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Sexually Transmitted Diseases: An Update

Posted on: Wednesday, 22 December 2004, 03:01 CST

Sexually transmitted diseases (STDs) have reached epidemic numbers in this country and represent considerable costs to the health care system. Nurses, who see clients in a variety of acute and community settings, have a unique opportunity to discuss STDs and their prevention. However, nurses must retain knowledge that is up-to-date on each of these diseases. Nurses need to take the lead in evaluating their clients' risk of acquiring STDs and tailor specific preventative techniques to the individual needs uncovered.

Sexually transmitted diseases (STDs) have reached epidemic numbers in this country and represent considerable costs to the health care system. The five major STDs are chlamydia, gonorrhea, syphilis, genital herpes, and infections with human papillomavirus (genital warts). The purpose of this article is to review each of these five diseases and provide information on microbiology, epidemiology, clinical manifestations, complications, and treatment for each disease. Treatment guidelines are from the Centers for Disease Control and Prevention (CDC) and were last updated in May 2002.

STDs are infections that can be transmitted to others during intimate behavior. STD has replaced the older term, venereal disease, as it is broader in scope, including sexually transmitted infections not limited to the genitals. Certain risk factors place individuals at risk for acquiring STDs. Among them are higher numbers of lifetime sexual partners, engaging in sexual activity while under the influence of drugs or alcohol, and not using barrier protection (condoms) during sexual activity. Early age at sexarche (the age when sexual activity begins) places adolescent girls at higher risk due to biologic differences in cervical mucosa. Older women may not realize their risk for STDs and may be hesitant to discuss prior sexual activity and condoms with a new partner. Their physicians often do not broach the topic of sexuality and STDs with them or may confuse symptoms with other problems of aging (Berger & Lee, 2002; CDC, 2002; Grigg, 2000).

Women in general are at higher risk of acquiring an STD than men. They have more exposed tissue and the exposure period is longer in women than in men. Women may not consider the need to use barrier protection if they are currently on other forms of birth control. Oral contraceptives increase the alkalinity of the vaginal pH, favoring the growth of certain microorganisms, particularly gonococci. In addition, intrauterine devices alter the endometrial barrier, which also favors persistent gonococcal infections (Berger & Lee, 2002; CDC, 2002). While women have a higher risk of acquiring an STD, both men and women are susceptible to their complications: pelvic inflammatory disease and infertility in women, and possible urethral strictures with urinary consequences and fertility problems in men.

All STDs represent risky sexual behavior and can lead to multiple complications, including infection with HIV, the virus that causes AIDS (CDC, 2002) (see Table 1). Nurses who see clients in a variety of acute and community settings have a unique opportunity to discuss STDs and their prevention. However, nurses must retain knowledge that is up-to-date on each of these diseases. Nurses must also be comfortable discussing aspects of sexuality that may differ from their own values, and must learn to approach this topic in a nonthreatening and nonjudgmental manner. Often clients with dysuria or penile discharge, common symptoms of STDs, will present to urologists' offices. Thus, it is very important that urologie nurses have a good working knowledge base and a high index of suspicion for STDs.

Chlamydia

Chlamydial infection is the most common bacterial STD. There are an estimated 5 million cases each year. Unfortunately, this number is considered to be the "tip of the iceberg" as chlamydia can remain dormant, or be asymptomatic, for years. C. trachomatis is an obligate intracellular parasite with bacterial characteristics. Infection occurs after exposure to contaminated secretions or tissues, with replication beginning after only 12 hours of invasion of host tissue. Rates of chlamydia are highest in the South, among women of color, in women aged 15 to 24, in women who have unprotected sexual activity, and in those with new or multiple partners. Chlamydia often co-exists with gonorrhea (Baddour & Gorbach, 2003; Berger & Lee, 2002; CDC, 2002).

Table 1.

Urological Manifestations and Complications of STDs

Signs and symptoms in men include urethritis (chlamydia causes 30%-50% of nongonoccocal urethritis, or NGU), dysuria, epididymitis, and clear or mucopurulent penile discharge. Some men complain only of urethral itching. Proctitis and pharyngitis can also occur. Scarring of the cpididymis leading to infertility is a complication in men. Although men generally seek care earlier than women because the symptoms are so noticeable, up to 25% of men with positive cultures are asymptomatic (Berger & Lee, 2002).

Women's symptoms are a yellow, mucopurulent vaginal discharge, abnormal vaginal bleeding, and dysuria. Bartholin glands can be involved, and women also can present with pharyngitis or proctitis. The most devastating complication of chlamydial infection is infertility. Known as the "Groat Sterilizer," chlamydia is the most important known cause of tuhal infertility, duo to scarring and ulceration of tissue. Another complication of chlamydial infection is salpingitis due to ascending infection. It is critical to understand that up to 70% of infected women are asymptomatic; thus aggressive screening of individuals in high-risk categories is crucial (Berg, 2002; Borger & Lee, 2002; CDC, 2002; Mehta et al., 2002; Todd, Haase, & Stoner, 2001).

Maintain a healthy index of suspicion for chlamydia, remembering the large numbers of asymptomatic individuals. Treatment should be aggressive and started on clinical presentation. Do not wait for definitive lab results. Two common options for treatment include doxycycline twice daily for 7 days, or one dose of azithromycin (see Table 2). Giving a client a single dose of azithromycin at the time of examination, instead of dismissal with a prescription, improves simplicity and compliance. Alternative drug regimes include erythromycin, ofloxacin, and levofloxacin.

All sexual partners need to be treated. Responsibility for contacting partners for treatment varies from state to state and by disease. Some diseases are not reportable to local health authorities, in which case, the person seeking treatment would be responsible for contacting the exposed partner(s). When local health departments are involved, they either contact the partner themselves, or occasionally, leave it up to the person seeking treatment to do so, after which they may follow up to see if the partner(s) have been contacted or treated. The patient should not have sexual activity until both she and her partner(s) have completed therapy. Test of cure is not necessary. The CDC recommends concomitant treatment for gonorrhea (CDC, 2002).

Gonorrhea

There are approximately 650,000 new cases of gonorrhea (GC) each year, and the number is rising. This is particularly worrisome as GC and syphilis are considered "heralds" for HIV infection. The causative agent for gonorrhea is Neisseria gonorrhoeae, which is a bacteria. Transmission occurs through exposure to infected body fluids and tissues. Incubation period is 3 to 8 days. Rates are highest in the South, and those in high-risk groups again are those who have new or multiple partners, younger age at sexarche, and unprotected sexual activities. Screening is a high-priority activity with GC as it, too, can be asymptomatic in women (CDC, 2002; "Gonorrhea Rates," 2002; Vastag, 2001).

Table 2.

Common Treatment Regimes for STDs 1,2

Clinical manifestations in men include a purulent penile discharge, dysuria, and urinary frequency. Proctitis, epididymitis, eye infections, and pharyngitis may also occur. As infection in men is generally in the anterior urethra, symptoms can appear quickly, although some men may be asymptomatic (Berger & Lee, 2002).

Women often present with a heavy, greenish-yellow purulent vaginal discharge, swollen vulva, abnormal vaginal bleeding, and urinary symptoms such as dysuria and frequency. Proctitis, pharyngitis, and eye infections can also occur. Complications include pelvic inflammatory disease; salpingitis with resulting scar formation and infertility; disseminated gonococcal infection that includes bacteremia, arthralgia, septic arthritis, endocarditis, and meningitis; and involvement of the liver capsule (Fitzhugh-Curtis syndrome) (Berger & Lee, 2002).

Treatment should begin on clinical suspicion; do not wait for diagnostic testing. As with chlamydia, maintain a high degree of suspicion, as a large number of women are asymptomatic. The most common regime for GC is a single IM dose of ceftriaxono. Alternative choices include spectinomycin, cefoxitin with probenecid, and some quinolonos. Quinolone resistance has been reported and should bo avoided in areas around the Pacific Rim. Test of cure is not necessary. All partners should be treated, and the client should avoid all sexual activity until she/he and all partner(s) have been treated. Treat for concomitant chlamydial infection at the same time (CDC, 2002).

Herpes Virus Infection

Genital herpes is a common, often painful STD. The causative agent is the Herpes si\mplex virus (HSV). Two subtypes exist; HSV1 generally causes oral lesions and HSV2 generally causes genital lesions, although either type can cause either lesion. Transmission most often occurs from an asymptomatic partner who is shedding virus. Friction during sexual activity creates an environment conducive fur the virus to pass into cells of the skin or mucus membranes. After destroying the infected epidermal cells, the virus enters peripheral sensory or autonomie root endings and ascends to the root ganglia where it becomes latent. At this point, the virus can stay dormant or become active (Baddour & Gorbach, 2003; Bron, 2002).

Infections arc classified as first-episode true primary, first- episode nonprimary, recurrent, or asymptomatic. A true primary infection is one in which there is no history of previous outbreaks and the client demonstrates no antibodies to HSV. Often these outbreaks are severe, and clients may present with a serious systemic disease requiring hospitalization. In a nonprimary first episode, the patient will report the first occurrence of herpes lesions, but blood tests will demonstrate antibodies to HSV, showing prior infection. Less than 40% of women with first episode who have antibodies will report previous outbreaks. This episode is usually less severe than a true primary first outbreak, and clients will frequently report a history of oral herpes lesions (Baddour & Gorbach, 2003; Bren, 2002; CDC, 2002).

Recurrent infection is the presence of repeated, sporadic episodes of lesion outbreaks. These tend to be less severe than in first episodes. The frequency, duration, and severity of attacks may lessen over time, although there is no way to predict this. The average is 6 to 12 outbreaks a year. Healing time seems to be quicker with recurrent infection (10-12 days). Clients can learn to identify trigger factors such as stress or other viral illnesses, and prodromal periods (prodrome refers to a period of time before the outbreak of lesions when other "warning" symptoms occur, such as burning or tingling around the site where lesions will appear). Identification and action to prevent triggers or begin treatment during the prodrome are considered the keys to self-care (Bren, 2002; Fraley, 2002).

Asymptomatic infection is the period of time during which there are no visible lesions, but virus shedding stills occurs. HSV infection can be transmitted even during asymptomatic periods. This is one factor leading to frustration in these clients (Bren, 2002; Fraley, 2002).

The incubation period is approximately 1 week. The outbreak consists of an eruption of painful, grouped, discrete vesicles. This lasts for 1 to 2 weeks, during which time the lesions develop into pustules, which then ulcerate. The ulcerations crust over and re- epithelialization may take as long as 20 days. Specific lesion sites continue to shed virus for approximately 2 weeks. New lesions can continue to appear until the 10th day of the outbreak (Baddour & Gorbach, 2003; Bren, 2002).

In men, lesions are often found on the glans, coronal sulcus, urethra, on the shaft of the penis, or in the perineal area. In women lesions typically are found in the introitus, urethral meatus, on the labia, and in the perineal area. Cervicitis is common. Other manifestations include dysuria, vaginal discharge, urethral discharge, and lymphadenopathy. The presence of open sores increases the client's risk of acquiring HIV infection (Bren, 2002).

Oral anti-viral agents are the mainstay of treatment. A course of acyclovir for 7 to 10 days is warranted in a first episode; while in recurrent disease, treatment is for 3 to 5 days. Other effective antivirals include famciclovir and valacyclovir. For recurrent disease, the client must know his/her prodromal symptoms and begin treatment immediately. This means the client must have a supply of medication or a health care provider who will willingly proscribe it. Daily suppressive therapy is used for people who have frequent recurrences. Suppressive anti-viral therapy reduces the frequency, duration, and severity of outbreaks, but does not stop viral shed. Clients on daily suppressive therapy need occasional reevaluation for continued need. Patients are counseled against sexual activity during the prodromal phase and during their outbreak until all lesions are gone. Unfortunately, herpes is transmissible even without noticeable lesions, and persons with herpes are advised to wear condoms for all sexual activity (Bren, 2002; CDC, 2002; Fraley, 2002).

Various symptomatic treatments are available. Sitz baths and aloe vera lotion have proven helpful. Dry, loose clothing is more comfortable. Health care providers must address the psychosocial aspects of this disease, including social isolation, frustration with recurrences, and the need to share information honestly with potential sexual partners. Many self-help groups, newsletters, and hotlines are available (Fraley, 2002).

Human Papillomavirus Infection

Genital warts, the most common STD, are caused by the human papillomavirus (HPV). There are an estimated 5.5 million new cases of HPV infection annually, with a cumulative 40 million exposed. There are over 30 known subtypes of HPV; some are strongly associated with cervical cancer. In fact, cervical cancer is now considered primarily a sexually transmitted disease (Carulli, 2003; Heise, 2003; Likes & Itano, 2003).

Infection with HPV occurs via contact with infected tissues. Oral contraceptive use and smoking appear to increase the likelihood of contracting the disease. The natural history of the infection is not clearly understood, but HPV infects the skin and mucous membranes, replicating in the nuclei of infected cells. The interval between exposure and outbreak is 3 to 8 months. Pregnancy seems to exacerbate the condition (Heise, 2003).

Clinical manifestations in both men and women are clusters of typical flesh-colored, wart-like growths (condyloma acuminata) on the external genitalia and perineum. The lesions can also be found on vaginal, cervical, perianal, oral, and urethral mucosa. Multiple lesions can join to form a plaque-like, multilobed mass, which may grow to several centimeters in size. Some lesions can grow so large as to deform normal structures. They thrive in warm moist environments and tend to bleed easily if traumatized (Heise, 2003; Likes & Itano, 2003).

Genital warts may recur or persist, despite treatment. They may also resolve without any treatment. Several subtypes are known to undergo malignant transformation and infection with HPV is now known to be the only major causative factor in cervical cancer (Carulli, 2003; Heise, 2003).

Diagnosis is generally made on visual examination. Treatment is a difficult issue. The most common medications are patient or health care provider-applied podofilox gel or imiquimod cream. To be able to self-treat, the patient must be able to see and reach all warts. Cryotherapy and laser surgery are also options for more severe cases. However, a series of treatments is usually needed, and the disease is not cured. Recurrences are common, leading to frustration for the client. Often, a "wait and see" approach is taken, and no treatment is utilized. Women presenting with HPV need to have a Papanocololau (PAP) smear and DNA hybridization testing to determine risk of carcinogenesis (Carulli, 2003; CDC, 2002; Heise, 2003).

Nursing care for these clients revolves around teaching. HPV infection is considered a sentinel disease, indicating risky sexual behaviors. Women also need education regarding the role of HPV and cervical cancer and future screening activities. The chance of transmission is unknown, but HPV can be spread in the absence of visible lesions and despite wearing a condom. This makes HPV infection a frustrating issue for many. Many Web sites and self- help groups are available (CDC, 2002; Heise, 2003; Likes & Itano, 2003).

Recommendations for sexual activity in persons with HPV infection are varied. Typically, sexual activity is not advised for the man with visible lesions or during treatment. Women having invasive treatments will need to avoid sexual activity until healed. Some health care providers caution all persons with HPV to use condoms, but since most cases resolve spontaneously and many women are unaware of their outbreak status, this is still an unresolved issue.

Syphilis

Unlike the previous four STDs, syphilis is a systemic condition. For years, the number of known syphilis cases was in decline. Recently, however, a jump in the number of cases has been reported in several cities. Epidemiologists worry that as syphilis rates increase, HIV rates will climb shortly afterward. Syphilis is considered a "herald" disease for HIV infection, as the presence of lesions increases the risk of acquiring HIV infection ("Gonorrhea Rates," 2002; Stephenson, 2003; "Syphilis Is Back," 2003).

The causative agent of syphilis is Treponema pallidum, a highly invasive spirochete. Untreated, T. pallidum causes a chronic condition that is spread throughout the body and which can produce manifestations in virtually every organ system. The course of disease is divided into phases: primary, secondary, latent (both early latent and late latent), and tertiary syphilis (Baddour & Gorbach, 2003; CDC, 2002).

Primary syphilis is characterized by the appearance of a chancre (a lesion that progresses from a macule to a papule, then to an ulcer) at the point of inoculation, usually on or near the genitals. Chancres can also appear on the cervix, pharynx, or rectum, where they are often missed. Usually painless, the chancre begins as a papule, and then ulcerates as the lesion begins to erode. The chancre usually is indurated with a clean base and "rolled" edges. The lesion usually heals spontaneously in 3 to 6 weeks. The client may have local lymphadenopathy, but will not have other systemic symptoms (Baddour & Gorbach, 2003; CDC, 20\12).

Untreated, the disease will progress to the secondary stage in 6 weeks to 6 months from infection. During this stage, the spirochetes enter the bloodstream and are spread to most systems and organs. At this point, the client will complain of "flu-like" symptoms, such as headache, fever, malaise, nasal discharge, watery eyes, sore throat, and anorexia. Generalized lymphadenopathy may appear. About 75% of infected people in this stage develop a rash that begins on the trunk and has a special affinity for the palms and the soles. The lesions may be erythomatous, hyperpigmented, or brown. After several weeks the rash develops a dry, thin scale that peels off easily. Condylomata lata, a moist hypertrophie papular lesion, may also appear. The syphilitic rash is the most contagious form of syphilis (Baddour & Gorbach, 2003).

During the latent period, no manifestations are present. The latent period is further divided into two parts: the early latent period (comprising the first year after the secondary stage) and the late latent stage (more than 1 year after the secondary stage; may persist for the lifetime of the individiial). Transmission diminishes as the time in the latent period expands. Latent syphilis may stay in this phase or move on to tertiary disease (Baddour & Gorbach, 2003).

Approximately 30% of untreated syphilis suffers will progress to tertiary disease, which carries a mortality rate of 28%, mostly due to cardiovascular complications. Manifestations of the stage usually appear decades after the initial infection. There are three main types of manifestations: cardiovascular, gummatous, and meningovascular. The common pathophysiology in all three types seems to be endarteritis and periarteritis of small and mediumsized vessels (Baddour & Gorbach, 2003).

Cardiovascular syphilis is uncommon today (approximately 10% of untreated cases), but may be considered when a client presents with aortic aneurysms or aortic valve disease. The main problems in this type of disease are aortic; root dilation, left ventricular hypertrophy, and aneurysm (Baddour & Gorbuch, 2003).

Gummatous lesions, or gummas, are caused by a local, severe inflammatory response to treponemal antigens. Active lesions are granulomas, while older lesions are characterized by extensive fibrosis. The lesions heal with deep scars and fibrotic tissue. Gummas may appear in asymmetric groups and are usually painless and slowly progressive. They may break down into ulcers. Gummas, while most often visible on the skin, can affect any body organ, or bones (Baddour & Gorbach, 2003).

Neurosyphilis occurs when T. pallidum invades the meninges and neural tissue during secondary infection. Spirochetes can be visualized in cerebrospinal fluid, and in ocular and middle ear fluid. There arc two subtypes of nourosyphilis: a chronic, low- grade meningitis, and an endarteritis of the small vessels in the brain and spinal cord. Most often, the two types coexist. There is a constellation of signs and symptoms accompanying neurosyphilis: personality changes, psychoses, and a wide variety of paralytic symptoms (Baddour & Gorbach, 2003).

Despite the varying presentations and stages of syphilis, penicillin is still the drug of choice in all cases. For primary, secondary, and early latent stages, benzathine penicillin G is given intramuscularly, once in primary and secondary and weekly for three doses in the early latent stage. Nonpregnant clients with penicillin allergy can be given alternate drugs, but the effectiveness is diminished and a longer course of treatment is needed. Some choices include doxycycline with tetracycline, and perhaps cef'triaxone in primary or secondary syphilis (in women, only if they are not pregnant). Close followup is required as efficacy of these regimes is not well established (CDC, 2002).

Tertiary syphilis, particularly neurosyphilis, is treated with aqueous crystalline penicillin G intravenously every 4 hours for 10 to 14 days. An alternative regimen uses procaine penicillin plus probenecid. Clients with penicillin allergy need to be desensitized following the CDC guidelines (CDC, 2002).

Management of sex partners involves presumptive treatment within 90 days after exposure to primary, secondary, or early latent disease. After 90 days, treatment should be guided by serological testing, or if not available, presumptive treatment (CDC, 2002).

Conclusion

STDs have many consequences. One of the major responsibilities of nurses who work with any client who engages in sexual activity is teaching and prevention. Engaging in uctivittos with high risk for acquiring an STD carries many consequences. Clients should understand their responsibilities to themselves, their partners, and perhaps to their unborn children. Clients should be shown that their activities fall on a continuum of risk, with unprotected intercourse (particularly unprotected anal intercourse) having the most risk of disease transmission.

Primary prevention techniques for women include urinating before and after sexual activity, inspection of themselves and of their partners, questioning their prospective partners about sexual history and willingness to use condoms, and having condoms readily available. A woman should be helped to learn to negotiate the use of a condom for every act of sex. Both men and women need to know the correct way to apply a condom. Nurses need to be comfortable discussing this topic and demonstrating it on a model, if needed. There are also Web sites (such as http:// www.ashastd.org) that show animated clips of applying a condom. The CDC no longer recommends using nonoxyl-9 spermicide with condoms, as it can lead to tissue irritation, which in turn increases the risk of acquiring a disease (CDC, 2002).

Nurses need to take the lead in evaluating their clients' risk of acquiring STDs and tailor specific preventive techniques to the individual needs uncovered. Health care providers must realize that adolescents and the elderly are often sexually active, and frequently do not understand STDs and their vulnerability to contracting such diseases. Women should also be taught about routine screening for cervical cancer and the difference between that examination and the examinations for STDs. In this author's experience, women are often confused about the purpose of these examinations, and frequently assume "all the tests" are being done. Typically, STD cultures are done without needing to perform a PAP smear, and a routine PAP smear does not include STD screening unless the woman indicates a need for it.

Individuals who have been exposed to, or have symptoms of, an STD often present for treatment at emergency departments, urology clinics, or other sites where this testing is not seen as a priority. Clients already feel humiliated and fearful; nurses who show judgmental attitudes and behaviors are hurting national, state, and local efforts to reduce the prevalence of STDs (Fortenberry et al., 2002). Every client should be treated in a manner that is caring, respectful, and that meets his or her needs for both adequate treatment and proactive teaching. "Paradoxically, a major obstacle to the optimal treatment of STDs is the inappropriate behavior of some health providers" (Berger & Lee, 2002, p. 672). Nurses who approach clients in a professional manner can do much to stem the tide of STDs and their sequelae in this country.

Answer/Evaluation Form: Sexually Transmitted Diseases: An Update

References

Baddour, L., & Gorbach, S.L. (2003). Therapy of infectious diseases. Philadelphia: W.B. Saunders.

Berg, A.O. (2002). Screening for chlamydial infection: Recommendations and rationale. American Journal of Nursing, 102(10), 87-92.

Borger, R.E., & Lee, J.C. (2002). Sexually transmitted diseases: The classic diseases. In P.C. Walsh (Ed.). Camphett's urology (8th ed.). Philadelphia: W.B. Saunders.

Bren, L. (2002, March-April). Genital herpes: The hidden epidemic. FDA Consumer, 10-16.

Carulli, D.T. (2003). Abnormal cervical cytology: New names, familiar smears. Journal of the American Academy of Nurse Practitioners, 15, 444-449.

Centers for Disease Control and Prevention. (2002). Sexually transmitted diseases treatment guidelines: 2002. MMWR, 51(RR06), 1- 80. Atlanta: Author.

Fortenberry, J.D., McFarlane, M., Bleakley, A., Bull, S., Fishbein, M., Grimley, D.M., et al. (2002). Relationships of stigma and shame to gonorrhea and HIV screening. American Journal of Public Health, 92, 378-381.

Fraley, S.S. (2002). Psychosocial outcomes in individuals living with genital herpes. Journal of Obstetric, Gynecologic, and Neonatal Nufsing, 31, 508-513.

Gonorrhea rates rising among hardest-hit. (2002, May). AIDS ALERT, 63-65.

Grigg, E. (2000). Sexually transmitted infections and older people. Nursing Standard, 14(39), 48-53.

Heise, A. (2003). The clinical significance of HPV. The Nurse Practitioner, 28(10), 8-16.

Likes, W.M., & Itano, J. (2003). Human papillomavirus and cervical cancer: Not just a sexually transmitted disease. Clinical Journal of Oncology Nursing, 7(3), 271-276.

Mehta, S.D., Bishia, D., Howell, R., Rothman, R.E., Quinn, T.C., & Zenilman, J.M. (2002). Cost effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients. Sexually Transmitted Diseases, 29(2), 83-91.

Stephenson, J. (2003). Syphilis outbreak sparks concerns. JAMA, 289, 974.

Syphilis is back. (2003). AIDS Patient Care and STDs, 17(4), 203.

Todd, C.S., Haase, C., & Stoner, B.P. (2001). Emergency department screening for asymptomatic sexually transmitted infections. American Journal of Public Health, 91, 461-464.

Vastag, B. (2001). CDC says rates are up for gonorrhea. JAMA, 285, 155.

Meg Blair, MSN, RN, CEN, is an Assistant Professor, Nebraska Methodist College, Omaha, NE.

Note: CE Objectives and Evaluation Form appear on page 474.

Copyright Anthony J. Jannetti, Inc. Dec 2004

Source: Urologic Nursing

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