GU

Sexually Transmitted Diseases

Prevalence

Prevalence of STDs in the US is 3 million adolescents every year (1 in 4!). There are many factors which contribute to this high prevalence. 

Psychosexual maturation: development of an understanding of relationships.

  • The ability to maintain emotional intimacy learned during adolescence.
  • Adolescent may feel more comfortable with having sex than with talking about sex with their partner.

Cognitive development

  • Many adolescents have not completely developed the ability to fully consider the future and consider future consequences to present actions. Thus, many have a very low perceived risk of sexual behaviors.

Knowledge base

  • Despite efforts to increase sex education and attempts to encourage safer sex, many still lack accurate information: risks of STDs; symptoms (or lack of symptoms) associated with STDs; long-term consequences of STDs.

Physiologic development

  • Biologic factors are more of an issue with females. Cervical ectopy, columnar epithelium of the pubertal cervix, increases susceptibility of STDs. This is especially true with chlamydia and gonorrhea. Uncircumcision may increase risk of HIV, human papillomavirus and genital ulcers.

First sexual experience

  • With young age of first sexual experience, there is an increased risk of more sexual partners. Furthermore, he/she may be more likely to engage in unprotected sex and may be more likely to choose partners with higher risk factors for STDs.

Perception of being "sexually active"

  • Lack of understanding as to what sex entails and manners in which STDs may be spread
  • Can be extremely problematic.

Barriers to health care

  • Lack of finances, lack of adequate insurance coverage, lack of knowledge of free resources, and lack of transportation may all serve as barriers to much needed services.

Risky behaviors

  • "Risky behavior syndrome" involves being irresponsible about various behaviors.
  • Participating in one risky behavior (i.e. drugs & alcohol) often leads to other risky behavior such as unprotected sex.

 

Chlamydia

C. trachomatis is an obligate intracellular parasite that can present as a symptomatic or asymptomatic infection.  It is known as a "silent" disease because the majority of infected people are asymptomatic.  Women who are symptomatic usually present with dysuria, and a yellow mucopurulent endocervical exudate.  They may also have lower abdominal pain, nausea, fever, dyspareunia, or  bleeding between periods.  Men who present with chlamydia tend to have dysuria, increased urinary frequency, and purulent urethral discharge.  Chlamydia is the most common reported STD in the United States.  Co-infection with Gonorrhea is extremely common among adolescents and young adults. 

Clinical Spectrum of Chlamydia

  • Urethritis
  • Epididymitis
  • Proctitis
  • Prostatitis
  • Cervicitis
  • Bartholinitis
  • Conjunctivitis

Complications of Chlamydia

  • Pelvic inflammatory disease (PID):  a severe infection of the upper female reproductive tract with severe complications such as infertility, chronic pelvic pain, tubo-ovarian abscesses and even death.
  • Perihepatitis (Fitz-Hugh-Curtis Syndrome):  an individual may present with right upper quadrant pain, fever, nausea and vomiting. Liver enzymes are usually normal and any elevation may be mild.
  • Epididymitis
  • Reiter's syndrome:  a triad of urethritis, conjunctivitis, and arthritis, with more than 80% of patients having a past or current chlamydia infection.

In women with untreated infections, there can be a subsequent risk of infertility, increased risk of ectopic pregnancy, and chronic pelvic pain.

Testing

The use of nucleic acid amplification techniques has improved the sensitivity of disease detection by 25 to 30%. Older non-culture techniques such as direct fluorescent antibody, enzyme immunoassay, and non-amplified nucleic acid hybridization are even less sensitive than culture.

Treatment

  • Azithromycin administered as a single oral dose of 1 g OR doxycycline 100mg orally BID for 7 days
  • Alternative regimens include erythromycin base, erythromycin ethylsuccinate, levofloxacin, and ofloxacin
  • Azithromycin 1 g orally has also been shown to be safe and effective in pregnancy.  Amoxicillin 500 mg orally TID for 7 days is an alternative.

Screening for Chlamydia/ Follow Up/ Management of Partners

  • Annual screening is recommended in all sexually active women under the age of 25 years. Data for women is more comprehensive than for men because the surveillance programs for asymptomatic infection have been more effectively applied to women.
  • There is no need to repeat testing after instituting therapy. Testing done less than three 3 weeks of the intervention may give false positive or false negative results.
  • Patients should abstain from unprotected sex for 7 days after treatment is started
  • Sex partners of symptomatic patients should be evaluated and treated if their last sexual contact with the index patient was within 30 day of onset of the symptoms. In the patient is asymptomatic; referral of the sex partner within the last 60 days is recommended.

 

Gonorrhea

N. gonorrhoeae is a fastidious gram negative diplococcus that infects mucous membranes. Women who are symptomatic usually report dysuria, abnormal menses, or abnormal vaginal discharge. Men may also present with dysuria, in addition they may present with increased frequency, and a purulent urethral discharge (more copious and purulent than in chlamydia). 80% of women can by asymptomatic in comparison to 95% of men having symptoms.

Clinical Spectrum

  • Urethritis
  • Epididymitis
  • Proctitis
  • Prostatitis
  • Cervictis
  • Infection of Bartholin's gland
  • Infection of Skene's gland
  • Pharyngitis
  • Conjunctivitis

Complications

  • Pelvic inflammatory disease (PID)
  • Preihepatitis (Fitz-Hugh-Curtis Syndrome)
  • Disseminated Gonoccocal infection (DGI):  more common in women particularly during pregnancy and within a week of menses. Other risk factors include pharyngeal infection and complement deficiencies. Presenting symptoms of DGI include arthritis (usually knee, wrist, ankle, or metacarpophalangeal joints), tenosynovitis, and dermatitis (usually on distal extremities).
  • Meningitis
  • Endocarditis

Testing

Nucleic acid amplification testing (NAAT) is recommended for rapid results when testing males for urethritis or females for cervicitis or urethritis.  NAAT is generally more sensitive than culture, however the test is more expensive and antibiotic susceptibility cannot be assessed.  Therefore, if drug resistance is suspected culture should be performed.  Culture is also the assay of choice for suspected extragenital infection in both men and women.  Urethral gram stain can be diagnostic in men; however this method does not provide an accurate diagnosis in women.

Treatment

  • Recommended that patients treated for gonococcal infection also be treated routinely with a regimen that is effective against uncomplicated genital Chlamydia infection
  • Due to increased resistance, quinolones are no longer recommended for use in the United States for treatment of gonorrhea and associated conditions such as PID; Cephalosporins are now the class of choice
  • For uncomplicated gonococcal infections of the cervix, urethra, and rectum:
  • o   Ceftriaxone 250 mg IM in a single dose OR, if not an option, Cefixime 400 mg orally single dose
  • o   PLUS - Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally BID for 7 days
  • Uncomplicated gonococcal infections of the pharynx:
  • o   Ceftriaxone 250 mg IM single dose
  • o   PLUS - Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally BID for 7 days
  • Pregnant patients should be treated with the recommended or alternate cephalosporin; azithromycin or amoxicillin is recommended for the presumptive Chlamydia infection
  • Patients with DGI should be admitted for intravenous therapy with Ceftriaxone for 24-48 hours after improvement begins and at that time can be switched to Cefixime 400 mg orally BID for at least 1 week.

Screening for Gonorrhea/ Follow Up/ Management of Partners

  • Annual screening is recommended in all sexually active women under the age of 25 years.
  • There is no need to repeat testing after instituting therapy.
  • All partners should be treated for both gonorrhea and chlamydia.
  • Patients should abstain from sexual intercourse until therapy is completed and they no longer have symptoms

 

Trichomoniasis

This infection is caused by the protozoan Trichomonal vaginalis. Male are usually asymptomatic, but the protozoan may cause an urthritis. Women may also present without symptoms.

Clinical Presentation

  • Vaginal discharge
  • Vulvar irritation
  • Urethritis
  • Strawberry cervix

Diagnosis

  • Motile trichomonad on saline wet mount of vaginal secretions
  • Wet mount is not the perfect method to detect the organism because in 30-50% of the cases, it is missed.
  • Urine samples from both men and women
  • Rapid tests are available with varying sensitivities and specificities
  • Culture of the organism is the most commercially available test.

Treatment

  • Single dose of metronidazole 2 g orally with the cure rate approaching 90-95%
  • No follow up is necessary and affected partners should be treated. Individuals should not engage in sexual intercourse until they are cured.

 

Herpes Simplex Virus

Genital herpes is caused by two strains of the herpes simplex DNA virus, HSV-1 and HSV-2. However HSV-2 is more common in the lower genital tract. Clusters of painful vesicles and ulcers characterize the infection. After the initial infection, the virus retreats to the nerve root ganglion, and recurrent infections are usually of shorter duration and less extensively involved. Atypical presentation of HSV includes appearance of a small linear ulceration or an individual may be asymptomatic and have shedding of the virus.

Clinical presentation

  • Fever
  • Myalgia
  • Headache
  • Tender inguinal adenopathy
  • Pain
  • Itching
  • Dysuria
  • Vaginal Discharge
  • Urethral Discharge

Complications

  • Aseptic meningitis
  • Transverse myelitis
  • Extragenital lesions
  • Bacterial superinfection
  • Hepatitis
  • Pneumonitis
  • Arthritis
  • Cutaneous dissemination

Diagnosis 

  • Definitive diagnosis of HSV is made from viral cultures of fresh blisters and/or ulcers. Culture is less sensitive once lesions begin to heal.
  • Cell culture and PCR are the preferred HSV tests (PCR more sensitive)
  • Cytologic detection of HSV is an insensitive and nonspecific method of diagnosis therefore should be not relied on (ie. Tzanck preparation)
  • Type-specific HSV serologic assays can be useful in certain situations such as recurrent symptoms with negative cultures, a clinical diagnosis without lab confirmation, or a partner with genital herpes.
  • Subtyping of the virus is recommended

Treatment 

  • For first clinical episode:  Acyclovir 400 mg orally TID for 7-10 days OR famciclovir 250 mg TID for 7-10 days OR Valacyclovir 1 g orally TID for 7-10 days
  • For established infection:  Acyclovir 400 mg BID OR Famciclovir 250 mg BID OR Valacyclovir 1 g orally once a day
  • Topical therapy is not recommended
  • Topical anesthetic therapy may be useful for symptomatic relief
  • IV therapy should be used in severe disease

 

Human Papilloma Virus Infection

A DNA virus that has more than 30 types affecting the genital tract.

Clinical presentation

  • Condylomata acuminata - appears as a raised lesion to subclinical infection and is only detected through cytology or by application of acetic acid revealing an aceto white reaction on the mucosa.
  • Asymptomatic patient
  • Symptomatic patients have lesions that are painful, friable or puritic.

Sequele 

  • Squamous intraepithelial neoplasia (Vaginal, anal, and cervical intraepithelial dysplasia)
  • Squamous cell carcinoma - HPV types 16, 18, 31, 33, and 35 are the high risk types most commonly associated with malignant transformation.

Sexually active women should be referred for Pap smears to screen for cervical abnormalities.

 

Syphilis

Treponema pallidum is a spirochete that is responsible for syphilis.

Stages

  • First stage:  Presents as a painless ulcer at the site of inoculation 3 weeks after infection, and the lesion resolves.
  • Second stage:  The patient may present with fever malaise, headache, adenopathy, generalized body rash, and mucosal lesions (condylomata lata). The rash of secondary syphilis can be confused with pitiriasis rosea. The symptoms of secondary syphilis resolves spontaneously and the infection enters a latent stage.
  • Third stage:  Can present years later and may manifest as neurologic, cardiovascular, and skeletal disease.

Diagnosis

  • Darkfield examination or by direct flouresscent antibody test
  • Screening for syphilis is done with the Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR)
  • A positive test is confirmed with a fluorescent treponemal antibody absorbed (FTA-ABS) or T. pallidum particle agglutination (TP-PA).

Treatment

  • Primary or Secondary Syphilis: Penicillin G IM once
  • Tertiary Syphilis: Penicillin G IM weekly for three weeks
  • Neurosyphilis: Penicillin G IV infusion every four hours for 10-14 days

It is preferable to desensitize penicillin allergic patients rather than use alternatives like doxycycline or tetracycline.

 

Bacterial Vaginosis

A condition associated with increased risk of some STDs in women resulting from the replacement of normal hydrogen peroxide producing Lactobacillus in the vagina with overgrowth of Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus species, and anaerobic gram-negative rods.

The cause is not fully understood, any woman can get bacterial vaginosis regardless of sexual activity.  However there are activities and behaviors that can increase the risk:

  • Having a new partner
  • Multiple male or female sexual partners
  • Douching

Clinical Presentation

  • Abnormal vaginal discharge with an unpleasant odor sometimes reported as a strong fish-like odor especially after intercourse
  • Discharge, if present, is usually white or gray
  • Patients may also have burning during urination or itching
  • Most are asymptomatic

Diagnosis

  • Clinical criteria may be used - Amsel's Diagnostic Criteria (three of the following four):
  • Thin homogeneous vaginal discharge
  • Presence of clue cells on microscopy
  • Vaginal fluid pH >4.5
  • a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test)
  • Results may be correlated with gram stain

Complications

  • Increased risk for developing sexually transmitted disease including HIV, herpes, Chlamydia, and gonorrhea
  • Increased susceptibility to HIV infection if the woman is exposed to the virus
  • Increased chance of an HIV-infected woman passing HIV to her partner
  • Increased risk of complications of pregnancy such as preterm delivery

Treatment

  • Metronidazole 500 mg orally BID for 7 days

 

References:

  1. CDC: National Center for HIV, STD and TB Prevention Division of Sexually Transmitted Diseases: Annual Trends: http://www.cdc.gov
  2. Cavanaugh, Robert M. Screening for Genitourinary Abnormalities in Adolescent Males. Pediatrics in Review 30.11 (2009): 431-438.
  3. Tulloch, Trisha, and Miriam Kaufman. Adolescent Sexuality. Pediatrics in Review 34.1 (2013): 29-38.
  4. Sieving, Renee E., Jennifer A. Oliphant, and Robert Wm Blum. Adolescent sexual behavior and sexual health. Pediatrics in review 23.12 (2002): 407-416.
  5. Comkornruecha, Metee. Gonococcal Infections. Pediatrics in Review 34.5 (2013): 228-234.
  6. Burstein, Gale R., and Pamela J. Murray. Diagnosis and management of sexually transmitted diseases among adolescents. Pediatrics in Review 24.4 (2003): 119-127.
  7. DiClemente, Ralph J., et al. Association between sexually transmitted diseases and young adults' self-reported abstinence. Pediatrics 127.2 (2011): 208-213.
  8. MMWR. Sexually Transmitted Diseases Guidelines 2010
  9. CDC Update of 2010 Guidelines for treatment of Gonorrhea MMWR August 2012