Sexually Transmitted Infections   Twin Cities Adolescent Medicine Seminar February 16, 2006 Eric Meininger, M.D. Internal ...
Case I <ul><li>A 15 year-old girl presents to the urgent care because she found out her partner has been having sex with s...
Why in adolescent medicine? <ul><li>Adolescents are at greatest risk for STDs </li></ul><ul><ul><li>Frequently have unprot...
<ul><li>Adolescents are at greatest risk for STDs </li></ul><ul><ul><li>Physiologically more susceptible to infection </li...
Why in adolescent medicine? <ul><li>Adolescents are at greatest risk for STDs </li></ul><ul><ul><li>Multiple obstacles to ...
Case II <ul><li>A 17 year-old boy presents to a medical provider for a “check-up” at the request of his girl friend. He de...
Bacterial STDs - Urethritis <ul><li>Symptoms </li></ul><ul><ul><li>often asymptomatic (80-90%) </li></ul></ul>
Bacterial STDs - Urethritis <ul><li>Screening </li></ul><ul><ul><li>Pyuria (+LET or >=10 WBC/HPF) on first void urine in m...
Bacterial STDs - Urethritis <ul><li>Empiric testing in high-risk </li></ul><ul><ul><li>Multiple sexual partners </li></ul>...
Bacterial STDs - Urethritis <ul><li>Diagnosis </li></ul><ul><ul><li>Urethral sample with calgi-swab </li></ul></ul><ul><ul...
Case III <ul><li>A 14 year-old adolescent presents to his medical provider with a chief complaint of dysuria and a penile ...
 
What should you do? <ul><li>A. Counsel him on abstinence, test for gonorrhea and chlamydia, and have him follow up for res...
Urethritis <ul><li>Gonorrhea </li></ul><ul><ul><li>Pearl: Thick green / yellow penile discharge, think gonorrhea  </li></u...
Urethritis Organisms <ul><ul><li>Chlamydia </li></ul></ul><ul><ul><li>Gonorrhea </li></ul></ul><ul><ul><li>Trichomonas </l...
Bacterial STDs - Treatment <ul><li>Treat the following patients after collecting tests before the results are available: <...
Bacterial STDs - Treatment <ul><li>Recommend abstinence from intercourse until 7 days after treatment is initiated </li></ul>
Case IV <ul><li>A 13 year-old girl presents with complaints of vaginal spotting, especially after intercourse and vaginal ...
Case IV <ul><li>A speculum exam reveals thin fluid in the vaginal vault and cervical friability </li></ul>
Case IV <ul><li>A wet prep of the vaginal fluid is not remarkable </li></ul>
What is her most likely diagnosis? <ul><li>A. Physiologic leukorrhea </li></ul><ul><li>B. Gonorrhea </li></ul><ul><li>C. C...
Cervicitis <ul><li>Chlamydia cases by age among females 1997 </li></ul>10 - 14 2% 15 - 19  41% 20 - 24 33% 25+ 24% 158,544...
Case V <ul><li>A 15 year-old girl presents with complaints of nausea and abdominal pain for the last week. One of her clas...
Case V <ul><li>On exam, she has normal vital signs and a vague lower quadrant abdominal tenderness. A urine pregnancy test...
 
What should you do? <ul><li>A. Hospitalize her immediately for IV antibiotics </li></ul><ul><li>B. Obtain a GYN consult </...
Pelvic Inflammatory Disease <ul><li>Presentation </li></ul><ul><ul><li>Uterine tenderness  or </li></ul></ul><ul><ul><li>A...
Pelvic Inflammatory Disease <ul><li>Initial etiology: </li></ul><ul><ul><li>Neisseria gonorrhea </li></ul></ul><ul><ul><li...
Pelvic Inflammatory Disease <ul><li>Hospitalize when </li></ul><ul><ul><li>Acute abdomen cannot be ruled out </li></ul></u...
Bacterial STDs - Cervicitis <ul><li>Organisms </li></ul><ul><ul><li>Gonorrhea </li></ul></ul><ul><ul><ul><li>Pearl: Fitzhu...
Special Cases - Pelvic Inflammatory Disease <ul><li>Followup </li></ul><ul><ul><li>Absolutely necessary </li></ul></ul><ul...
Case VI <ul><li>Case V’s 14 year-old boyfriend shows up a few days later to another clinic and tells the practitioner that...
Case VI <ul><li>He admits to being sexually active with three lifetime female partners. He has never had any symptoms and ...
Source: Internet Dermatology Society, http://telemedicine.org/ids.htm
What should you do? <ul><li>A. Test for GC and Chlamydia, but treat him now with PO Ciprofloxacin 500 mg and PO Azithromyc...
Followup <ul><li>Patients should be re-evaluated if symptoms persist or recur after completion of therapy </li></ul>
 
Genital Ulcer Disease - Lymphogranuloma venereum <ul><li>Rare disease in US (113 US Cases 1997) </li></ul><ul><li>Cause </...
Genital Ulcer Disease - Lymphogranuloma venereum <ul><li>Presentation </li></ul><ul><ul><li>Genital ulcer </li></ul></ul><...
Genital Ulcer Disease - Lymphogranuloma venereum <ul><li>Diagnosis </li></ul><ul><ul><li>Usually made after exclusion of o...
End
Gonorrhea Gram Stain <ul><li>Organisms </li></ul><ul><ul><li>Gonorrhea </li></ul></ul><ul><ul><ul><li>Intracellular gram n...
Trichomonas Discharge <ul><li>Diagnosis </li></ul><ul><ul><li>Discharge </li></ul></ul><ul><ul><ul><li>Creamy curd-like wh...
Wet Prep - Trichomonas & BV <ul><li>Diagnosis </li></ul><ul><ul><li>Wet Prep </li></ul></ul><ul><ul><ul><li>Unicellular fl...
Genital Ulcer Disease - Herpes <ul><li>Presentation </li></ul><ul><ul><li>Primary ulcers </li></ul></ul><ul><ul><ul><li>Ma...
Exophytic STDs - Genital Warts (Condyloma accuminatum) <ul><li>Human Papillomavirus </li></ul><ul><ul><li>Presentation </l...
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Sexually Transmitted Infections

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A presentation given at the Minneapolis city-wide adolescent health meeting on 2.16.2006. Intended for healthcare providers.

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  • Sexually Transmitted Infections

    1. 1. 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
    2. 2. Case I <ul><li>A 15 year-old girl presents to the urgent care because she found out her partner has been having sex with someone else </li></ul>
    3. 3. Why in adolescent medicine? <ul><li>Adolescents are at greatest risk for STDs </li></ul><ul><ul><li>Frequently have unprotected intercourse </li></ul></ul><ul><ul><ul><li>“Can’t happen to me” myth </li></ul></ul></ul><ul><ul><li>More likely to have multiple sequential or concurrent sexual partners </li></ul></ul><ul><ul><li>May select partners at higher risk </li></ul></ul>
    4. 4. <ul><li>Adolescents are at greatest risk for STDs </li></ul><ul><ul><li>Physiologically more susceptible to infection </li></ul></ul><ul><ul><ul><li>Cervical transition zone (ectopy) </li></ul></ul></ul><ul><ul><ul><li>Lack of immunity to previously exposed STDs </li></ul></ul></ul>Why in adolescent medicine?
    5. 5. Why in adolescent medicine? <ul><li>Adolescents are at greatest risk for STDs </li></ul><ul><ul><li>Multiple obstacles to utilization of health care </li></ul></ul><ul><ul><ul><li>Cost of prevention and treatment, lack of insurance </li></ul></ul></ul><ul><ul><ul><li>Fear of parental knowledge (confidentiality) </li></ul></ul></ul><ul><ul><ul><li>Infrequent users of healthcare (no established provider) </li></ul></ul></ul><ul><ul><ul><li>Lack of education </li></ul></ul></ul><ul><ul><ul><ul><li>Abstinence only message </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Education too late </li></ul></ul></ul></ul><ul><ul><ul><li>Physical maturity precedes emotional maturity </li></ul></ul></ul>
    6. 6. Case II <ul><li>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. </li></ul>
    7. 7. Bacterial STDs - Urethritis <ul><li>Symptoms </li></ul><ul><ul><li>often asymptomatic (80-90%) </li></ul></ul>
    8. 8. Bacterial STDs - Urethritis <ul><li>Screening </li></ul><ul><ul><li>Pyuria (+LET or >=10 WBC/HPF) on first void urine in males </li></ul></ul><ul><ul><ul><li>Some advocate doing a dipstick UA for leukocyte esterase as a screening test in all young males </li></ul></ul></ul>
    9. 9. Bacterial STDs - Urethritis <ul><li>Empiric testing in high-risk </li></ul><ul><ul><li>Multiple sexual partners </li></ul></ul><ul><ul><li>History of previous STDs </li></ul></ul><ul><ul><li>Unprotected intercourse </li></ul></ul>
    10. 10. Bacterial STDs - Urethritis <ul><li>Diagnosis </li></ul><ul><ul><li>Urethral sample with calgi-swab </li></ul></ul><ul><ul><li>First void urine LCx/PCx </li></ul></ul>
    11. 11. Case III <ul><li>A 14 year-old adolescent presents to his medical provider with a chief complaint of dysuria and a penile discharge </li></ul>
    12. 13. What should you do? <ul><li>A. Counsel him on abstinence, test for gonorrhea and chlamydia, and have him follow up for results in 1 week </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>D. Obtain a urine culture and sensitivity </li></ul>
    13. 14. Urethritis <ul><li>Gonorrhea </li></ul><ul><ul><li>Pearl: Thick green / yellow penile discharge, think gonorrhea </li></ul></ul><ul><ul><ul><li>Usually symptomatic in men </li></ul></ul></ul><ul><ul><li>Intracellular gram negative diplococci on gram stain </li></ul></ul><ul><ul><li>MN ranks 33rd in US </li></ul></ul><ul><ul><li>As of 2004, CDC recommends using alternative therapy in MSM due to increasing resistance </li></ul></ul>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.
    14. 15. Urethritis Organisms <ul><ul><li>Chlamydia </li></ul></ul><ul><ul><li>Gonorrhea </li></ul></ul><ul><ul><li>Trichomonas </li></ul></ul><ul><ul><li>Ureaplasma urealyticum </li></ul></ul><ul><ul><ul><li>Herpes simplex </li></ul></ul></ul><ul><ul><ul><li>Mycoplasma hominis </li></ul></ul></ul><ul><ul><ul><li>Mycoplasma genitalium </li></ul></ul></ul><ul><ul><ul><li>Yeasts </li></ul></ul></ul><ul><ul><ul><li>Staphylococcus saphrophyticus </li></ul></ul></ul>
    15. 16. Bacterial STDs - Treatment <ul><li>Treat the following patients after collecting tests before the results are available: </li></ul><ul><ul><li>Contacts </li></ul></ul><ul><ul><li>Symptomatic patients </li></ul></ul><ul><ul><li>Patients who may not return for results </li></ul></ul><ul><ul><ul><li>Juvenile detention </li></ul></ul></ul><ul><ul><ul><li>Street youth </li></ul></ul></ul>
    16. 17. Bacterial STDs - Treatment <ul><li>Recommend abstinence from intercourse until 7 days after treatment is initiated </li></ul>
    17. 18. Case IV <ul><li>A 13 year-old girl presents with complaints of vaginal spotting, especially after intercourse and vaginal pruritis </li></ul>
    18. 19. Case IV <ul><li>A speculum exam reveals thin fluid in the vaginal vault and cervical friability </li></ul>
    19. 20. Case IV <ul><li>A wet prep of the vaginal fluid is not remarkable </li></ul>
    20. 21. What is her most likely diagnosis? <ul><li>A. Physiologic leukorrhea </li></ul><ul><li>B. Gonorrhea </li></ul><ul><li>C. Chlamydia </li></ul><ul><li>D. Trichomonas </li></ul><ul><li>E. Yeast vaginitis </li></ul><ul><li>F. Bacterial Vaginosis </li></ul>
    21. 22. Cervicitis <ul><li>Chlamydia cases by age among females 1997 </li></ul>10 - 14 2% 15 - 19 41% 20 - 24 33% 25+ 24% 158,544 92,402 130,368 9,168
    22. 23. Case V <ul><li>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. </li></ul>
    23. 24. Case V <ul><li>On exam, she has normal vital signs and a vague lower quadrant abdominal tenderness. A urine pregnancy test is negative. </li></ul>
    24. 26. What should you do? <ul><li>A. Hospitalize her immediately for IV antibiotics </li></ul><ul><li>B. Obtain a GYN consult </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>E. Treat with PO Azithromycin 1g and PO Ciprofloxacin 500 mg </li></ul>
    25. 27. Pelvic Inflammatory Disease <ul><li>Presentation </li></ul><ul><ul><li>Uterine tenderness or </li></ul></ul><ul><ul><li>Adnexal tenderness or </li></ul></ul><ul><ul><li>Cervical motion tenderness </li></ul></ul><ul><ul><li>Additional criteria that support diagnosis </li></ul></ul><ul><ul><ul><li>Fever >101F / 38.5C </li></ul></ul></ul><ul><ul><ul><li>Abnormal cervical discharge </li></ul></ul></ul><ul><ul><ul><li>Elevated ESR </li></ul></ul></ul><ul><ul><ul><li>Elevated CRP </li></ul></ul></ul><ul><ul><ul><li>Documented cervical infection with GC or Chlamydia </li></ul></ul></ul>
    26. 28. Pelvic Inflammatory Disease <ul><li>Initial etiology: </li></ul><ul><ul><li>Neisseria gonorrhea </li></ul></ul><ul><ul><li>Chlamydia trachomatis </li></ul></ul><ul><ul><li>Mycoplasma hominis </li></ul></ul><ul><ul><li>Ureaplasma urealyticum </li></ul></ul><ul><ul><li>Other vaginal flora </li></ul></ul><ul><li>Often the infection is polymicrobial with anaerobic organisms at the time of presentation </li></ul>
    27. 29. Pelvic Inflammatory Disease <ul><li>Hospitalize when </li></ul><ul><ul><li>Acute abdomen cannot be ruled out </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Oral treatment failure </li></ul></ul><ul><ul><li>Tubo-ovarian abscess </li></ul></ul><ul><ul><li>Severe illness / nausea + vomiting / high fever </li></ul></ul>
    28. 30. Bacterial STDs - Cervicitis <ul><li>Organisms </li></ul><ul><ul><li>Gonorrhea </li></ul></ul><ul><ul><ul><li>Pearl: Fitzhugh-Curtis (Perihepatic inflammation) in PID equals GC </li></ul></ul></ul>
    29. 31. Special Cases - Pelvic Inflammatory Disease <ul><li>Followup </li></ul><ul><ul><li>Absolutely necessary </li></ul></ul><ul><ul><li>Hospitalize patients who do not demonstrate substantial improvement within 3 days of initiation </li></ul></ul>
    30. 32. Case VI <ul><li>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.” </li></ul>
    31. 33. Case VI <ul><li>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. </li></ul>
    32. 34. Source: Internet Dermatology Society, http://telemedicine.org/ids.htm
    33. 35. What should you do? <ul><li>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 </li></ul><ul><li>B. Counsel him on abstinence, test for GC and Chlamydia, and have him follow up in one week for results </li></ul><ul><li>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 </li></ul><ul><li>D. Counsel him on abstinence, and treat him empirically with IM Ceftriaxone 250 mg and PO Doxycycline 100 mg bid x 14 days. </li></ul>
    34. 36. Followup <ul><li>Patients should be re-evaluated if symptoms persist or recur after completion of therapy </li></ul>
    35. 38. Genital Ulcer Disease - Lymphogranuloma venereum <ul><li>Rare disease in US (113 US Cases 1997) </li></ul><ul><li>Cause </li></ul><ul><ul><li>Invasive Chlamydia trachomatis serovars L1, L2, L3 </li></ul></ul><ul><li>As of 9/04 Netherlands saw 19-fold increase in confirmed cases amongst MSM </li></ul>
    36. 39. Genital Ulcer Disease - Lymphogranuloma venereum <ul><li>Presentation </li></ul><ul><ul><li>Genital ulcer </li></ul></ul><ul><ul><ul><li>Self limited </li></ul></ul></ul><ul><ul><ul><li>Usually resolved at time of presentation for medical care </li></ul></ul></ul><ul><ul><li>Tender inguinal or femoral lymphadenopathy </li></ul></ul><ul><ul><ul><li>Usually unilateral </li></ul></ul></ul><ul><ul><li>Proctocolitis </li></ul></ul><ul><ul><li>Inflammatory involvement of perirectal or perianal lymphatic tissues </li></ul></ul>
    37. 40. Genital Ulcer Disease - Lymphogranuloma venereum <ul><li>Diagnosis </li></ul><ul><ul><li>Usually made after exclusion of other causes of ulcers or lymphadenopathy </li></ul></ul><ul><ul><li>Complement fixation titers >1:64 consistent with diagnosis </li></ul></ul>Source: Weill Medical College of Cornell University http://edcenter.med.cornell.edu/Pathophysiology_Cases/STDs/5215.gif
    38. 41. End
    39. 42. Gonorrhea Gram Stain <ul><li>Organisms </li></ul><ul><ul><li>Gonorrhea </li></ul></ul><ul><ul><ul><li>Intracellular gram negative diplococci on gram stain </li></ul></ul></ul><ul><ul><ul><li>Incidence varies by race 0.04%-4% </li></ul></ul></ul><ul><ul><ul><li>Usually symptomatic </li></ul></ul></ul><ul><ul><ul><li>Pearl: Thick green / yellow penile discharge, think gonorrhea </li></ul></ul></ul>
    40. 43. Trichomonas Discharge <ul><li>Diagnosis </li></ul><ul><ul><li>Discharge </li></ul></ul><ul><ul><ul><li>Creamy curd-like white – yeast </li></ul></ul></ul><ul><ul><ul><li>Frothy, carbonated white to yellow-green, malodorous with vulvar irriation – Trichomonas </li></ul></ul></ul><ul><ul><ul><li>Gray-White thin discharge, +whiff test, pH >4.5 – Bacterial vaginosis </li></ul></ul></ul><ul><ul><ul><li>Clear/muciod - physiologic </li></ul></ul></ul><ul><ul><li>Odor </li></ul></ul><ul><ul><ul><li>Musty – yeast </li></ul></ul></ul><ul><ul><ul><li>Foul – Trichomonas, foreign body </li></ul></ul></ul><ul><ul><ul><li>Fishy – Bacterial vaginosis </li></ul></ul></ul><ul><ul><ul><li>No odor – physiologic </li></ul></ul></ul>Trichomonas Source: http://www.sti.healthcare.org.uk
    41. 44. Wet Prep - Trichomonas & BV <ul><li>Diagnosis </li></ul><ul><ul><li>Wet Prep </li></ul></ul><ul><ul><ul><li>Unicellular flagellated protozoan (moving), many WBC – Trichomonas </li></ul></ul></ul><ul><ul><ul><li>Clue cells (epithelial cells coated with bacteria) – Bacterial vaginosis </li></ul></ul></ul>clue cells Source: http://www.aafp.org/afp/980315ap/majeroni.html Source: http://www.biosci.ohio-state.edu/~parasite/trichomonas.html
    42. 45. Genital Ulcer Disease - Herpes <ul><li>Presentation </li></ul><ul><ul><li>Primary ulcers </li></ul></ul><ul><ul><ul><li>Many painful small blisters which leave ulcers after breaking </li></ul></ul></ul><ul><ul><ul><li>Fever </li></ul></ul></ul><ul><ul><ul><li>Malaise </li></ul></ul></ul><ul><ul><li>Secondary </li></ul></ul><ul><ul><ul><li>Few lesions </li></ul></ul></ul>Source: http://www.sti.healthcare.org.uk/
    43. 46. Exophytic STDs - Genital Warts (Condyloma accuminatum) <ul><li>Human Papillomavirus </li></ul><ul><ul><li>Presentation </li></ul></ul><ul><ul><ul><li>Painful, friable or pruritic lesions depending on location </li></ul></ul></ul><ul><ul><ul><ul><li>Characteristic fleshy growths are usually caused by HPV subtype 6 or 11. </li></ul></ul></ul></ul><ul><ul><ul><li>Most are asymptomatic, subclinical or unrecognized </li></ul></ul></ul>

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