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. CervicitisSymptoms • Asymptomatic usually. • Must screen q 6-12 mos. • Spotting after intercourse. • Friability. • Mucopurulent discharge.

5. Gonococcal cervicitis

6. CervicitisNeisseria 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. CervicitisTreatment - 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. CervicitisTreatment - 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. UrethritisScreening • Male: Urine leukocyte esterase 79% specificity 31% sensitivity Urine LCR, PCR - expensive • Complications: Epididymitis Prostatitis

13. Bartholin’s abscess

14. Bartholin’s abscess

15. Disseminated gonorrhea - skin lesion

16. Disseminated gonorrhea - skin lesion

17. Pelvic Inflammatory DiseaseDefinition • 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 2002 - 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 q12h plus cefotetan 2.0 g IVPB q12h or cefoxitin 2.0 g IVPB q6h • Pelvic ultrasound ASAP

29. PID - ComplicationsTubo-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 - ComplicationsFitz-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 - 50-75% • 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 1 200 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 0.3-0.4/100,000 • 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

47. Primary syphilis - chancre

48. Primary syphilis - chancre of anus

49. Primary syphilis - chancre

50. Primary syphilis - chancre