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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.

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

Published in: Health & Medicine, Education

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  • Transcript

    • 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. 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
    • 3. 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
    • 4.
      • 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?
    • 5. 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
    • 6. 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.
    • 7. Bacterial STDs - Urethritis
      • Symptoms
        • often asymptomatic (80-90%)
    • 8. 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
    • 9. Bacterial STDs - Urethritis
      • Empiric testing in high-risk
        • Multiple sexual partners
        • History of previous STDs
        • Unprotected intercourse
    • 10. Bacterial STDs - Urethritis
      • Diagnosis
        • Urethral sample with calgi-swab
        • First void urine LCx/PCx
    • 11. Case III
      • A 14 year-old adolescent presents to his medical provider with a chief complaint of dysuria and a penile discharge
    • 12.  
    • 13. 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
    • 14. 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.
    • 15. Urethritis Organisms
        • Chlamydia
        • Gonorrhea
        • Trichomonas
        • Ureaplasma urealyticum
          • Herpes simplex
          • Mycoplasma hominis
          • Mycoplasma genitalium
          • Yeasts
          • Staphylococcus saphrophyticus
    • 16. 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
    • 17. Bacterial STDs - Treatment
      • Recommend abstinence from intercourse until 7 days after treatment is initiated
    • 18. Case IV
      • A 13 year-old girl presents with complaints of vaginal spotting, especially after intercourse and vaginal pruritis
    • 19. Case IV
      • A speculum exam reveals thin fluid in the vaginal vault and cervical friability
    • 20. Case IV
      • A wet prep of the vaginal fluid is not remarkable
    • 21. What is her most likely diagnosis?
      • A. Physiologic leukorrhea
      • B. Gonorrhea
      • C. Chlamydia
      • D. Trichomonas
      • E. Yeast vaginitis
      • F. Bacterial Vaginosis
    • 22. 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
    • 23. 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.
    • 24. Case V
      • On exam, she has normal vital signs and a vague lower quadrant abdominal tenderness. A urine pregnancy test is negative.
    • 25.  
    • 26. 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
    • 27. 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
    • 28. 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
    • 29. Pelvic Inflammatory Disease
      • Hospitalize when
        • Acute abdomen cannot be ruled out
        • Pregnancy
        • Oral treatment failure
        • Tubo-ovarian abscess
        • Severe illness / nausea + vomiting / high fever
    • 30. Bacterial STDs - Cervicitis
      • Organisms
        • Gonorrhea
          • Pearl: Fitzhugh-Curtis (Perihepatic inflammation) in PID equals GC
    • 31. Special Cases - Pelvic Inflammatory Disease
      • Followup
        • Absolutely necessary
        • Hospitalize patients who do not demonstrate substantial improvement within 3 days of initiation
    • 32. 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.”
    • 33. 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.
    • 34. Source: Internet Dermatology Society, http://telemedicine.org/ids.htm
    • 35. 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.
    • 36. Followup
      • Patients should be re-evaluated if symptoms persist or recur after completion of therapy
    • 37.  
    • 38. 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
    • 39. 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
    • 40. 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
    • 41. End
    • 42. 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
    • 43. 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
    • 44. 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
    • 45. 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/
    • 46. 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