Chlamydia and gonorrhea are most common among 15- to 19-year-old women.
Throughout the United States, medical care for sexually transmitted diseases (STDs) can be provided to all adolescents without parental consent or knowledge.
Human immunodeficiency virus (HIV) screening is recommended for patients seeking STD treatment in all health care settings. The patient should be notified that testing will be performed unless the patient declines (opt-out screening).
Oral antibiotics are no longer the treatment of choice for gonorrhea, but rather ceftriaxone parenterally.
Many STDs occur concurrently. Therefore, evaluate and treat the patient appropriately at the initial examination. Do not forget to recommend treatment for sexual partners.
STDs constitute a broad range of over 25 infectious organisms.1 These include bacteria, parasites, and viruses. The morbidity and economic impact to our health care system as a result of these infections is significant. It is estimated that almost 25% of female adolescents between the ages of 14 and 19 years are infected with a pathogen.1 Many infections go untreated as a result of the patient being asymptomatic, barriers to access of care, or the stigma associated with these disease processes. The National Institutes of Health (NIH) referred to STDs as the hidden epidemic. “They are hidden from public view because many Americans are reluctant to address sexual health issues in an open way and because of the biological and social factors associated with these diseases.”2
STDs are also referred to as sexually transmitted infections (STIs). This distinction is made to indicate that often these processes are not symptomatic. Hence, while they do not result in an apparent disease process, they are silent carriers of a contagious illness. This reinforces the recommendation for routine STD screening for sexually active individuals.
Chlamydia, caused by a bacterium Chlamydia trachomatis, is among the most common STDs.3 It is the most common treatable STD in the United States, occurring in 10% or more of sexually active adolescent female patients, with increasing rates of reported disease since the late 1980s.4 The burden of disease is likely at least double the 1,412,791 cases reported to the CDC in 2011. The reported rate is two-and-a-half times higher in females than males, likely a result of screening rates. There is a higher prevalence in African American adolescents as well as in patients of lower socioeconomic status. Approximately 33% to 45% of patients with gonorrhea are coinfected with C. trachomatis. Patients with chlamydial infections are at increased risk of acquiring HIV infection.5
Presentation of symptoms is variable, but many patients are asymptomatic. Vaginal discharge, mild abdominal pain, dysuria, urinary frequency, or postcoital/intermenstrual bleeding is observed in women. Physical examination reveals pyuria without bacteriuria, cervical edema, erythema, easily induced cervical bleeding, and mucopurulent discharge. In men, symptoms include dysuria, urethral itching, or clear to whitish urethral discharge. Often, the discharge may be slight and noted as stained underwear in the morning resulting from minimal overnight discharge. Physical examination in men demonstrates meatal edema, erythema, and a whitish/clear discharge. Pyuria is common.6
Culture of cervical swabs from women and urethral swabs in men for C. trachomatis remain the standard for diagnosis, but are labor-intensive and have variable sensitivity. It is still preferred for cases with medicolegal implications (i.e., sexual assault). When obtaining specimens, do not use swabs with a wooden shaft, as wood may contain substances toxic to Chlamydia. For prepubertal female patients, vaginal rather than cervical specimens should be taken. Specificity for this test is virtually 100%.
Nucleic acid amplification tests (NAAT) have largely replaced culture as the screening test of choice. The sensitivity of this test is superior to culture while maintaining excellent specificity.7 Specimen sources can include urine, endocervix, and vaginal. There is increasing evidence that for patients with receptive rectal intercourse, a rectal swab utilizing NAAT is both sensitive and specific.8,9
Using NAAT for STD surveillance and confirmation in sexual assault has become more accepted.9,10 There is a growing consensus in the field of child sexual assault that two separate positive NAAT tests constitute a conclusive positive test.
As rapid results are desirable in the emergency department to help instruct the need for treatment, point-of-care (POC) tests are being developed. At this time, there are no approved POC tests that are recommended, although there are some promising tests on the horizon.11
Treatment in adolescents and adults is a single oral dose of azithromycin or a 7-day course of oral doxycycline. Other options include a 7-day course of erythromycin, ofloxacin, or levofloxin. For preadolescent children, treatment includes oral erythromycin for 14 days in children weighing less than 45 kg, a single dose of azithromycin in children weighing at least 45 kg but younger than 8 years, and a single oral dose of azithromycin or a 7-day course of oral doxycycline in children 8 years or older (Table 89-1). Given the risks of noncompliance, single-dose therapy is generally preferable.12 Doxycycline hyclate delayed-release 200-mg tablet (Doryx) once a day for 7 days has shown equal efficacy to doxycycline bid schedule and may improve compliance.13 As with all STDs, it is important to recommend that the patient should abstain from sexual activity for 7 days and that all sexual partners seek care.
| Disease | Etiology | Clinical Manifestations | Diagnosis | Therapy | Treatment Administration |
|---|---|---|---|---|---|
| Chlamydia | Chlamydia trachomatis | Vaginal discharge, dysuria, abdominal or testicular pain, or asymptomatic | NAAT, culture | po
po
po
po
po
po po | Azithromycin 1 g or Doxycycline 100 mg bid × 7d or EES base 500 mg qid × 7d or EES ethylsuccinate 800 mg qid × 7d or Ofloxacin 300 mg bid × 7d or Levofloxacin 500 mg qid × 7d Children <45 kg: EES (base or ethylsuccinate) 50/kg/dose × 14 d Children >45 kg + <8y: Azithromycin 1 g × 1 Children >45 kg + >8y: Adult dosing |
| Gonorrhea | Neisseria gonorrhoeae | Asymptomatic, dysuria, penile or vaginal discharge, abdominal pain, rash | NAAT, culture, DNA probe | IM
po
po
po
po IM | Ceftriaxone 125 mg × 1 or Cefixime 400 mg × 1 or Ciprofloxacin 500 mg × 1 or Ofloxacin 400 mg × 1 or Levofloxacin 250 mg × 1 Children >45 kg: Adult dosing used on above medications Children <45 kg: Ceftriaxone 125 mg × 1 Add treatment for chlamydia if not ruled out |
| Trichomoniasis | Trichomonas vaginalis (protozoan) | Asymptomatic (men and women) or frothy, odorous vaginal discharge, dyspareunia, urgency | Saline wet prep, culture, rapid antigen testing | po
po | Metronidazole 2 g × 1 or Tinidazole 2 g × 1 |
| Genital warts | Human papilloma virus (HPV), types 6,11, 16,18 | Asymptomatic or pain, itching, bleeding, or obstructive effects from wart size | Visual exam, biopsy, | Topical
Specialist administered | Podofilox 0.5% gel/solution bid × 3d or Imiquimod 5% cream qhs 3 times/wk × 16 wk Cryotherapy, intralesional interferon, podophyllin, laser & surgical removal |
| Genital ulcers Syphilis | Treponema pallidum | Chancre, genital ulceration Secondary: Lymphadenopathy rash, condyloma lata Latent syphilis: No evidence of disease Tertiary: Neuropathy, dementia, tabes dorsalis, aortitis, gumma of skin | Dark-field DAT, serologic testing (treponemal & nontreponemal) | IM IM po po IM IM | Benzathine penicillin G 2.4 million units × 1 Children: Benzathine penicillin G 50,000 U/kg up to adult dose × 1 Alternatives: Doxycycline 100 mg bid × 14d Tetracycline 500 mg qid × 14 d; not recommended for children <8y Ceftriaxone 1 g qid × 8–10 d Secondary syphilis treatment: Same as primary Late Latent disease: Benzathine penicillin G 2.4 million units q wk × 3wk Children: Benzathine penicillin G 50,000 U/kg up to adult dose q wk × 3wk |
| Herpes simplex | Herpes simplex virus type 2 | Painful genital ulcers, dysuria, dyspareunia | Viral culture-specific antibody assays | po
po
po
po
po
po
po
po
po
po
po | First clinical episode Acyclovir 400 mg tid 7–10 d or Acyclovir 200 mg 5 × d × 7–10 d or Famciclovir 250 mg tid × 7–10 d or Valacyclovir 1 g bid × 7–10 d Episodic treatment for recurrent infections Acyclovir 400 mg tid × 5d or Acyclovir 800 mg bid × 5d or Acyclovir 800 mg tid × 2d or Famciclovir 125 mg bid × 5d or Famciclovir 1000 mg bid × 1d or Valacyclovir 500 mg tid × 3d or Valacyclovir 1 g qid × 5d |
Human papillomavirus (HPV) infections are a common cause of STDs, as well as the most common sexually transmitted infection in the United States. It is estimated that over 50% of sexually active individuals will acquire infection at some point in their lives.14 HPV is associated with genital warts as well as genital cancers. This is a DNA-containing virus which is spread by skin-to-skin contact, causing external growths in the perigenital and perianal areas.14 The incubation period is 1 to 6 months. Treatment may not eradicate the HPV infection, and recurrences are common. Other common names for genital warts are condyloma acuminata, anogenital wart, verruca acuminata, and venereal warts. HPV serotypes 6 and 11 commonly cause external genital warts. Types 16 and 18 cause endocervical wart infections and may predispose to cervical cancer.14
The prevalence of HPV is approximately 1% of the entire adult population.6 Ten to twenty percent of sexually active women are infected annually. It is three times more common than genital herpes. Its occurrence is most common in 15- to 30-year-olds and equally common in men and women. Perinatal transmission of HPV also occurs.3,6
Genital warts are the most easily recognized sign of HPV infection. However, the majority of people are asymptomatic carriers of the infection. Pain, itching, irritation, and bleeding may occur depending on the size and location of the warts. Difficulties in urination and defecation have been reported secondary to their local obstructive effects. In female patients, physical examination may reveal lesions on the external genitalia, cervix, vaginal wall, urethra, or perianal region (Figs. 89-1 and 89-2). In male patients, lesions are noted in the subpreputial area, on the coronal sulcus or penile shaft, and in the urethra. The conjunctiva, nose, mouth, and larynx may also be affected.15 Intra-anal warts are seen predominantly in male and female patients who have had receptive anal sex. The appearance of external genital warts is variable. They may be soft, pink or gray, occurring in clusters; flat, papular, cauliflower-like clusters or pedunculated growths. Keratotic papules are genital warts that have a thick horny layer and may resemble common warts or seborrheic keratosis.15
Other conditions that may be confused with genital warts include pearly penile papules, molluscum contagiosum, Bowenoid papules, and condyloma lata. Bowenoid papules are usually flat-topped papules and associated with HPV type 16, which predisposes to genital neoplasia. Condyloma lata are flat, warty lesions secondary to syphilis. Often, they are adjacent to the previous chancre site. An aspirate of this lesion will show spirochetes on dark-field microscopy. Serologic tests for syphilis will be positive.15
Diagnosis is visual examination. Biopsy can be used to confirm the diagnosis. There are no commercially available serologic tests, and the organism cannot be grown in culture. However, diagnostic testing should include evaluation for other STDs, including serologic testing for syphilis (VDRL and rapid plasma reagin [RPR]).15,16
The patient should be referred to a specialist who can provide definitive care. It is estimated that in immunocompetent children, three-quarters of anogenital warts will resolve within months to a few years. If lesions persist beyond 2 years, it is less likely they will resolve without treatment.16 Several options are available. Options for self-treatment include podofilox, a keratolytic and antimitotic that is applied to external genital warts. It is not indicated for treatment of mucous membrane warts. Imiquimod is an immunomodulator that enhances the immune response to viral infections and tumors by inducing immune system cells, cytokine, and interferon. This also is indicated for the treatment of external genital warts in patients 12 years of age or older. Other treatment options requiring professional administration include cryotherapy, podophyllin, intralesional interferon alfa-2b, surgical removal, and laser therapy.
Genital warts in children should raise suspicion of sexual abuse. Increasingly, however, there is evidence that a significant number of prepubertal children with anogenital warts did not acquire them through sexual contact.17,18 Genital warts in adolescents should prompt questioning as to whether sexual contact was forced. Genital warts during pregnancy may increase in size and are always referred to obstetrics/gynecology for treatment.
