1) STI's are common among adolescents in the United States, with about 24% of adolescent females having evidence of at least one of the main STI's. Left untreated, STI's can cause infertility and other serious health issues. 2) Common STI's include chlamydia, gonorrhea, trichomoniasis, HPV, HSV-2, and syphilis. Symptoms and signs vary depending on the specific infection, but may include abnormal discharge, ulcers, rashes, or pelvic pain. Many infections can also be asymptomatic. 3) Screening and treatment guidelines exist for various STI's. Regular screening is recommended for sexually active adolescents and young

1. Sexperts: Basic STI Knowledge
Mike Guyton, MD
Assistant Clinical Professor/Academic Faculty in General
Pediatrics

2. Confidentiality Disclaimer
• Cornerstone of Adolescent Medicine and
Medical Healthcare in general
• Not to be breached except for 2 circumstances
– Immediate harm to self
– Immediate harm to others
• Engenders trust, develops rapport, and allows
proper treatment and counseling

3. What is sex?
• Definitions vary from person to person
– Vaginal Intercourse, Anal Sex, Oral Sex
• Also, definition of abstinence vary
• Risk is the same if not increased with certain
types of sex
– Virtually all STI’s can be transmitted by all forms of sex
– Anal Sex can be associated with increased incidence of
anal/rectal cancers
– Transmission of HSV 1 to genitals via oral sex

4. Reportable STI’s in SC (2014)
• Chancroid
• Chlamydia trachomatis, genital site
• Gonorrhea (include susceptibility profile)
• (URGENT) Acute Hepatitis (A-E)
• Chronic Hepatitis (B-D)
• Hepatitis B Surface Antigen + with each pregnancy
• HIV and AIDS Clinical Diagnosis and positive test
results*
• Lymphogranuloma Venereum
• (URGENT) Syphilis (congenital, primary, secondary,
latent, tertiary, positive test

5. STI’s in the US
• The US ranks first among developed nations in the rate of STI’s
– In addition to teen pregnancies
• 24% of adolescent females (14-19) have lab evidence of at least 1/5
STI’s
– HPV (18%)
– Chlamydia (4%)
– Trichomonas (3%)
– HSV 2 (2%)
– Gonorrhea
• Repeated STI infection is a recognized risk factor for development of
HIV infection
– 3X higher in students with h/o multiple gonorrhea infections vs. no
infections

6. Quick CDC Facts
• FACT: 19 million new infections occur every year in the US
• FACT: STI’s cost the US HealthCare System $17 billion yearly
• FACT: Untreated STI’s cause 24,000 women in the US to
become infertile yearly
• FACT: While young people only represent 25% of the
sexually experienced population in the US, they account for
almost 50% of newly diagnosed STI infections
• FACT: ~20% of adolescents fail to fill Rx for STI treatment

7. Specific To Adolescents
• Behavioral
– Time elapsed since first
intercourse
– Multiple or new partners
– Inconsistent use of condoms
– Alcohol/drug use*
• Biologic
– Cervical ectopy/immaturity
– Low levels of sIgA
• Unique Issues
– Self-consent for Dx and Tx
– Concerns about privacy and
confidentiality
– Pregnancy/fear of pregnancy
– Self-treatment
– Preference to notify partners
themselves

8. STI Screening
• Chlamydia
– All SA females (</=25yo) annually
– All SA MSM (</= 25yo) for urethral and/or rectal annually; screen
every 3-6 months if high risk
– Screen those </=25yo exposed to an infected partner within the last
60 days
– Consider screening sexually active males in high prevalence areas
• Gonorrhea
– Overall same as above, but also screen pharyngeal swabs in MSM if
engaging in oral sex
• Trichomonas
– Routine screening not recommended in asymptomatic individuals
• Syphilis
– All SA </= 25yo MSM annually or every 3-6 months (no routine
heterosexual/non-pregnant screening)

9. STI Clinical Patterns
• Discharge Syndromes
– Gonorrhea and Chlamydia
– Bacterial Vaginosis/Candidiasis
– Non-Gonoccocal Urethritis
• Genital Ulcer Syndromes
– Herpes Simplex Virus
– Primary Syphilis
– Other Ulcer Syndromes
• Pelvic Inflammatory Disease
• Dermatologic Syndromes
– HPV
– Secondary Syphilis
– Disseminated Gonococcal Infection
– Pediculosis Pubis

10. Chlamydia and Gonorrhea
• Chlamydia is the most common bacterial STI in men and women
– Cervicitis (not vaginitis) with menometrorrhagia
– Dysuria-Pyuria Syndrome
– PID
– Perihepatitis
– Proctitis
– Men: See Urethritis, Prostatitis, Proctitis, Epididymitis, Reactive
Arthritis (1%)
• Gonorrhea
– Similar to above, but also can see higher incidence of pharyngitis (1-
12%)
– While mucoprulent discharge common, asymptomatic cases also occur
(50% in women vs 10-15% in men)

12. Chlamydia and Gonorrhea: Treatment
• Gonorrhea:
– Ceftriaxone 250mg IM x 1 PLUS Azithromycin 1g po x 1 OR
Doxycycline 100mg po BID x 7 days
– Other:
• ceftizoxime 500 mg intramuscularly/ cefotaxime 500 mg
intramuscularly/cefoxitin 2 g intramuscularly PLUS Azithro or Doxy
• Oral Cefixime 400mg x 1 dose PLUS Azithro OR Doxy
• Azithromycin Monotherapy with 2g x 1 dose
• Chlamydia:
– Azithromycin 1g po x 1 dose
– Doxycycline 100mg po BID x 7 days
– Other:
• Ofloxacin 300 mg orally twice daily for seven days
• Levofloxacin 500 mg orally once daily for seven days
• Erythromycin/PCN if pregnant and intolerant to Azithro

13. Rescreening
• “Rescreen all adolescents infected with
chlamydia or gonorrhea 3 months after
treatment, regardless of whether they believe
that their sex partners were treated.”

14. Bacterial Vaginosis/Candidiasis
• Bacterial Vaginosis:
– Most common cause of vaginal discharge in women of
childbearing age (40-50%); abnormal alteration of vaginal flora
– Tx: Metronidazole 500mg po BID x 7 days OR Metronidazole
Gel 0.75% qday x 5 days OR Clindamycin 2% cream qhs x 7 days
– Other
• Clindamycin 300mg po x 7 days; Clindamycin Ovule; Tinidazole
• Candidiasis:
– Common in healthy reproductive age women; less likely sexual
transmission; often clinical diagnosis
– Tx: Recommended: Fluconazole 150mg po x 1 dose or if
severe/complicated, 150mg po every 72h x 2-3 doses.

15. Non-Gonoccocal Urethritis
• Many causes, some bacterial/some viral
– Chlamydia
– Mycoplasma Genitalium
– Adenovirus, Herpes
– Chemical Urethritis
• Many are often treated as a bacterial urethritis
– Most assumed to be chlamydia
• While some are self limited without
consequence, still needs medical evaluation

16. Genital Herpes
• Belongs to the Genital Ulcer Syndromes
– HSV, T. pallidum, and H. ducreyi
• HSV2 is predominant, with increasing HSV1 genital
occurrence in females
• Lesions begin as vesicles, which then rupture to form
painful ulcers
– Usually occurring as clusters
• Occurs as a Primary Outbreak, Recurrent Outbreak,
and Latent Infection
– Primary outbreak last 2-3 weeks and often associated
with systemic symptoms (fever, malaise, dysuria)
– Recurrent Outbreaks usually are shorter, 7-12 days
• HSV has a high infectivity and high recurrence rate
– Infectivity 75-80% with active infection
– HSV1 Recurrence: 60%; HSV2 Recurrence: 90%

17. Genital Herpes: Treatment
• Treatment differs based on type of
infection
– Primary:
• Acyclovir 400mg po TID or 200mg po 5x/d x 7-
10 days
• Famciclovir 250mg TID x 7-10 days
• Valacyclovir 1g BID x 7-10 days
– Recurrent:
• Acyclovir 800mg TID x 2 days or BID x 5 days
• Famciclovir 1g BID x 1 day or 125mg BID x 5 days
• Valacyclovir 500mg BID x 3 days
– Suppression:
• Valacyclovir 1g po qday (can be 500mg daily if
<9 recurrences/year)
– 500mg BID if immunoompromised

19. Primary Syphilis
• After incubation, a
ulcerating, painless papule
occurs at site of inoculation;
heal 3-6 weeks later
• Usually singular, but can be
multiple in setting of HIV
• Associated with regional
mild-moderate bilateral LAN
• Secondary Syphilis can
occur weeks to months later

20. Syphilis: Treatment
• Primary, Secondary, or
Latent <1 year
– PCN G Benzathine 2.4
million units IM x 1
– Doxycycline 100mg po BID
x 7 days
• Jarish-Herxheimer
Reaction
– Acute febrile reaction with
HA and myalgias in first 24
hours of treatment

21. Other Ulcerative Disease
• Chancroid
• Lymphogranuloma
Venereum
– Chlamydial Serovar
– Associated with HIV
infection
• Granuloma Inguinale
(Donovanosis)

22. Pelvic Inflammatory Disease
• Acute infection of the upper genital tract of women
– Chlamydia, Gonorrhea, or Vaginal Flora organisms (Anaerobes and
GNR)
– RF for subsequent ectopic pregnancy and infertility
• Clinical Diagnosis of PID is often imprecise; need evaluation of risk
factors
– Lower Quadrant Abdominal Pain, acute in nature
– Abnormal uterine bleeding (1/3 of patients)
– New onset discharge, urethritis, Proctitis, fever (non-specific)
• Empiric Treatment often initiated if 1 out of three clinical findings
present (in the setting of abdominal pain):
– Cervical Motion Tenderness
– Uterine Tenderness
– Adnexal Tenderness

23. Pelvic Inflammatory Disease:
Treatment
• Indications for Hospitalization
– Pregnancy
– Nonresponse/tolerance to po
medications
– Noncompliance
– Inability to take oral medications
– Severe clinical illness (high fever,
nausea, vomiting, severe
abdominal pain)
– Complicated PID with pelvic
abscess
– Possible need for surgical
intervention or diagnostic
exploration for alternative etiology
(e.g., appendicitis)
• Outpatient:
– Ceftriaxone 250mg IM x 1 PLUS
Doxy 100mg po BID x 14 days
– Cefoxitin 2mg IM with
Probenecid 1g po x 1 PLUS
Doxy 100mg po BID x 14 days
• Inpatient:
– Cefoxitin (2g IV q6) OR
Cefotetan (2g IV q12) PLUS
Doxy100mg po q12
– Clindamycin 900mg IV q8 PLUS
Gentamicin (Load: 2mg/kg;
Maint: 1.5mg/kg q8)

24. Genital Warts
• Condyloma Accuminata, caused by Human Papilloma Virus
– >70 different subtypes; High risk associated with cancers (16, 18) and low risk associated with
genital warts (6, 11)
– Incubation is 3w-8m and most infections are cleared within 2 years
• Risk Factors
– Sexual activity (more partners increases the risk in men and women)
– Concomitant/history of recurrent STI’s
– Individuals who are HIV positive
• Clinical
– Ranges from asymptomatic (M and F) to problematic, depending on the size of warts
– Can see Pruritus, pain, bleeding, tenderness, or vaginal discharge
• Differential Diagnosis
– Condyloma Lata
– Micropapillomatosis
– Pearly Penile Papules
– Squamous Cell Carcinoma

25. Genital Warts: Treatment
• Multiple Modalities of Treatment
– Spontaneous Remission (20-30% of cases)
– Chemical Agents
• Podophyllin: Teratogenic, risk of chemical burns
• Trichloroacetic Acid: can be used internally, but highly caustic
• 5-Fluorouracil Epinephrine Gel: Injected Intralesionally
– Immune Modulation
• Imiquimod: Complete clearance rates of 40-70% with few recurrence
• Interferon Alfa: side effects of interferon
• Sinecatechins: botanical
– Surgery
• Cryotherapy, Laser, Excisional
– HPV Vaccination
• Highly effective

27. Secondary Syphilis

28. Disseminated Gonococcus
• 0.5-3% of those infected with Nisseria gonorrheae (M>F 3X)
• Certain Risk Factors Exist
– Recent menstruation, Pregnancy/immediate post-partum,
complement deficiencies, or SLE
• Clinical Findings:
– Triad: Tenosynovitis, dermatitis, polyarthralgias without purulent
arthritis
• Acute Fever, chills, malaise is heralding
• Lesions often painless, pustular or vesiculopustular
– Purulent arthritis without skin lesions
• Asymmetric, usually knees/wrists/ankles
• Treatment:
– Ceftriaxone 1g q24 hours initially PLUS Azithromycin 1g po x 1 OR
Doxycycline 100mg po BID x 7 days
– Duration: 7-14 days; step down therapy controversial

29. Disseminated Gonococcus

30. Pediculosis Pubis
• Crab Louse, transmitted through sex or sometimes Fomites
• Clinical:
– Itching
– Maculae Cerulae: pale blue macules (0.5-1cm) from the
anticoagulant present in saliva of parasite, prolonged infestation
– Sometimes LAN
• Treatment:
– Permethrin 1% cream applied and washed off after 10 minutes
– Pyrethrins with piperonyl butoxide, same as above
– Alternative
• Malathion 0.5% lotion applied and washed off after 8-12 hours
• Ivermectin 250mcg/kg orally x 1, repeated in 1-2 weeks
• Lindane not recommended

31. Which is Which?

32. A word on HIV screening
• Test: HIV Ag/Ab Combo
• CDC Recommendations:
– Opt-Out HIV testing for all patients 13-64 years old
• AAP Recommendations:
– Routine HIV testing to be offered at least once to all
adolescents (despite report of sexual activity) by 16-
18yo in clinic settings where HIV prevalence is >0.1%
– Prevalence <0.1%: HIV testing for all sexually active
adolescents and those with other risk factors

33. Questions?