on the opening (cervix) to the womb (uterus), or around the anus. In men, genital warts are less common. If present, they usually are seen on the tip of the penis. They also may be found on the shaft of the penis, on the scrotum, or around the anus. Rarely, genital warts also can develop in the mouth or throat of a person who has had oral sex with an infected person.

Genital warts often occur in clusters and can be very tiny or can spread into large masses in the genital or anal area.

A doctor or other health care worker usually can diagnose genital warts by seeing them on a patient. Women with genital warts also should be examined for possible HPV infection of the cervix.

The doctor may be able to identify some otherwise invisible warts in the genital tissue by applying vinegar (acetic acid) to areas of suspected infection. This solution causes infected areas to whiten, which makes them more visible, particularly if a procedure called colposcopy is performed. During colposcopy, the doctor uses a magnifying instrument to look at the vagina and cervix. In some cases, the doctor takes a small piece of tissue from the cervix and examines it under the microscope.

A Pap smear test also may indicate the possible presence of cervical HPV infection. In a Pap smear, a laboratory worker examines cells scraped from the cervix under a microscope to see if they are cancerous. If a woman’s Pap smear is abnormal, she might have an HPV infection.

Genital warts often disappear even without treatment. In other cases, they eventually may develop a fleshy, small raised growth that looks like cauliflower. There is no way to predict whether the warts will grow or disappear.

Depending on factors such as the size and location of the genital warts, a doctor will offer one of several ways to treat them.

Imiquimod, an immune response cream which you can be applied to the affected area

A 20 percent podophyllin anti-mitotic solution, which can be applied to the affected area and later wash off

A 0.5 percent podofilox solution, applied to the affected area shouldn’t be washed off

A 5 percent 5-fluorouracil cream

Trichloroacetic acid (TCA)

If an infected woman is pregnant, she should not use podophyllin or podofilox because they are absorbed by the skin and may cause birth defects in the baby.

If an infected person has small warts, the doctor can remove them by freezing (cryosurgery), burning (electrocautery), or laser treatment. Occasionally, the doctor will have to use surgery to remove large warts that have not responded to other treatment.

Some doctors use the antiviral drug alpha interferon, which they inject directly into the warts, to treat warts that have returned after removal by traditional means. The drug is expensive, however, and does not reduce the rate that the genital warts return.

Although treatments can get rid of the warts, none gets rid of the virus. Because the virus is still present in the body, warts often come back after treatment.

The only way you can prevent getting an HPV infection is to avoid direct contact with the virus, which is transmitted by skin-to-skin contact. Studies have not confirmed that male latex condoms prevent transmission of HPV itself, but results do suggest that condom use may reduce the risk of developing diseases linked to HPV, such as genital warts and cervical cancer.

Some types of HPV can cause cervical cancer. Others, however, cause cervical cancer and also are associated with vulvar cancer, anal cancer, and cancer of the penis (a rare cancer).

Most HPV infections do not progress to cervical cancer. If a woman does have abnormal cervical cells, a Pap test will detect them. It is particularly important for women who have abnormal cervical cells to have regular pelvic exams and Pap tests so that they can be treated early, if necessary.

Genital warts may cause a number of problems during pregnancy. Sometimes they get larger during pregnancy, making it difficult to urinate. If the warts are in the vagina, they can make the vagina less elastic and cause obstruction during delivery.

Rarely, infants born to women with genital warts develop warts in their throats (laryngeal papillomatosis). Although uncommon, it is a potentially life-threatening condition for the child, requiring frequent laser surgery to prevent obstruction of the breathing passages. Research on the use of interferon therapy in combination with laser surgery indicates that this drug may show promise in slowing the course of the disease. .

Approximately 400,000 cases of gonorrhea are reported to the U.S. Centers for Disease Control and Prevention (CDC) each year in this country. The most common symptoms of gonorrhea are a discharge from the vagina or penis and painful or difficult urination. The most common and serious complications occur in women and, as with chlamydial infection, these complications include PID, ectopic pregnancy, and infertility. Historically, penicillin has been used to treat gonorrhea, but in the last decade, four types of antibiotic resistance have emerged. New antibiotics or combinations of drugs must be used to treat these resistant strains.

Gonorrhea is a curable sexually transmitted disease (STD) caused by a bacterium called Neisseria gonorrhoeae. These bacteria can infect the genital tract, the mouth, and the rectum. In women, the opening to the uterus, the cervix, is the first place of infection.

The disease however can spread into the uterus and fallopian tubes, resulting in pelvic inflammatory disease (PID). PID affects more than 1 million women in this country every year and can cause infertility in as many as 10 percent of infected women and tubal (ectopic) pregnancy.

In 2000, 358,995 cases of gonorrhea were reported to the U.S. Centers for Disease Control and Prevention (CDC). In the United States, approximately 75 percent of all reported cases of gonorrhea is found in younger persons aged 15 to 29 years. The highest rates of infection are usually found in 15- to 19-year old women and 20- to 24-year-old men. Health economists estimate that the annual cost of gonorrhea and its complications is close to $1.1 billion.

Gonorrhea is spread during sexual intercourse. Infected women also can pass gonorrhea to their newborn infants during delivery, causing eye infections in their babies. This complication is rare because newborn babies receive eye medicine to prevent infection. When the infection occurs in the genital tract, mouth, or rectum of a child, it is due most commonly to sexual abuse.

The early symptoms of gonorrhea often are mild. Symptoms usually appear within 2 to 10 days after sexual contact with an infected partner. A small number of people may be infected for several months without showing symptoms.

Bleeding associated with vaginal intercourse
Painful or burning sensations when urinating
Vaginal discharge that is yellow or bloody

More advanced symptoms, which may indicate development of PID, include cramps and pain, bleeding between menstrual periods, vomiting, or fever.

Pus from the penis and pain
Burning sensations during urination that may be severe

Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood on the feces.

Doctors or other health care workers usually use three laboratory techniques to diagnose gonorrhea: staining samples directly for the bacterium, detection of bacterial genes or DNA in urine, and growing the bacteria in laboratory cultures. Many doctors prefer to use more than one test to increase the chance of an accurate diagnosis.

The staining test involves placing a smear of the discharge from the penis or the cervix on a slide and staining the smear with a dye. Then the doctor uses a microscope to look for bacteria on the slide. An infected person can usually can get the test results while in the office or clinic. This test is quite accurate for men but is not good in women. Only one in two women with gonorrhea have a positive stain.

More often, doctors use urine or cervical swabs for a new test that detects the genes of the bacteria. These tests are as accurate or more so than culturing the bacteria, and many doctors use them. The culture test involves placing a sample of the discharge onto a culture plate and incubating it up to 2 days to allow the bacteria to grow. The sensitivity of this test depends on the site from which the sample is taken. Cultures of cervical samples detect infection approximately 90 percent of the time. The doctor also can take a culture to detect gonorrhea in the throat. Culture allows testing for drug-resistant bacteria.

Gonorrhea and chlamydial infection, another common STD, often infect people at the same time. Therefore, doctors usually prescribe a combination of antibiotics, such as ceftriaxone and doxycycline or azithromycin, which will treat both diseases. If an infected person has gonorrhea, all of their sexual partners should get tested and then treated if infected, whether or not they have symptoms of infection.

Doctors usually prescribe a single dose of one of the following antibiotics to treat gonorrhea:

Cefixime
Ceftriaxone
Ciprofloxacin
Ofloxacin
Levofloxacin

For women that have gonorrhea and are pregnant or are younger than 18 years old, they should not take ciprofloxacin or ofloxacin.

In untreated gonorrhea infections, the bacteria can spread up into the reproductive tract, or more rarely, can spread through the blood stream and infect the joints, heart valves, or the brain. The most common result of untreated gonorrhea is PID, a serious infection of the female reproductive tract. Gonococcal PID often appears immediately after the menstrual period. PID causes scar tissue to form in the fallopian tubes. If the tube is partially scarred, the fertilized egg may not be able to pass into the uterus. If this happens, the embryo may implant in the tube causing a tubal (ectopic) pregnancy. This serious complication may result in a miscarriage and can cause death of the mother.

Rarely, untreated gonorrhea can spread through the blood to the joints. This can cause an inflammation of the joints which is very serious. If an infected person has gonorrhea, their risk of getting HIV infection increases (HIV, human immunodeficiency virus, causes AIDS).

If an infected woman is pregnant and has gonorrhea, she may give the infection to her baby as it passes through the birth canal during delivery. A doctor can prevent infection of the baby's eyes by applying silver nitrate or other medications to the eyes immediately after birth. Because of the risks from gonococcal infection to both the mother and baby, doctors recommend that pregnant women have at least one test for gonorrhea during pregnancy.

The incidence of syphilis has increased and decreased dramatically in recent years, with more than 11,000 cases reported in 1996. The first symptoms of syphilis may go undetected because they are very mild and disappear spontaneously. The initial symptom is a chancre; it is usually a painless open sore that usually appears on the penis or around or in the vagina. It can also occur near the mouth, anus, or on the hands. If untreated, syphilis may go on to more advanced stages, including a transient rash and eventually, serious involvement of the heart and central nervous system. The full course of the disease can take years. Penicillin remains the most effective drug to treat people with syphilis.

Syphilis is a sexually transmitted disease (STD), once responsible for devastating epidemics. It is caused by a bacterium called Treponema pallidum. The rate of primary and secondary syphilis in the United States declined by 89.2 percent from 1990 to 2000. The number of cases rose, however, from 5,979 in 2000 to 6,103 in 2001. The U.S. Centers for Disease Control and Prevention reported in November 2002 that this was the first increase since 1990.

Of increasing concern is the fact that syphilis increases by 3- to 5-fold the risk of transmitting and acquiring HIV (human immunodeficiency virus), the virus that causes AIDS (acquired immunodeficiency syndrome).

The syphilis bacterium is very fragile, and the infection is almost always transmitted by sexual contact with an infected person. The bacterium spreads from the initial ulcer (sore) of an infected person to the skin or mucous membranes (linings) of the genital area, mouth, or anus of an uninfected sexual partner. It also can pass through broken skin on other parts of the body. In addition, a pregnant woman with syphilis can pass T. pallidum to her unborn child, who may be born with serious mental and physical problems as a result of this infection.

The initial infection causes an ulcer at the site of infection. The bacteria, however, move throughout the body, damaging many organs over time. Medical experts describe the course of the disease by dividing it into four stages-primary, secondary, latent, and tertiary (late). An infected person who has not been treated may infect others during the first two stages, which usually last 1 to 2 years. In its late stages, untreated syphilis, although not contagious, can cause serious heart abnormalities, mental disorders, blindness, other neurologic problems, and death.

The first symptom of primary syphilis is an ulcer called a chancre ("shan-ker"). The chancre can appear within 10 days to 3 months after exposure, but it generally appears within 2 to 6 weeks. Because the chancre may be painless and may occur inside the body, the infected person might not notice it. It usually is found on the part of the body exposed to the infected partner's ulcer, such as the penis, vulva, or vagina. A chancre also can develop on the cervix, tongue, lips, or other parts of the body. The chancre disappears within a few weeks whether or not a person is treated. If not treated during the primary stage, about one-third of people will go on to the chronic stages.

A skin rash, with brown sores about the size of a penny, often marks this chronic stage of syphilis. The rash appears anywhere from 3 to 6 weeks after the chancre appears. While the rash may cover the whole body or appear only in a few areas, it is almost always on the palms of the hands and soles of the feet.

Because active bacteria are present in the sores, any physical contact—sexual or nonsexual—with the broken skin of an infected person may spread the infection at this stage. The rash usually heals within several weeks or months.

Other symptoms also may occur, such as mild fever, fatigue, headache, sore throat, patchy hair loss, and swollen lymph glands throughout the body. These symptoms may be very mild and, like the chancre of primary syphilis, will disappear without treatment. The signs of secondary syphilis may come and go over the next 1 to 2 years of the disease.

If untreated, syphilis may lapse into a latent stage during which the disease is no longer contagious and no symptoms are present. Many people who are not treated will suffer from no further signs and symptoms of the disease.

Approximately one-third of people who have had secondary syphilis go on to develop the complications of late, or tertiary, syphilis, in which the bacteria damage the heart, eyes, brain, nervous system, bones, joints, or almost any other part of the body. This stage can last for years, or even for decades. Late syphilis can result in mental illness, blindness, other neurologic problems, heart disease, and death.

Syphilis is sometimes called "the great imitator" because its early symptoms are similar to those of many other diseases. Sexually active people should consult a doctor or other health care worker about any rash or sore in the genital area. Those who have been treated for another STD, such as gonorrhea, should be tested to be sure they do not also have syphilis.

Recognizing the signs and symptoms
Examining blood samples
Identifying syphilis bacteria under a microscope

The doctor usually uses all these approaches to diagnose syphilis and decide upon the stage of infection.

Blood tests also provide evidence of infection, although they may give false-negative results (not show signs of an infection despite its presence) for up to 3 months after infection. False-positive tests (showing signs of an infection when it is not present) also can occur. Therefore, two blood tests are usually used. Interpretation of blood tests for syphilis can be difficult, and repeated tests are sometimes necessary to confirm the diagnosis.

Unfortunately, the early symptoms of syphilis can be very mild, and many people do not seek treatment when they first become infected. Doctors usually treat patients with syphilis with penicillin, given by injection. They use other antibiotics for patients allergic to penicillin. A person usually can no longer transmit syphilis 24 hours after starting treatment. Some people, however, do not respond to the usual doses of penicillin. Therefore, it is important that people being treated for syphilis have periodic blood tests to check that the infectious agent has been completely destroyed.

People with neurosyphilis may need to be retested for up to 2 years after treatment. In all stages of syphilis, proper treatment will cure the disease. But in late syphilis, damage already done to body organs cannot be reversed.

A pregnant woman with untreated, active syphilis is likely to pass the infection to her unborn child. In addition, miscarriage may occur in as many as 25 to 50 percent of women acutely infected with syphilis during pregnancy. Between 40 to 70 percent of women with active syphilis will give birth to a syphilis-infected infant.

Rarely, the symptoms of syphilis go undetected in infants. As infected infants become older children and teenagers, they may develop the symptoms of late-stage syphilis, including damage to their bones, teeth, eyes, ears, and brains.

Some infants with congenital syphilis may have symptoms at birth, but most develop symptoms between 2 weeks and 3 months later. These symptoms may include:

People who care for infants with congenital syphilis must use special cautions because the moist sores are infectious.

Syphilis bacteria frequently invade the nervous system during the early stages of infection. Approximately 3 to 7 percent of persons with untreated syphilis develop neurosyphilis, a sometimes serious disorder of the nervous system. In some instances, the time from infection to developing neurosyphilis may be up to 20 years.

Some people with neurosyphilis never develop any symptoms. Others may have headache, stiff neck, and fever that result from an inflammation of the lining of the brain. Some people develop seizures. People whose blood vessels are affected may develop symptoms of stroke with numbness, weakness, or visual problems. Neurosyphilis may be more difficult to treat, and its course may be different, in people with HIV infection or AIDS.

The open sores of syphilis may be visible and infectious during the active stages of infection. Any contact with these infectious sores and other infected tissues and body fluids must be avoided to prevent spread of the disease. As with many other STDs, using latex male condoms properly during sexual intercourse may give some protection from the disease.

Screening and treatment of infected individuals, or secondary prevention, is one of the few options for preventing the advanced stages of the disease. Testing and treatment early in pregnancy are the best ways to prevent syphilis in infants and should be a routine part of prenatal care.

Other diseases that may be sexually transmitted include trichomoniasis, bacterial vaginosis, cytomegalovirus infections, scabies, and pubic lice. STDs in pregnant women are associated with a number of adverse outcomes, including spontaneous abortion and infection in the newborn. Low birth weight and prematurity appear to be associated with STDs, including chlamydial infection and trichomoniasis. Congenital or perinatal infection (infection that occurs around the time of birth) occurs in 30 to 70 percent of infants born to infected mothers, and complications may include pneumonia, eye infections, and permanent neurologic damage.

The best way to prevent STDs is to avoid sexual contact with others. There are things that can be done to reduce the risk of developing an STD.

Having a mutually monogamous sexual relationship with an uninfected partner.
Correctly and consistently using a male condom.
Using clean needles if injecting intravenous drugs.
Prevent and control other STDs to decrease susceptibility to HIV infection and to reduce infectiousness if a person is HIV-infected.
Delay having sexual relations as long as possible. The younger people are when having sex for the first time, the more susceptible they become to developing an STD. The risk of acquiring an STD also increases with the number of partners over a lifetime.

Have regular checkups for STDs even in the absence of symptoms, and especially if having sex with a new partner. These tests can be done during a routine visit to the doctor's office.

Learn the common symptoms of STDs. Seek medical help immediately if any suspicious symptoms develop, even if they are mild.

Avoid having sex during menstruation. HIV-infected women are probably more infectious, and HIV-uninfected women are probably more susceptible to becoming infected during that time.

Avoid anal intercourse, but if practiced, use a male condom.

Avoid douching because it removes some of the normal protective bacteria in the vagina and increases the risk of getting some STDs.

Be treated to reduce the risk of transmitting an STD to an infant.
Discuss with a doctor the possible risk of transmission in breast milk and whether commercial formula should be substituted.
Notify all recent sex partners and urge them to get a checkup.
Follow the doctor's orders and complete the full course of medication prescribed. A follow-up test to ensure that the infection has been cured is often an important step in treatment.
Avoid all sexual activity while being treated for an STD.

Sometimes people are too embarrassed or frightened to ask for help or information. Most STDs are readily treated, and the earlier a person seeks treatment and warns sex partners about the disease, the less likely the disease will do irreparable physical damage, be spread to others or, in the case of a woman, be passed on to a newborn baby.

Private doctors, local health departments, and STD and family planning clinics have information about STDs. In addition, the American Social Health Association (ASHA) provides free information and keeps lists of clinics and private doctors who provide treatment for people with STDs.