Sexually Transmitted Infections

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89 Sexually Transmitted Infections

Sexually transmitted infections (STIs) present a significant source of morbidity among adolescents, especially young women. According to 2007 surveillance data, adolescents represent 25% of the sexually active population but account for 50% of new STIs. The high incidence of STIs is associated with greater susceptibility of the adolescent female reproductive tract, poor access to STI prevention services, inconsistent use of barrier prophylaxis, and high prevalence among sexual partners.

STIs present with a wide range of symptoms and physical findings. Moreover, many infections are asymptomatic. Thus, regular screening among sexually active adolescents is highly recommended.

This chapter focuses on the most common clinical syndromes among adolescents: vaginitis, urethritis, cervicitis, human papillomavirus (HPV) infection, herpes genitalis, chlamydia, gonorrhea, and syphilis.

Urethritis and Cervicitis

Clinical Presentation

The clinical presentations of urethritis and cervicitis and their associated infections are detailed in Table 89-2 and Figure 89-1.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an important complication of cervicitis, most commonly caused by N. gonorrhoeae and C. trachomatis. Other vaginal and enteric pathogens may be involved, including Bacteroides spp., Ureaplasma urealyticum, and Mycoplasma hominis. Gonococcus, C. trachomatis, and other organisms may ascend into the uterus and fallopian tubes. Infected material in the fallopian tubes may result in tubo-ovarian abscess, and overflow may lead to peritonitis or perihepatitis. The risk of PID is associated with young age at first intercourse, multiple partners, vaginal douching, and use of intrauterine devices.

The presenting symptoms of patients with PID are described in Table 89-2. Some patients may have subclinical infection that is not diagnosed until evaluation for infertility reveals fallopian tube scarring. On examination, patients usually have lower abdominal tenderness. Pelvic examination may reveal cervical discharge; an inflamed cervix; cervical, adnexal, or uterine tenderness; or an adnexal mass. Timely diagnosis of PID is important to prevent infertility. Because the signs and symptoms of infection are not specific, the Centers for Disease Control and Prevention developed criteria to guide diagnosis and empiric treatment (Table 89-3). Fulfillment of minimal criteria indicates presumptive treatment.

Table 89-2 Signs and Symptoms of Urethritis, Cervicitis, and Associated Syndromes in Men and Women

  Men Women

     

PID, pelvic inflammatory disease; RUQ, right upper quadrant.

Table 89-3 Signs and Symptoms of Pelvic Inflammatory Disease

Minimal Criteria Additional Criteria Definitive Criteria

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; WBC, white blood cell.

Evaluation and Management

Gonorrhea can be diagnosed by gram stain and culture from urethral and endocervical swabs. Chlamydia, as an intracellular organism, is difficult to grow in culture and has therefore been more difficult to diagnose. Newer and more rapid diagnostic methods include nucleic acid amplification techniques that have greatly increased the ease and sensitivity of testing. They can be performed on urine samples in addition to urethral or endocervical swabs. The other bacterial causes of urethritis—cervicitis and PID—are not generally isolated from cultures.

Patients with gonorrhea or chlamydia are at risk for co-infection. Therefore, treatment guidelines recommend covering for both pathogens when treating urethritis, cervicitis, or PID (Table 89-4). This is critical in PID, in which cervical culture results are often negative. Recommendations for PID also include anaerobic coverage because of the polymicrobial nature of the infection.

Table 89-4 Treatment Recommendations for Urethritis, Cervicitis, and Pelvic Inflammatory Disease*

  Treatment Special Considerations
Nongonococcal urethritis or cervicitis

Gonococcal urethritis or cervicitis Pelvic inflammatory disease Epididymitis  

IM, intramuscular; IV, intravenous; NAAT, nucleic acid amplification test; PO, oral; TOA, tubo-ovarian abscess.

* Additional alternate regimens for special populations or for those with allergies are available at www.cdc.gov/std/treatment.

Anogenital Lesions

The most common causes of anogenital lesions in adolescents include herpes genitalis, HPV, and syphilis. The differential diagnosis should also include chancroid caused by Haemophilus ducreyi. Although only 23 cases of chancroid were reported in the United States in 2007, it is prevalent in certain regions and groups. In general, painful ulcerative lesions are associated with herpes genitalis and chancroid. Painless ulcers are associated with syphilis, and HPV causes painless anogenital growths.

Secondary syphilis Latent syphilis Late syphilis Neurosyphilis

CSF, cerebrospinal fluid; FTA-ABS, fluorescent treponemal antibody absorption test; VDRL, Venereal Disease Research Laboratory.

Treatment

The mainstay of treatment for syphilis is penicillin. Although other regimens are available to treat primary and secondary syphilis for patients who are allergic to penicillin, their efficacy has not been well demonstrated. The treatment regimens are shown in Table 89-6. Follow-up should include repeat nontreponemal quantitative antibodies (VDRL) at 6, 12, and 24 months after completion of therapy. If initially high titers have not decreased fourfold or if the titers have increased, treatment should be repeated. Further detail is available at www.cdc.gov/std/treatment.

Table 89-6 Treatment of Syphilis

Primary or secondary syphilis Benzathine penicillin G IM
Other preparations of penicillin are not appropriate for treatment.
In the setting of penicillin allergy, doxycycline or tetracycline can be used.
Early latent syphilis Benzathine penicillin G Alternate: doxycycline
Late latent or tertiary syphilis Benzathine penicillin G LP should be performed to look for neurosyphilis
Neurosyphilis Aqueous crystalline penicillin G or
Procaine penicillin + probenecid
LP should be repeated every 6 months until pleocytosis has resolved

IM, intramuscular; LP, lumbar puncture.

Herpes Genitalis

Diagnosis and Management

If the clinical history and appearance of lesions suggest herpes genitalis, the most rapid and inexpensive test is a Tzanck smear of scrapings from the base of the lesions, looking for multinucleated giant cells. It has a sensitivity of only 30% to 80%. Other diagnostic tests are available; the historic gold standard is viral culture, which is most sensitive when samples are obtained from vesicles, pustules, or ulcers. HSV can grow in 1 to 7 days. Immunofluorescence microscopy, DNA probes, and polymerase chain reaction are highly sensitive and specific assays. HSV type-specific serologic tests exist but may be falsely negative in early infection.

Treatment will not clear infection but may decrease the duration of symptoms and viral shedding in both primary and recurrent infection. To be effective, episodic treatment should begin within 1 day of lesion appearance. In severe infection, patients require intravenous acyclovir, 5 to 10 mg/kg every 8 hours for 2 to 7 days until improved followed by oral therapy to complete a 10-day course. Topical therapy has not been shown to be effective for herpes genitalis. Long-term suppressive antiviral therapy can also be given to decrease the frequency of recurrences. See Table 89-7 for treatment of HSV infections.

Table 89-7 Treatment of Herpes Simplex Virus

Primary Infection Suppressive Therapy Episodic Therapy

BID, twice a day; PO, oral; QD, every day; TID, three times a day.

Human Papillomavirus

HPV is the most common STI in the United States, affecting at least 80% of women and men at some point during their lives. Similar to other STIs, adolescent and young adult women are most likely to be affected. In the United States, a recent study found that 25% of 14- to 19-year-old individuals and 45% of 20- to 24-year-old individuals were infected with at least one type of HPV. HPV is usually acquired shortly after sexual initiation, and the number of partners is the most important risk factor for HPV infection.

Diagnosis and Management

The diagnosis of genital warts is generally made by visual inspection. If external genital lesions are found in women, an internal examination of the genital tract is warranted. Anoscopy and urethroscopy may be indicated. Cervical dysplasia is diagnosed by Pap smear testing. Currently, Pap smears are recommended within 3 years of sexual initiation or by age 18 years. Testing should be performed yearly until a patient has three consecutive normal tests. Screening can then be performed every 3 years unless the patient is engaging in any high-risk sexual behavior or has had other STIs.

Treatment of genital warts includes multiple patient- and clinician-directed methods (Table 89-8). Treatment of an abnormal Pap smear depends on the degree of cervical dysplasia. For the most recent updates regarding cervical cancer screening, refer to www.asccp.org.

Table 89-8 Management of Human Papillomavirus Infections

External genital warts
For treatment of vaginal, cervical, or urethral warts, see www.cdc.gov/std/treatment

ASCUS

LSIL HSIL

ASCUS, atypical squamous cells of undetermined significance; BCA, bichloracetic acid; CIN, cervical intraepithelial neoplasia; HPV, human papillomavirus; HSIL, high-grade squamous intraepithelial dysplasia; LSIL, low-grade squamous intraepithelial dysplasia; TCA, trichloroacetic acid.

In addition to current cervical cancer screening, a quadrivalent HPV vaccine was approved in 2006 for the prevention of genital lesions and cervical cancers caused by HPV types 6, 11, 16 and 18. The vaccine is recommended for routine administration to 11- and 12-year-old girls and for catch-up vaccination to 13- to 26-year-old girls and women. It has been shown to be highly effective in girls and young women who have not yet been exposed to any of the HPV vaccine types.