Sexually Transmitted Infections Twin Cities Adolescent Medicine Seminar February 16, 2006 Eric Meininger, M.D. Internal Medicine / Pediatrics / Adolescent Health Community-University Health Care Center Supported in part by grant # 5-T71-MC00006-24 Leadership Education in Adolescent Health, Maternal and Child Health Bureau, and grant #U48CCU513331 National Teen Pregnancy Prevention Research Center, Centers for Disease Control and Prevention

Case I A 15 year-old girl presents to the urgent care because she found out her partner has been having sex with someone else

A 15 year-old girl presents to the urgent care because she found out her partner has been having sex with someone else

Why in adolescent medicine? Adolescents are at greatest risk for STDs Frequently have unprotected intercourse “Can’t happen to me” myth More likely to have multiple sequential or concurrent sexual partners May select partners at higher risk

Adolescents are at greatest risk for STDs

Frequently have unprotected intercourse

“Can’t happen to me” myth

More likely to have multiple sequential or concurrent sexual partners

May select partners at higher risk

Adolescents are at greatest risk for STDs Physiologically more susceptible to infection Cervical transition zone (ectopy) Lack of immunity to previously exposed STDs Why in adolescent medicine?

Adolescents are at greatest risk for STDs

Physiologically more susceptible to infection

Cervical transition zone (ectopy)

Lack of immunity to previously exposed STDs

Why in adolescent medicine? Adolescents are at greatest risk for STDs Multiple obstacles to utilization of health care Cost of prevention and treatment, lack of insurance Fear of parental knowledge (confidentiality) Infrequent users of healthcare (no established provider) Lack of education Abstinence only message Education too late Physical maturity precedes emotional maturity

Adolescents are at greatest risk for STDs

Multiple obstacles to utilization of health care

Cost of prevention and treatment, lack of insurance

Fear of parental knowledge (confidentiality)

Infrequent users of healthcare (no established provider)

Lack of education

Abstinence only message

Education too late

Physical maturity precedes emotional maturity

Case II A 17 year-old boy presents to a medical provider for a “check-up” at the request of his girl friend. He denies any complaints or symptoms.

A 17 year-old boy presents to a medical provider for a “check-up” at the request of his girl friend. He denies any complaints or symptoms.

Bacterial STDs - Urethritis Symptoms often asymptomatic (80-90%)

Symptoms

often asymptomatic (80-90%)

Bacterial STDs - Urethritis Screening Pyuria (+LET or >=10 WBC/HPF) on first void urine in males Some advocate doing a dipstick UA for leukocyte esterase as a screening test in all young males

Screening

Pyuria (+LET or >=10 WBC/HPF) on first void urine in males

Some advocate doing a dipstick UA for leukocyte esterase as a screening test in all young males

Bacterial STDs - Urethritis Empiric testing in high-risk Multiple sexual partners History of previous STDs Unprotected intercourse

Empiric testing in high-risk

Multiple sexual partners

History of previous STDs

Unprotected intercourse

Bacterial STDs - Urethritis Diagnosis Urethral sample with calgi-swab First void urine LCx/PCx

Diagnosis

Urethral sample with calgi-swab

First void urine LCx/PCx

Case III A 14 year-old adolescent presents to his medical provider with a chief complaint of dysuria and a penile discharge

A 14 year-old adolescent presents to his medical provider with a chief complaint of dysuria and a penile discharge

What should you do? A. Counsel him on abstinence, test for gonorrhea and chlamydia, and have him follow up for results in 1 week B. Counsel him on abstinence, test for gonorrhea and chlamydia. Consider HIV and RPR testing. Treat empirically before he leaves with both PO Azithromycin 1g and PO Ciprofloxacin 500 mg C. Obtain a history for risk factors for STDs, but counsel him that you cannot test or treat him without parental consent since he is only 14 D. Obtain a urine culture and sensitivity

A. Counsel him on abstinence, test for gonorrhea and chlamydia, and have him follow up for results in 1 week

B. Counsel him on abstinence, test for gonorrhea and chlamydia. Consider HIV and RPR testing. Treat empirically before he leaves with both PO Azithromycin 1g and PO Ciprofloxacin 500 mg

C. Obtain a history for risk factors for STDs, but counsel him that you cannot test or treat him without parental consent since he is only 14

D. Obtain a urine culture and sensitivity

Urethritis Gonorrhea Pearl: Thick green / yellow penile discharge, think gonorrhea Usually symptomatic in men Intracellular gram negative diplococci on gram stain MN ranks 33rd in US As of 2004, CDC recommends using alternative therapy in MSM due to increasing resistance Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1997. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention (CDC), September, 1998.

Gonorrhea

Pearl: Thick green / yellow penile discharge, think gonorrhea

Usually symptomatic in men

Intracellular gram negative diplococci on gram stain

MN ranks 33rd in US

As of 2004, CDC recommends using alternative therapy in MSM due to increasing resistance

Urethritis Organisms Chlamydia Gonorrhea Trichomonas Ureaplasma urealyticum Herpes simplex Mycoplasma hominis Mycoplasma genitalium Yeasts Staphylococcus saphrophyticus

Chlamydia

Gonorrhea

Trichomonas

Ureaplasma urealyticum

Herpes simplex

Mycoplasma hominis

Mycoplasma genitalium

Yeasts

Staphylococcus saphrophyticus

Bacterial STDs - Treatment Treat the following patients after collecting tests before the results are available: Contacts Symptomatic patients Patients who may not return for results Juvenile detention Street youth

Treat the following patients after collecting tests before the results are available:

Contacts

Symptomatic patients

Patients who may not return for results

Juvenile detention

Street youth

Bacterial STDs - Treatment Recommend abstinence from intercourse until 7 days after treatment is initiated

Recommend abstinence from intercourse until 7 days after treatment is initiated

Case IV A 13 year-old girl presents with complaints of vaginal spotting, especially after intercourse and vaginal pruritis

A 13 year-old girl presents with complaints of vaginal spotting, especially after intercourse and vaginal pruritis

Case IV A speculum exam reveals thin fluid in the vaginal vault and cervical friability

A speculum exam reveals thin fluid in the vaginal vault and cervical friability

Case IV A wet prep of the vaginal fluid is not remarkable

A wet prep of the vaginal fluid is not remarkable

What is her most likely diagnosis? A. Physiologic leukorrhea B. Gonorrhea C. Chlamydia D. Trichomonas E. Yeast vaginitis F. Bacterial Vaginosis

A. Physiologic leukorrhea

B. Gonorrhea

C. Chlamydia

D. Trichomonas

E. Yeast vaginitis

F. Bacterial Vaginosis

Cervicitis Chlamydia cases by age among females 1997 10 - 14 2% 15 - 19 41% 20 - 24 33% 25+ 24% 158,544 92,402 130,368 9,168

Chlamydia cases by age among females 1997

Case V A 15 year-old girl presents with complaints of nausea and abdominal pain for the last week. One of her classmates had the flu a few weeks ago. She has a boyfriend, but denies being sexually active.

A 15 year-old girl presents with complaints of nausea and abdominal pain for the last week. One of her classmates had the flu a few weeks ago. She has a boyfriend, but denies being sexually active.

Case V On exam, she has normal vital signs and a vague lower quadrant abdominal tenderness. A urine pregnancy test is negative.

On exam, she has normal vital signs and a vague lower quadrant abdominal tenderness. A urine pregnancy test is negative.

What should you do? A. Hospitalize her immediately for IV antibiotics B. Obtain a GYN consult C. Treat her empirically with IM Ceftriaxone 250 mg and PO Doxycycline 100 mg bid x 14 days and have her follow up in 2-3 days D. Treat her empirically with IM Ceftriaxone 250 mg and PO Doxycycline 100 mg bid x 14 days and have her follow up in 2-3 days, but call her parents because you are worried she may not follow up E. Treat with PO Azithromycin 1g and PO Ciprofloxacin 500 mg

A. Hospitalize her immediately for IV antibiotics

B. Obtain a GYN consult

C. Treat her empirically with IM Ceftriaxone 250 mg and PO Doxycycline 100 mg bid x 14 days and have her follow up in 2-3 days

D. Treat her empirically with IM Ceftriaxone 250 mg and PO Doxycycline 100 mg bid x 14 days and have her follow up in 2-3 days, but call her parents because you are worried she may not follow up

E. Treat with PO Azithromycin 1g and PO Ciprofloxacin 500 mg

Pelvic Inflammatory Disease Presentation Uterine tenderness or Adnexal tenderness or Cervical motion tenderness Additional criteria that support diagnosis Fever >101F / 38.5C Abnormal cervical discharge Elevated ESR Elevated CRP Documented cervical infection with GC or Chlamydia

Presentation

Uterine tenderness or

Adnexal tenderness or

Cervical motion tenderness

Additional criteria that support diagnosis

Fever >101F / 38.5C

Abnormal cervical discharge

Elevated ESR

Elevated CRP

Documented cervical infection with GC or Chlamydia

Pelvic Inflammatory Disease Initial etiology: Neisseria gonorrhea Chlamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Other vaginal flora Often the infection is polymicrobial with anaerobic organisms at the time of presentation

Initial etiology:

Neisseria gonorrhea

Chlamydia trachomatis

Mycoplasma hominis

Ureaplasma urealyticum

Other vaginal flora

Often the infection is polymicrobial with anaerobic organisms at the time of presentation

Pelvic Inflammatory Disease Hospitalize when Acute abdomen cannot be ruled out Pregnancy Oral treatment failure Tubo-ovarian abscess Severe illness / nausea + vomiting / high fever

Hospitalize when

Acute abdomen cannot be ruled out

Pregnancy

Oral treatment failure

Tubo-ovarian abscess

Severe illness / nausea + vomiting / high fever

Bacterial STDs - Cervicitis Organisms Gonorrhea Pearl: Fitzhugh-Curtis (Perihepatic inflammation) in PID equals GC

Organisms

Gonorrhea

Pearl: Fitzhugh-Curtis (Perihepatic inflammation) in PID equals GC

Special Cases - Pelvic Inflammatory Disease Followup Absolutely necessary Hospitalize patients who do not demonstrate substantial improvement within 3 days of initiation

Followup

Absolutely necessary

Hospitalize patients who do not demonstrate substantial improvement within 3 days of initiation

Case VI Case V’s 14 year-old boyfriend shows up a few days later to another clinic and tells the practitioner that his girlfriend dumped him because she said, “I gave her PID.”

Case V’s 14 year-old boyfriend shows up a few days later to another clinic and tells the practitioner that his girlfriend dumped him because she said, “I gave her PID.”

Case VI He admits to being sexually active with three lifetime female partners. He has never had any symptoms and does not believe he has an STD.

He admits to being sexually active with three lifetime female partners. He has never had any symptoms and does not believe he has an STD.

Source: Internet Dermatology Society, http://telemedicine.org/ids.htm

What should you do? A. Test for GC and Chlamydia, but treat him now with PO Ciprofloxacin 500 mg and PO Azithromycin 1 g and counsel him on abstinence B. Counsel him on abstinence, test for GC and Chlamydia, and have him follow up in one week for results C. Test for GC and Chlamydia, but treat him now with PO Azithromycin 1 g and counsel him on abstinence. Have him follow up in one week and treat for gonorrhea only if positive D. Counsel him on abstinence, and treat him empirically with IM Ceftriaxone 250 mg and PO Doxycycline 100 mg bid x 14 days.

A. Test for GC and Chlamydia, but treat him now with PO Ciprofloxacin 500 mg and PO Azithromycin 1 g and counsel him on abstinence

B. Counsel him on abstinence, test for GC and Chlamydia, and have him follow up in one week for results

C. Test for GC and Chlamydia, but treat him now with PO Azithromycin 1 g and counsel him on abstinence. Have him follow up in one week and treat for gonorrhea only if positive

D. Counsel him on abstinence, and treat him empirically with IM Ceftriaxone 250 mg and PO Doxycycline 100 mg bid x 14 days.

Followup Patients should be re-evaluated if symptoms persist or recur after completion of therapy

Patients should be re-evaluated if symptoms persist or recur after completion of therapy

Genital Ulcer Disease - Lymphogranuloma venereum Rare disease in US (113 US Cases 1997) Cause Invasive Chlamydia trachomatis serovars L1, L2, L3 As of 9/04 Netherlands saw 19-fold increase in confirmed cases amongst MSM

Rare disease in US (113 US Cases 1997)

Cause

Invasive Chlamydia trachomatis serovars L1, L2, L3

As of 9/04 Netherlands saw 19-fold increase in confirmed cases amongst MSM

Genital Ulcer Disease - Lymphogranuloma venereum Presentation Genital ulcer Self limited Usually resolved at time of presentation for medical care Tender inguinal or femoral lymphadenopathy Usually unilateral Proctocolitis Inflammatory involvement of perirectal or perianal lymphatic tissues

Presentation

Genital ulcer

Self limited

Usually resolved at time of presentation for medical care

Tender inguinal or femoral lymphadenopathy

Usually unilateral

Proctocolitis

Inflammatory involvement of perirectal or perianal lymphatic tissues

Genital Ulcer Disease - Lymphogranuloma venereum Diagnosis Usually made after exclusion of other causes of ulcers or lymphadenopathy Complement fixation titers >1:64 consistent with diagnosis Source: Weill Medical College of Cornell University http://edcenter.med.cornell.edu/Pathophysiology_Cases/STDs/5215.gif

Diagnosis

Usually made after exclusion of other causes of ulcers or lymphadenopathy

Complement fixation titers >1:64 consistent with diagnosis

End

Gonorrhea Gram Stain Organisms Gonorrhea Intracellular gram negative diplococci on gram stain Incidence varies by race 0.04%-4% Usually symptomatic Pearl: Thick green / yellow penile discharge, think gonorrhea

Organisms

Gonorrhea

Intracellular gram negative diplococci on gram stain

Incidence varies by race 0.04%-4%

Usually symptomatic

Pearl: Thick green / yellow penile discharge, think gonorrhea

Trichomonas Discharge Diagnosis Discharge Creamy curd-like white – yeast Frothy, carbonated white to yellow-green, malodorous with vulvar irriation – Trichomonas Gray-White thin discharge, +whiff test, pH >4.5 – Bacterial vaginosis Clear/muciod - physiologic Odor Musty – yeast Foul – Trichomonas, foreign body Fishy – Bacterial vaginosis No odor – physiologic Trichomonas Source: http://www.sti.healthcare.org.uk

Diagnosis

Discharge

Creamy curd-like white – yeast

Frothy, carbonated white to yellow-green, malodorous with vulvar irriation – Trichomonas

Gray-White thin discharge, +whiff test, pH >4.5 – Bacterial vaginosis

Clear/muciod - physiologic

Odor

Musty – yeast

Foul – Trichomonas, foreign body

Fishy – Bacterial vaginosis

No odor – physiologic

Wet Prep - Trichomonas & BV Diagnosis Wet Prep Unicellular flagellated protozoan (moving), many WBC – Trichomonas Clue cells (epithelial cells coated with bacteria) – Bacterial vaginosis clue cells Source: http://www.aafp.org/afp/980315ap/majeroni.html Source: http://www.biosci.ohio-state.edu/~parasite/trichomonas.html

Diagnosis

Wet Prep

Unicellular flagellated protozoan (moving), many WBC – Trichomonas

Clue cells (epithelial cells coated with bacteria) – Bacterial vaginosis

Genital Ulcer Disease - Herpes Presentation Primary ulcers Many painful small blisters which leave ulcers after breaking Fever Malaise Secondary Few lesions Source: http://www.sti.healthcare.org.uk/

Presentation

Primary ulcers

Many painful small blisters which leave ulcers after breaking

Fever

Malaise

Secondary

Few lesions

Exophytic STDs - Genital Warts (Condyloma accuminatum) Human Papillomavirus Presentation Painful, friable or pruritic lesions depending on location Characteristic fleshy growths are usually caused by HPV subtype 6 or 11. Most are asymptomatic, subclinical or unrecognized

Human Papillomavirus

Presentation

Painful, friable or pruritic lesions depending on location

Characteristic fleshy growths are usually caused by HPV subtype 6 or 11.

Most are asymptomatic, subclinical or unrecognized