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Chapter 233. Sexually Transmitted Infections

Loris Y. Hwang; Anna-Barbara Moscicki; Mary-Ann Shafer

Currently, substantial numbers of adolescents engage in sexual intercourse: 34% have experienced their sexual debut by ninth grade and 63% by 12th grade.1 Although these rates have slowly decreased from 15 years ago the adolescent age group continues to be at the highest risk for STIs.

This chapter provides an overview of common STIs including the pathogenesis, common clinical syndromes, diagnostic approach and treatment for bacterial, fungal and viral infections (see Table 233-1), and for clinical For the most contemporary guidelines on treatment regimens it is useful to refer to the Centers for Disease Control and Prevention (CDC) web site since alterations in optimal treatment approaches may change as antibiotic-resistance patterns and the availability of specific medications changes.

Table 233-1. Common Sexually Transmitted Diseases in Adolescents
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Table 233-1. Common Sexually Transmitted Diseases in Adolescents...
NamePathogenesisCommon SyndromesDiagnosisTreatment*Comments
Bacterial
Neisseria gonorrhoeae (Gonorrhea) Gram (–) diplococcus Genetic ability to frequently change antigenic surface structuresUncomplicatedMale: UrethritisSee Table 233-2Many asymptomatic infections in men and women
UrethritisGram stain [Gram (–) intracellular diplococci]
EndocervicitisScreen all gonorrhea patients for syphilis, chlamydia; R/O HIV
(See Chapter 274)PharyngitisCulture
ProctitisFemale: CervicitisTreat all gonorrhea patients empirically for chlamydia
ConjunctivitisEndocervical culture
ComplicatedGram stain but ↓ sensitivity
Disseminated gonococcal infectionDNA probe and NAATs applied to genital and FCU specimens
Pelvic inflammatory disease (PID)
Epididymitis
Chlamydia trachomatis (Chlamydia) Obligate intracellular bacteria that cause cell damage directly at end of their growth cycle and indirectly by stimulation of inflammatory host immune responseUncomplicatedMale: Non-gonococcal urethritis (NGU)See Table 233-2Many asymptomatic infections in men and women; most common cause of urethritis in adolescent boys and cervicitis in adolescent girls
EndocericitisNegative gonococcal culture and/or
(See Chapter 259)UrethritisGram stain > 4 PMNs/oil (mean of 5 hpf × 1000×) immersion and no GNID
Proctitis
Conjunctivitis
Urethral culture (+)
Complicated
Nonculture tests
PIDDNA probe and NAATs applied to genital and FCU specimens
PharyngitisFemale: Endocervicitis
EpididymitisMucopus and/or > 10–30 PMNs/hpf on Gram stain (confirm with specific chlamydia test)
DNA probe and NAATs applied to genital and FCU specimens
Treponema pallidum (Syphilis) Enters through small abrasions in mucosa during intercourse and stimulates a local immune response and spreads hematogenously (secondary)Primary: chancrePrimary: treponemes on dark-field microscopyBenzathineb Pen G: 2.4 × 106 UI IM or, if penicillin allergy, Doxycycline 100 mg PO b.i.d. or Tetracycline 500 mg PO qid × 14 daysScreen with VDRL or RPR if contact history, at diagnosis of any STI, or in population with high syphilis rate; penicillin in pregnancy; screen for HIV
(See Chapter 288)Secondary: generalized skin rash, especially palms and soles
Secondary: VDRL or RPR, confirmed by fluorescent antibody test (FTA–ABS) or microhemagglutination assay (MHA-TP)
Early, late latent, and tertiary: rare in adolescents
Viral
Herpes simplex virus (HSV)Enters host through mucosa or abraded epithelium

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