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Sexually Transmitted Diseases in Adolescents - UPDATE 2002 Marcia J. Nackenson, M.D. Section of Adolescent Medicine New York Medical College.

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Presentation on theme: "Sexually Transmitted Diseases in Adolescents - UPDATE 2002 Marcia J. Nackenson, M.D. Section of Adolescent Medicine New York Medical College."— Presentation transcript:

1 Sexually Transmitted Diseases in Adolescents - UPDATE 2002 Marcia J. Nackenson, M.D. Section of Adolescent Medicine New York Medical College

2 STD’s: General Principles If sexually active, inquire specifically. STD’s go together. Partner treatment. Test of cure? Test of reinfection? Condoms not 100% effective.

3 Adolescents: Highest Rates of STD’s Cervical ectropion. Less use of barrier methods. Multiple lifetime sexual partners. Obstacles to healthcare, perceived and real.

4 Cervicitis Symptoms Asymptomatic usually. Must screen q 6-12 mos. Spotting after intercourse. Friability. Mucopurulent discharge.

5 Gonococcal cervicitis

6 Cervicitis Neisseria gonorrheae, Chlamydia trachomatis PMN’s per high power field - not useful. Gram neg. intracellular diplococci. Gonorrhea culture - special media, hi CO2 DNA probe - GC and Chlam Chlamydia culture - prepubertal Chlamydia non-culture: DFA, EIA, PCR, LCR, NAAT

7 Gonorrhea - gram stain of urethral discharge

8 Cervicitis Treatment - Gonorrhea Cefixime (Suprax) 400 mg PO x 1 ($7.50) Off the market 11/02! ceftriaxone 125 mg IM x 1 ciprofloxacin 500 mg PO x 1 ($4.00) Beware quinolone resistance (QRNG) - Asia, Pacific, Hawaii

9 Cervicitis Treatment - Chlamydia doxycycline 100 mg PO BID x 7d. ($1.40) azithromycin 1.0 g PO x 1 ($26.00) erythromycin in pregnancy Rescreen in 3-4 months

10 Urethritis Usually male; in female acute urethral syndrome Usually symptomatic - discharge, dysuria Etiology: Gonorrhea Chlamydia Mycoplasma Ureaplasma Screen: First void urine - + leukocyte esterase or >10 pmn’s/hpf Diagnosis & Treatment : same as cervicitis

11 Gonococcal urethritis

12 Urethritis Screening Male: Urine leukocyte esterase 79% specificity 31% sensitivity Urine LCR, PCR - expensive Complications: Epididymitis Prostatitis

13 Bartholin’s abscess


15 Disseminated gonorrhea - skin lesion


17 Pelvic Inflammatory Disease Definition Acute salpingitis Endometritis Tubo-ovarian abscess Sexually transmitted, ascending infection of the upper genital tract (uterus and fallopian tubes).

18 PID - Epidemiology >1,000,000 cases /yr in US 20% are adolescents; 1:8 risk for 15 yr old Cost $4 billion/ yr Risk factors - Previous PID

19 PID - Etiology Chlamydia trachomatis Neisseria gonorrhoeae Anaerobes Group B Strep Gram neg. Mycoplasma Ureaplasma

20 PID - History Sexual activity Lower abdominal pain Fever, vomiting, anorexia, dysuria, dyspareunia Exposure to STD Previous PID Complete Gyn. history

21 PID - Physical Exam Fever Abdomen - tenderness, rebound, masses Pelvic exam: Speculum - cervical specimens Bimanual - cervical motion tenderness adnexal tenderness Rectovaginal - masses in the cul-de-sac

22 PID - Laboratory Studies Pregnancy test CBC with differential ESR, CRP UA; UC (cath) if symptomatic RPR Tests for Gonorrhea and Chlamydia Pelvic ultrasound

23 PID - Diagnosis High index of suspicion High sensitivity (few dx criteria) = low specificity = overtreatment High specificity (many dx criteria) = low sensitivity = undertreatment

24 Specific PID Diagnosis Endometrial biopsy Laparoscopy US or MRI : –TOA –hydro- or pyosalpinx

25 CDC PID Diagnosis Begin treatment if: Uterine/adnexal tenderness OR Cervical motion tenderness

26 PID - Supporting Diagnostic Criteria Temperature > 38.3 C Abnormal cervical or vaginal DC WBC’s on vaginal wet mount Elevated ESR or CRP Evidence of GC or Chlam from endocervix

27 PID Criteria for Admission ( All Adolescents) Cannot comply with outpt. PO or FU 72 hrs Surgical emergency Pregnancy Severe illness Failed outpt treatment Tubo-ovarian abscess

28 PID - Management Gyn consult only if diagnosis in doubt Antibiotics: doxycycline 100 mg PO q12hplus cefotetan 2.0 g IVPB q12h or cefoxitin 2.0 g IVPB q6h Pelvic ultrasound ASAP

29 PID - Complications Tubo-ovarian Abscesses Suspect: Adnexal mass Poor clinical response Persistently hi WBC or ESR Pelvic sono: Complex adnexal mass >30cc. Add Flagyl 500 mg IVPB q12h Gyn consult

30 PID - Complications Fitz-Hugh-Curtis Syndrome Perihepatitis - Gonorrhea or Chlamydia RUQ pain - pleuritic, radiating to shoulder 50% increased LFT’s

31 PID - Sequelae Infertility: 1st episode - 10% 2nd - 35% 3rd % Ectopic pregnancy: 6-10 times risk Chronic pelvic pain: 18-24% R/O endometriosis Rx NSAIDs Repeat PID: 12-33%

32 PID - Discharge Instructions HIV counseling Complete all antibiotics No sex Partner treatment Contraceptive counseling Condoms Follow-up

33 Vaginitis Abnormal vaginal discharge: Profuse Foul-smelling Pruritic Abnormal color

34 Physiologic Leukorrhea Requires estradiol Can be pre-menarcheal Minimal to moderate amount Clear to whitish Not bothersome Desquamated epithelial cells

35 Vaginitis - Infectious Etiologies Trichomonas vaginalis Bacterial vaginosis (BV) Candida (usually albicans)

36 Vaginitis - Diagnosis Saline wet mount: clue cells in BV Trichomonads KOH prep:budding yeast and pseudohyphae + whiff test - fishy odor (BV) pH >4.5: BV or Trichomonas

37 Trichomonas vaginalis Sexually transmitted Thin, green discharge,strawberry cervix Culture most sensitive May be identified on Pap or UA Treatment: Flagyl 2.0 g PO stat or Flagyl 500 mg PO BID x 7d

38 Bacterial vaginosis Gardnerella vaginalis and other anerobes ?STD, link with PID 50% asymptomatic, do not treat Pap No partner treatment Treatment: Flagyl 500 mg BID x7d or Metrogel qHS x 5

39 Candida Pruritus, thick, white discharge Do not treat Pap or culture Underlying conditions: 1. Antibiotic treatment 2. Pregnancy 3. Diabetes mellitus 4. Immunosuppression Vulvitis secondary to intertrigo

40 Candida Treatment Imidazole group; nystatin less effective Creams 3-7 d Suppositories: 500 mg x mg x 3 d 100 mg x 7 d OTC: Monistat 200 mg x 3 d Prescription: Terazol 80 mg x 3 d PO: fluconazole 150 mg PO x 1

41 Recurrent Vulvovaginal Canididias Overdiagnosed clinically Treat: 7-14 days of topical Rx fluconazole 150 mg PO, repeat in 3 da. Maintenance therapy - 6 mo course: clotrimazole 500 mg vag. Q wk fluconazole 150 mg PO Q wk

42 Genital Ulcers Painless: Syphilis Painful: Herpes genitalis Chancroid Increased risk for HIV infection

43 Syphilis (Treponema pallidum) Incidence peaked ‘90, NY 400/100,000 men 2001 Westchester /100,000 Usually asymptomatic Diagnosis: Darkfield microscopy Non-treponemal serology - screening RPR, VDRL Treponemal antibody tests -confirmatory FTA-ABS, MHA-TP

44 Syphilis Diagnosis - NYS DOH T. pallidum IgG ELISA for screening RPR done only if ELISA + Treponemal Passive Particle Agglutination Test then done as a confirmation

45 Primary Syphilis Incubation period 9-90 d (mean 21d) Chancre : Single, site of innoculation Painless, punched out, indurated Regional lymphadenopathy Heals 4-6 weeks

46 Primary syphilis-chancre


48 Primary syphilis - chancre of anus

49 Primary syphilis - chancre


51 Secondary Syphilis 6-8 wk after exposure, 3 wk after chancre Rash - palms and soles, “great imitator” Condyloma lata Lymphadenopathy Flulike syndrome

52 Latent Syphilis Early < 1 year Late > 1 year LP if: Neurologic symptoms Tertiary syphilis Treatment failure HIV infection

53 Syphilis (cont.) Neurosyphilis: % after 2 yrs Asymptomatic - abnormal CSF Acute meningitis Meningovascular - tabes dorsalis Late Syphilis: 2-30 yrs Cardiovascular - aortic aneurysms Gummas

54 Syphilis - Treatment Primary, secondary, or early latent: Benzathine PCN G 2.4 million U IM x 1 Late latent or tertiary: Benzathine PCN G 2.4 million U IM x3, 1 week apart Neurosyphilis: Aq PCN IV x d Jarisch-Herxheimer Reaction - fever, chills within 2-24 hrs

55 Syphilis - Follow Up Repeat non-treponemal serology 6, 12, 24 months for latent Titres should decrease four-fold Retreat if four-fold increase Treponemal antibodies stay + for life

56 Herpes genitalis HSV-2 more common than HSV-1 Primary infection: Incubation mean 6-8 d Multiple 1-2mm vesicles Erode to ulcers Tender adenopathy Fever, malaise Dysuria Three weeks to resolve

57 HSV Recurrent Episodes Fewer lesions, unilateral Prodromal paresthesias One week duration

58 Diagnosis of HSV Not Tzanck or Pap Culture - Cotton or Dacron swab Viral media 7 days to results Preferred method Type specific serology to identify HSV2

59 HSV Treatment Primary - dec. viral shedding, new lesions, shortens symptoms. acyclovir 400 mg PO TID x 7-10 d valacyclovir 1 g PO BID x 7-10 d famciclovir 250 mg PO TID x 7-10 d Episodic Recurrent Infection recommended acyclovir 400 mg TID x 5 d valacyclovir 1g QD x 5 d famciclovir 125 mg TID x 5 d

60 HSV Daily Suppressive Therapy Recommended If > 6 recurrences per year acyclovir 400 mg BID valacyclovir 1 g qd famciclovir 250 mg BID DC after 1 yr and observe

61 Chancroid Hemophilus ducreyi - special culture media Painful, ragged, undermined, multiple ulcers. Tender, suppurative adenopathy Treatment: azithromycin 1 g PO or ceftriaxone 250 mg IM Symptoms improve 3-7 d after treatment.

62 Chancroid ulcers

63 Chancroid Male - regional adenopathy

64 Chancroid - ruptured node

65 Chancroid - gram stain of H. ducreyi

66 Lymphogranuloma Venereum L1,2,3 serovars of Chlamydia trachomatis Tender adenopathy, “groove sign” Fistulae, strictures Diagnosis: serology Treatment: doxycycline 100 mg BID x 21 d

67 LGV primary lesion

68 Chronic lymphogranuloma venereum in female. Genital elephantiasis

69 LGV lymphadenopathy

70 Granuloma Inguinale Calymmatobacterium granulomatis Nodules erode to beefy red ulcers No adenopathy Diagnosis: Donovan bodies on microscopy Treatment: Bactrim DS BID x 21 d or doxycycline 100 mg BID x 21 d

71 Granuloma inguinale, male

72 Human Papillomavirus Probably most common STD Types 6 & 11 - external warts Types 16,18,31,33,35 - cervical dysplasia Incubation 3 wks - 8 mos (mean 2-3 mos) Genital warts - Condyloma acuminata

73 HPV - Treatment Goal: to dec. symptoms, does not affect course of HPV. Patient-applied: Preferred podofilox (Condylox) imiquimod (Altara) Provider-applied: podophyllin TCA cryotherapy, surgery

74 HIV Infection and Adolescents 20% AIDS cases in yr olds Incubation period 10 yrs Seroprevalence Studies: Job Corps 3.9/1000 Military recruits 0.3/1000 STD clinics 11/1000

75 Risk Factors among HIV+ Youth Males: Homosexual activity Hemophilia Females: Heterosexual activity Injection drug use Congenital HIV Infection

76 Adolscent Issues Risk-taking behavior, experimentation Sexual activity High incidence of STD’s Drug use Runaway youth - “survival sex”

77 HIV Testing of Adolescents Should be voluntary Anonymous vs. Confidential Adolescent should give informed consent if capable. Risk reduction counseling Condom availability

78 Granuloma inguinale, female

79 Granuloma inguinale, chronic destructive lesion


81 Granuloma inguinale with both active and healed lesions

82 Granuloma inguinale, chronic destructive lesion

83 Granuloma inguinale with both active and healed lesions

84 Granuloma inguinale, Donovan bodies

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