Prevalence of STDs highest among adolescents (10-19) and young adults (20-24)

3 million adolescents in US get an STD each year; thatís 1 in 4!

Why is the risk of STD infection so high in adolescents?

Psychosexual maturation: development of an understanding of relationships.

The ability to maintain emotional intimacy learned during adolescence.

Adolescent may feel more comfortable with having sex than with talking

about sex with their partner.

Cognitive development

Many adolescents have not completely developed the ability to fully consider the future

and consider future consequences to present actions. Thus, many have a very low

perceived risk of sexual behaviors.

Knowledge base

Despite efforts to increase sex education and attempts to encourage safer sex, many

still lack accurate information: risks of STDs; symptoms (or lack of

symptoms) associated with STDs; long-term consequences of STDs.

Physiologic development

Biologic factors are more of an issue with females. Cervical ectopy, columnar epithelium

With young age of first sexual experience, there is an increased risk of more sexual

partners. Furthermore, he/she may be more likely to engage in unprotected sex and may

Lack of understanding as to what sex entails and manners in which STDs may be spread

Can be extremely problematic.

Barriers to health care

Lack of finances, lack of adequate insurance coverage, lack of knowledge of free

"Risky behavior syndrome" involves being irresponsible about various behaviors.

Chlamydia and Gonorrhea co-infection is extemely common among adolescents and young adults

Chlaydia and Gonorrhea are found in up to 40% of patients with pelvic inflammatory disease, a severe infection of the upper female reproductive tract with severe complications such as infertility, chronic pelvic pain, tubo-ovarian abscesses and even death.

Chlamydia
C. trachomatis is an intracellular parasite that can present as a symptomatic or asymptomatic infection. Women who are symptomatic usually present with dyuria, and a yellow mucopurulent endocervical exudate. Men who present with chlamydia tend to have dysuria, increased urinary frequency, and purulent urethral discharge.

Clinical Spectrum of Chlamydia
Urethritis
Epididymitis
Proctitis
Prostatitis
Cervictis
Bartholinitis
Conjunctivitis

Complications of Chlamydia
Pelvic inflammatory disease (PID)
Preihepatitis (Fitz-Hugh-Curtis Syndrome)
In association with perihepatits, an individual may present with right upper quadrant pain, fever, nausea and vomiting. Liver enzymes are usually normal and any elevation may be mild.
Epididymitis
Reiter’s syndrome
Reiters syndrome is a triad of urethritis, conjunctivitis, and arthritis, with more than 80% of patients having a past or current chlmaydia infection.

In women with untreated infections, there can be a subsequent risk of infertility, increased risk of ectopic pregnancy, and chronic pelvic pain.

Chlamydia Testing
The use of nucleic acid amplification techniques has improved the sensitivity of disease detection by 25 to 30%. Older non-culture techniques such as direct fluorescent antibody, enzyme immunoassay, and non-amplified nucleic acid hybridization are even less sensitive than culture.

Treatment of Chlamydia
Azithromycin administered as a single oral dose of 1 g is as effective as a week of doxycline (100mg, bid).
Erthromycin base, ethyl succinate, and amoxicillin are treatment alternatives in pregnancy. Azithromycin is listed as a secondary line of treament in preganancy. Pregnant patients should not be treated with doxycycline.

Screening for Chlamydia/ Follow Up/ Management of Partners
* Annual screening is recommended in all sexually active women under the age of 25 years. Data for women is more comprehensive than for men because the surveillance programs for asymptomatic infection have been more effectively applied to women.
* There is no need to repeat testing after instituting therapy. Testing done less than three 3 weeks of the intervention may give false positive or false negative results.
* Sex partners of symptomatic patients should be evaluated and treated if their last sexual contact with the index patient was within 30 day of onset of the symptoms. In the patient is asymtomatic; referral of the sex partner within the last 60 days is recommended.

Nisseria gonorrhoeae
N. gonorrhoeae is a fastidious gram negative diplococcus that infects mucous membranes. Women who are symptomatic usually report dysuria, abnormal menses, or abnormal vaginal discharge. Men may also present with dysuria, in addition they may present with increased frequency, and a purulent urethral discharge (more copious and purulent than in chlamydia). 80% of women can by asymptomatic in comparison to 95% of men having symptoms.

Clinical Spectrum of Gonorrhea
Urethritis
Epididymitis
Proctitis
Prostatitis
Cervictis
Infection of Bartholin’s gland
Infection of Skene’s gland
Pharyngitis
Conjunctivitis

Complications of Gonorrhea
Pelvic inflammatory disease (PID)
Preihepatitis (Fitz-Hugh-Curtis Syndrome)
Disseminated Gonoccocal infection (DGI)
 DGI more common in women particularly during pregnancy and within a week of menses. Other risk factors include pharyngeal infection and complement deficiencies. Presenting symptoms of DGI include arthritis (usually knee, wrist, ankle, or metacarpophalangeal joints), tenosynovitis, and dermatitis (usually on distal extremities).
Meningitis
Endocarditis

Gonorrhea Testing
Both gonorrhea culture and nonamplified nucleic acid hybridization and amplified testing are available. Under ideal transport situations, cultures are an excellent and have sensitivities that approach nucleic acid amplification testing. Urethral gram stain is diagnostic in men; however this method does not provide an accurate diagnosis in women.

Treatment of Gonorrhea
Single does of oral cefixime, ciprofloxacin, ofloxacin, levofloxacin, or an intramuscular dose of ceftriaxone.
Ceftriaxone and Ciprofloxacin for pharyngeal infections.
Ceftriaxone is recommended for conjunctivitis.
Patients with DGI should be admitted for intravenous therapy which will continue until at least 24 to 48 hours.
Pregnant patients should not be given quinolones.

Screening for Chlamydia/ Follow Up/ Management of Partners
* Annual screening is recommended in all sexually active women under the age of 25 years.
* There is no need to repeat testing after instituting therapy.
* All partners should be treated for both gonorrhea and chlamydia.

Clinical Criteria for the Diagnosis of PID
Minimal Criteria
* Uterine/adenexal tenderness or Cervical motion tenderness
Additional Criteria
* Oral temperature of greater than 101 F or 38.3 C
* Abnormal cervical or vaginal mucopurulent discharge
* Presence of WBCs on saline microscopy of vaginal secretions
* Elevated ESR
* Elevated C-reactive protein
* Laboratory documentation of cervical infection with chlamydia or gonorrhea
Specific Criteria
* Endometiral biopsy with endometritis
* Ultrasound or MRI showing thickened, fluid filled tubes with or without free fluid pelvis, or tubo-ovarian complex
* Laproscompy consistent with PID
 

Trichomoniasis
This infection is caused by the protozoan Trichomonal vaginalis. Male are usually asymptomatic, but the protozoan may cause an urthritis. Women may also present without symptoms.

The clinical presentation
Vaginal discharge
Vulvar irritation
Urethritis
Strawberry cervix

Diagnosis of Trichomonas
* Motile trichomonad on saline wet mount of vaginal secretions
Wet mount is not the perfect method to detect the organism because in 30-50% of the cases, it is missed.
* Urine samples from both men and women
* Culture of the organism is the most commercially available test.

Treatment
* Single dose of metronidazole with the cure rate approaching 90-95%
* No follow up is necessary and affected partners should be treated. Individuals should not engage in sexual intercourse until they are cured.

Herpes Simplex Virus
Genital herpes is caused by two strains of the herpes simplex DNA virus, HSV 1 and HSV 2. However HSV 2 is more common in the lower genital tract. Clusters of painful vesicles and ulcers characterize the infection. After the initial infection, the virus retreats to the nerve root ganglion, and recurrent infections are usually of shorter duration and less extensively involved. Atypical presentation of HSV includes appearance of a small linear ulceration or an individual may be asymptomatic and have shedding of the virus.

Clinical presentation of HSV
Fever
Myalgia
Headache
Tender inguinal adenopathy
Pain
Itching
Dysuria
Vaginal Discharge
Urethral Discharge

Complications of HSV
Aseptic meningitis
Transverse myelitis
Extragenital lesions
Bacterial superinfection
Hepatitis
Pneumonitis
Arthritis
Cutaneous dissemination

Diagnosis of HSV
* Definitive diagnosis of HSV is made from  viral cultures of fresh blisters and/or ulcers. Culture is less sensitive once lesions begin to heal.
* Direct fluorescent antibodies are less sensitive than culture.
* Subtyping of the virus is recommended
 

Treatment of HSV
* Acyclovir
Acyclovir is the drug of choice for the pregnant patient.
* Famciclovir
* Valacyclovir
Valacylovir can be given in once daily dosing and useful in individuals with recurrent infections and physician is considering suppressive therapy.
* Topical therapy is not recommended
* Topical anesthetic therapy may be useful for symptomatic relief
* IV therapy should be used in severe disease
 

Human Papilloma Virus Infection
A DNA virus that has more than 30 types affecting the genital tract

Clinical presentation of HPV
* Condylomata acuminata - appears as a raised lesion to subclinical infection and is only detected through cytology or by application of acetic acid revealing an aceto white reaction on the mucosa.
* Asymptomatic patient
* Symptomatic patients have lesions that are painful, friable or puritic.

Sequele of HPV
* Squamous intraepithelial neoplasia (Vaginal, anal, and cervical intraepithelial dysplasia)
* Squamous cell carcinoma - HPV types 16, 18, 31, 33, and 35 are the high risk types most commonly associated with malignant transformation.

Sexually active women should be referred for Pap smears to screen for cervical abnormalities.

Syphilis
Treponema pallidum is a spirochete that is responsible for syphilis.
Untreated s yphilis can progress through three stages
* The first stage presents as a painless ulcer at the site of inoculation 3 weeks after infection, and the lesion resolves.
* In the second stage, the patient may present with fever malaise, headache, adenopathy, generalized body ra sh, and mucosal lesions (condylomata lata). The rash of secondary syphilis can be confused with pitiriasis rosea. The symptoms of secondary syphilis resolves spontaneously and the infection enters a latent stage.
* Third stage can present years later and may manifest as neurologic, cardiovascular, and skeletal disease.

Diagnosis of syphilis
* Darkfield examination or by direct flouresscent antibody test
* Screening for syphilis is done with the Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR)
* A positive test is confirmed with a fluorescent treponemal antibody absorbed (FTA-ABS) or T. pallidum particle agglutination (TP-PA).

Treatment of Syphilis
* Penicillin
It is preferable to desensitize penicillin allergic patients rather than use alternatives like doxycycline or tetracycline.
 

References:

1.CDC: National Center for HIV, STD and TB Prevention Division of Sexually Transmitted Diseases: Annual Trends: http://www.cdc.gov

2. Bonny, Andrea E., Biro, Frank. Recognizing and treating STDs in adolescent girls. Contemporary Pediatrics. March 1998

3. Gevelber, Mitchell A. and Biro, Frank M. Adolescent Gynecology, Part II: The Sexually Active Adolescent. Pediatric Clinics of North America. August 1999.

4. Braverman, Paula. Sexually Transmitted Diseases in Adolescents. Medical Clinics of North America. July 2000.

5. Houry, Debra E.and Lavely, Richard. Chlamydia. EMedicine Journal. April 2001.

6. Behrman, Amy J. and Michelson, Edward A. Gonorrhea. EMedicine journal. May 2001.