Sexually transmitted diseases (STDs) remain common in adolescents, with one in every four sexually active teens between the ages of 13 and 19 years being infected annually. This chapter reviews the evaluation, diagnosis, and management of the more common STDs in adolescence, including Chlamydia trachomatis infection, Neisseria gonorrhoeae infection, herpes simplex, syphilis, chancroid, and Trichomonas vaginalis infection. The recognition and management of physiologic leukorrhea, yeast vaginitis, and bacterial vaginosis are also reviewed because the presentation of each of these entities can be confused with those of the aforementioned STDs. Recent advances in testing strategies are discussed, including urine screening with DNA probes (nucleic acid amplification tests [NAATs], which have been found to be more sensitive than the previously used ligase chain reaction [LCR] and polymerase chain reaction [PCR]) and the appropriate use of culture versus other modalities.
STD rates are highest in the 15- to 24-year-old age group for a variety of reasons. Biologic factors include the prominent exocervix of adolescent girls, which involutes with age. During adolescence, this accessible transition zone serves as a magnet for STD organisms. Adolescents also have lower levels of protective antibodies because of a lesser degree of cumulative exposure to disease. Sperm can carry disease to the upper genital tract. Retrograde menstruation, which occurs in 25% of healthy women, spreads the infection to the fallopian tubes and contiguous areas.
Behavioral factors also increase the prevalence of STDs in adolescents, especially because risky behaviors in teenagers tend to be interrelated and clustered. The earlier teens begin sexual activity, the less likely they are to use a condom and the more likely they are to have multiple partners. In some cultures, it is normative for girls to date boys or young men much older than they are, so that condom negotiation is made difficult by the age and power differential. The use of alcohol or drugs also decreases the use of condoms. Furthermore, the adolescent mindset contributes to the acquisition of STDs; the personal sense of invulnerability of early to middle adolescence coincides with the concrete thought processes that impede an adolescent’s ability to see the consequences of behavior. The lack of education or awareness regarding STDs, the perceived lack of access to contraceptive services, fear of pelvic examination, and fear of disclosure to parents or other adults can serve as barriers to care and increase the risk for adolescent STD acquisition. Legally, with limited exceptions, all teens in the United States may consent to the confidential diagnosis and treatment of STDs. Moreover, teens can receive medical care for STDs without parental consent or knowledge, and adolescents may consent to human immunodeficiency virus (HIV) testing without parental consent in many states. Unfortunately, the lack of awareness among many teens and even healthcare providers of the adolescent and the adolescent’s right to confidential care for STDs further blocks access to care.
After confidentiality has been established, the primary care clinician should ask all teens the HEADS questions:
home (Who lives at home? What happens when someone argues at home?);
education (grades this year compared with those last year, grade level; recognizing that a slide in grades is a risk factor for various risk behaviors, including sexual activity);
activities;
drugs (including cigarettes and alcohol);
depression/
suicide;
sex. The method of motivational interviewing allows for behavioral interventions to occur nonjudgmentally as questions are asked of the teen, helping them to shape healthier responses and finding motivation to change risk behavior patterns. Questions can move from less threatening to more invasive, allowing the teen to gain comfort and be empowered to make healthy choices using motivational interviewing. For example, when asking a teen who has admitted to having sex in the past, the clinician can
ask, “What methods of contraception did you use?” If she answers condoms, the clinician can ask if she uses them sometimes, most of the time, or all the time. The clinician can then move on to asking what second method of contraception she uses, and if this question is met with an inquisitive look, the clinician can remind the teen that condoms are only 85% effective at pregnancy prevention with typical teen usage, so that means that “15 out of every shots will find their mark.” The clinician can then discuss with the teen which second method the teen wishes to use if she has heterosexual sexual relations in the future. Adolescents should be asked about number of lifetime partners, and whether they have engaged in oral sex or anal sex, with motivational interviewing used to educate without having to step onto a soapbox, in a way that seems relevant to a specific teen’s life. For those girls who are younger, it is easy to ask questions about the menstrual cycle first: when the last menstrual period occurred; whether they have experienced dysmenorrhea and vaginal itching, discharge, or odor; whether they have noted any changes in their cycle. Girls and boys should be asked if they have ever had anyone do anything to them sexually that made them uncomfortable; careful phrasing can make it “safe” to answer questions about sexual abuse for the teen who has been in a coercive situation where she or he may have been put at risk but may not self define it as “abuse.” Teens should also be asked about sexual preference (“Are you attracted to guys, girls, or both?”); nonjudgmental phrasing can open doors for harm reduction in adolescents experimenting sexually in both same sex and opposite sex relationships. Boys should be asked about penile discharge, dysuria, and lesions and should be taught to perform a testicular self-examination.
Traditionally, the pelvic examination has been used to:
Screen all sexually active teens for an abnormal result of the Papanicolaou (Pap) test and for STDs
Determine the stage of a pregnancy
Evaluate a patient with abdominal or pelvic pain
Evaluate a patient with vaginitis or vaginal discharge (although urine screening and self-applied vaginal swabs may change this indication)
Evaluate an adolescent with menstrual irregularity or evidence of androgen excess
Perform a routine Pap test in patients older than 18 years
The question of who requires a pelvic examination continues to evolve. All sexually active teens require screening for STDs 3 to 6 months after acquiring each new partner; urine nucleic acid amplification strategies may be utilized for screening, with excellent sensitivity and specificity. With the ACOG recommendations of 2003, a pelvic examination should be first performed 3 years after coitarche, then annually in sexually active young people. For those who have not yet initiated sexual activity, the 2003 ACOG guidelines recommend a first pelvic at age 21 years, not at 18 years. Of note, adolescents tend not to differentiate the Pap smear from the pelvic examination; therefore, a teenager who underwent a pelvic examination in an emergency department setting, in which Pap smears are not performed, may not realize that the test was not done.
NEWER DEVELOPMENTS IN SCREENING FOR SEXUALLY TRANSMITTED DISEASE
Culture remains the gold standard for STD testing and must be used in cases of sexual abuse. In contrast to the older detection tests, amplified DNA testing does not require the presence of viable organisms or even large amounts of DNA to detect disease. If the question of the Pap smear is set aside, urine screening can improve the detection of STDs in settings in which pelvic examinations cannot be performed easily (e.g., schools, juvenile detention centers, shelters for the homeless, mobile crisis vans, and some pediatric clinics not set up for gynecologic services). Even beauty parlors and sporting event centers have been mentioned as possible sites where teens congregate and could be screened! Urine screening costs less than obtaining cervical specimens; in a hypothetical cohort of 100,000 young women, urine screening in asymptomatic women reduces the cost of preventing a case of pelvic inflammatory disease (PID) by 50%.
Self-obtained vaginal swabs have been used to detect infection with N. gonorrhoeae (found in 5.3% of asymp-tomatic girls), C. trachomatis (17.8%), and T. vaginalis (12.9%); this study did not compare pelvic examination with vaginal swabs, so some infections may have been missed. Adolescents, when asked to follow relatively simple printed instructions, successfully obtained their own vaginal introitus specimens for PCR testing for C. trachomatis; the sensitivity was 100% in a direct comparison with clinician-obtained cervical specimens. Urine culture for T. vaginalis infection has been found to yield poor results, and it may be easier for a patient to deliver a swab than urine to a laboratory. Vaginal infections with T. vaginalis, bacterial vaginosis, and vulvovaginal candidiasis can be diagnosed easily without a speculum, with no significant advantage noted for provider-obtained vaginal and cervical samples.
NONGONOCOCCAL URETHRITIS
Epidemiology
Nongonococcal urethritis is caused by C. trachomatis in 23% to 35% of cases. Other pathogens include Ureaplasma urealyticum, Mycoplasma genitalium, T. vaginalis, and herpes simplex virus (HSV).
Presentation
Most boys infected with C. trachomatis, N. gonorrhoeae, and other pathogens are asymptomatic. Complications in men can include epididymitis and Reiter syndrome.
Diagnosis
The added sensitivity of urine DNA testing eliminates the need to screen boys with urethral swab, so that urine or penile discharge is sufficient for testing. The argument can now be made that all sexually active males should be screened annually for STD by urine testing. Certainly all boys with dysuria, discharge, or known STD exposure should be screened. Prescreening for leukocyte esterase with dipstick can also identify asymptomatic boys whose urine should definitely be tested. Further studies are required to determine the cost-effectiveness of screening all sexually active boys versus only those who test positive for leukocyte esterase with urine dipstick.
Treatment
According to the U.S. Centers for Disease Control and Prevention (CDC) 2006 guidelines for the treatment of STDs, first-line treatment consists of 1 g of azithromycin orally or 100 mg of doxycycline twice a day orally for 7 days. Alternative regimens include 500 mg of erythromycin base orally four times a day for 7 days, 800 mg of erythromycin ethylsuccinate orally four times a day for 7 days, or 300 mg of ofloxacin orally twice a day for 7 days or levofloxacin 500 mg orally once daily for 7 days. For those teens and young adults who have been compliant with recommended dosing and in whom re-exposure to infection has been excluded, recurrent and persistent urethritis can be treated with 2 g of metronidazole orally as a single dose or tinidazole 2 grams orally as a single dose. Alternative regimens include 500 mg of erythromycin base orally four times a day for 7 days, or 800 mg of erythromycin ethylsuccinate orally four times a day for 7 days.
CHLAMYDIA TRACHOMATIS INFECTION
Epidemiology
In the United States, four million new cases of Chlamydia infection occur annually, with one million cases in the 15-to 19-year-old age group. The prevalence ranges from 5% to 15% in asymptomatic sexually active adolescents and young adults, 20% to 30% in adolescents and young adults seen in STD clinics, 40% to 50% in symptomatic patients, and 15% to 50% in patients with simultaneous N. gonorrhoeae infection.
Presentation
Most patients are asymptomatic. Boys may present with nongonococcal urethritis, epididymitis, conjunctivitis, Reiter syndrome, rectal infection, or proctitis. Girls may present with cervicitis, salpingitis (PID), urethritis, endometritis (postpartum and following abortion), Fitz-Hugh-Curtis syndrome (perihepatis associated with PID), premature rupture of membranes, or premature labor.
Diagnosis
In cases that do not involve sexual abuse, DNA tests, or nucleic acid amplification strategies, of a cervical swab or a urine specimen are now commonly used in many centers. Cell culture, the gold standard for cases of sexual abuse, involves identification of characteristic intracytoplasmic inclusions with fluorescent antibody stain after 48 to 72 hours of growth. Culture is labor intensive, expensive, has low sensitivity (80%-90%), is technician dependent, and only detects live organisms. Enzyme immunoassays (EIAs) have sensitivities of 63% and 68.6% to 85%, respectively. A new qualitative dual-amplified EIA for the detection of chlamydial specific lipopolysaccharide antigens are now available and have a sensitivity of 85.7% to 95% and a specificity of 98.2% to 99%. Used on vaginal specimens, this test is less expensive than NAATs.
DNA probes can allow for single swab detection of both
C. trachomatis and
N. gonorrhoeae. Biro et al. found that nucleic acid-based assays (GenProbe PACE 2) had a specificity of 96% and a sensitivity of 72%. NAATs are highly sensitive and specific for the detection of
C. trachomatis in both urine and endocervical specimens. These tests can also be used for self-collected or clinician-collected vaginal
swabs, although this is not yet approved by the U.S. Food and Drug Administration. The NAAT, which uses endocervical or urine specimens, tends to be the preferred test for screening.
Treatment
Cervicitis, urethritis, and asymptomatic infection are treated with 1 g of azithromycin orally as a single dose or 100 mg of doxycycline orally twice a day for 7 days. Alternative regimens include 500 mg of erythromycin base orally four times daily for 7 days, 800 mg of erythromycin ethylsuccinate orally four times daily for 7 days, or 300 mg of ofloxacin orally twice daily for 7 days, or levofloxacin 500 mg orally once daily for 7 days. One third of the patients show resistance to ofloxacin in major cities. Azithromycin is ideal because of its single-dose regimen and minimal gastrointestinal side effects. Test of cure is no longer deemed necessary according to the CDC 2006 guidelines for the treatment of STDs, but testing for reinfection 4 weeks after initial screening may be indicated in adolescent patients in particular.
NEISSERIA GONORRHOEAE INFECTION
Epidemiology
The number of cases of gonorrhea reported to the CDC has decreased from one million annually to an estimated 400,000, at an estimated annual cost of $288 million per year.
Presentation
Girls and women often have asymptomatic infections. Symptomatic women may present with dysuria, dysmenorrhea, and dyspareunia with pain often beginning within 7 days of menses, lower abdominal pain, vaginal discharge, or a change in menstrual pattern. Perianal infection in men or women may present as proctitis, tenesmus, pruritus, or rectal bleeding. Pharyngeal infections can present as patchy erythema, exudates, and cervical lymphadenopathy with or without vesicopustular lesions on the soft palate and tonsils. Inflamed Bartholin glands present as pain and swelling of the labia minora, and inflamed Skene glands may present with periurethral pain or swelling. Men may present with urethritis, dysuria, or discharge, or they may be asymptomatic.
Diagnosis
The diagnosis is as discussed in the diagnosis section for C. trachomatis. As stated, NAATs are ideal for screening in an office-based setting, with culture reserved for cases of potential abuse.
Treatment
The treatment regimens for uncomplicated and disseminated gonorrhea are outlined in
Table 45.1. Of note, a patient should be treated for
Chlamydia infection when gonorrhea is suspected or diagnosed. Resistance to fluoroquinolones has been shown in larger cities.