COMMON SEXUALLY TRANSMITTED INFECTIONS IN ADOLESCENTS OVERVIEW AND

COMMON SEXUALLY TRANSMITTED INFECTIONS IN ADOLESCENTS

OVERVIEW AND PREVALENCE • Adolescents have the highest risk of sexually transmitted infections (STIs) of any other sexually active group • Biological factors • Behavioral factors • Developmental factors 1

CONCERNS RELATED TO SEXUAL RISK TAKING BEHAVIORS • Initiation of sexual activity before 16 years of age • Poor contraceptive use • Increased alcohol and drug use • Poor academic achievement • Lower self esteem • Increased depression 2

TAKING A SEXUAL HISTORY • Utilize a non-judgmental open manner • Discuss confidentiality • Avoid medical j argon • Ask questions in a open straightforward manner • “Do you have sex with men, women or both? ” • “How many different partners have you had in the last three months ? ” • “How often do you use condoms? ” 3

PREVENTION GUIDANCE • Education and counseling of persons at risk on ways to avoid STIs through changes in sexual behavior • Abstinence and delaying or limiting sexual activity • Condom use with spermicidal barriers • Risk of multiple partners • Identification of asymptomatic infected persons (screenings) • Effective diagnosis, treatment and counseling of infected persons including partner treatment • Pre-exposure vaccination of persons at risk 4

CHLAMYDIAL INFECTIONS IN ADOLESCENTS • Most frequently reported infectious disease in the United States • Caused by Chlamydia trachomatis (bacterium) • Infects the epithelium of the urogenital tract or rectum • Prevalence is highest in persons under 24 • Asymptomatic infection is common for both men and women 5

COMMON SYMPTOMS • Difficulty urinating, which includes painful urination or burning during urination • Discharge from the penis • Redness, swelling, or itching of the opening of the urethra at the tip of the penis • Swelling and tenderness of the testicles • Pain in the lower part of the belly, possibly with fever • Painful intercourse • Vaginal discharge or bleeding after intercourse 6

DIAGNOSTIC CRITERIA • First-catch urine specimens • Swabs of the endocervix or vagina • Rectal or oropharyngeal testing can be done by testing at the anatomical site of exposure 7

TREATMENT • Azithromycin 1 gm orally in a single dose • Alternatives • Doxycycline 100 mg orally twice daily for 7 days (contraindicated in pregnancy) • Erythromycin 800 mg orally 4 x/day for 7 days • Abstinence for 7 days after treatment and until all partners have been treated Treatment of sexual partners of last 60 days and most recent partner if > 60 days 8

GONORRHEA • Caused by Neisseria gonorrhoeae (bacteria) • Co-infection with CT is common • Second most common communicable disease • May be asymptomatic • Diagnostic criteria is similar to GC • Symptoms similar to CT although discharge generally more purulent with edema of the male meatus • Rectal infection is common • Oral and GC conjunctivitis has been reported 9

TREATMENT • Ceftriaxone 250 mg IM Once PLUS Azithromycin 1 gm orally in a single dose • Alternative • Cefixime 400 mg orally once Also treat for CT due to the frequency of co-infection 10

PELVIC INFLAMMATORY DISEASE (PID) • Ascending infection of upper reproductive tract in women • Includes a spectrum of inflammatory disorders • Sexually active adolescents have a 7 to 10 fold greater risk • Most often a complication of GC or CT 11

CLINICAL PRESENTATION/COMPLICATIONS • Lower abdominal pain, vaginal discharge, fever, nausea, vomiting and right upper quadrant abdominal pain • Usually clinical diagnosis based on cervical motion tenderness, uterine tenderness or adnexal tenderness and supportive findings • Complications include perihepatitis (Fitz-Hugh-Curtis syndrome) • Long term complications include chronic pelvic pain and infertility 12

TREATMENT OF PID • Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg orally twice daily for 14 days • May require hospitalization for severe symptoms or to rule out a surgical emergency such as an ectopic pregnancy 13

DISEASE CHARACTERIZED BY VAGINAL DISCHARGE • Bacterial Vaginosis (BV) • Trichomoniasis (trich) • Vulvovaginal Candidiasis (yeast infection) 14

VULVOVAGINAL CANDIDIASIS • “yeast infection” common in adolescents • Vulvar irritation, burning on urination, thick vaginal discharge and ITCH! • Can be diagnosed with direct microscopic exam • PH<4. 5 15

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TREATMENT • Intravaginal creams or suppositories • Oral Fluconazole • Male partners do not need treatment if asymptomatic 17

BACTERIAL VAGINOSIS (BV) • Overgrowth and replacement of lactobacilli • Characteristic odor due to amine production • Thin white vaginal discharge which adheres to the walls • Associated with a high number of sexual partners or a new sexual partner • May be asymptomatic 18

DIAGNOSIS • Amsels Criteria (3 of 4 criteria) • Thin white discharge adhering to the walls • Vaginal PH greater than 4. 5 • Characteristic “fishy odor” • Presence of “clue cells” 19

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TREATMENT • Recommended for those with symptoms • Metronidazalone (flagyl) 500 mg orally twice daily for 7 days • Metronidazalone gel once a day for 7 days 21

DISEASES CHARACTERIZED BY GENITAL ULCERS • Genital Herpes is the most prevalent • Chronic lifelong viral infection • HSV type-1 and HSV type-2 • Most recurrent genital herpes are caused by type-2 • Most HSV type-2 go undiagnosed because of sub clinical or no symptoms at all but continue to intermittedly shed the virus • More viral shedding in HSV type-2 22

SYMPTOMS OF HSV • Painful ulcerations • First episode often associated with fatigue, enlarged lymph nodes, fever and may cause prolonged illness • All patients with a first episode of genital herpes should be treated with antiviral medications (Acyclovir, Valacyclovir or Famcyclovir) 23

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TREATMENT • First Clinical Episode • Acyclovir 400 mg orally TID for 7 -10 days • Episodic Therapy • Acyclovir 400 mg orally TID for 5 days • Valacyclovir 500 mg BID for 3 days • Suppressive therapy for recurrent genital herpes • Valacyclovir 500 mg to 1 gm orally once a day • Acyclovir 400 mg orally twice a day 25

COUNSELING POINTS • The risk of recurrent episodes • The effectiveness of suppressive therapy and the effect on decreasing the risk of transmission • The importance of informing present and potential future sex partners • The importance of abstaining from sexual activity when lesions are present 26

COUNSELING POINTS (continued) • The effectiveness of latex condoms to help reduce (but not eliminate) transmission • The risk of neonatal transmission 27

HUMAN PAPILLOMAVIRUS (HPV) • 100 types identified of which about 40 can infect the genital tract • Most sexually active persons become infected at least once in their lifetimes • Most are self limited and often unrecognized • High risk types 16 and 18 cause most cervical, penile, vaginal, and oropharyngeal cancers • Types 6 and 11 cause genital warts 28

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DIAGNOSIS AND TREATMENT • Cervical cancer screening and management of abnormal cervical cytology • Visual inspection of warts • Untreated may resolve, remain unchanged, or increase • Cyrotherapy, patient applied creams, surgical removal 30

COUNSELING POINTS • Infection is VERY common. Most sexually active people get it • Most people who acquire HPV clear the infection and have no associated health problems • The type of HPV that cause genital warts are different from the types that cause cancer • HPV may be transmitted through genital to genital contact • No HPV test can determine which HPV infection will clear and which will not 31

COUNSELING POINTS • Women with genital warts do not need Pap tests more often then other women • Although genital warts can be treated, treatment does not cure the virus itself 32

CONFIDENTIALITY • The consultation, examination, and treatment of an STD for a minor is confidential and must not be divulged to parents – including the sending of a bill. • DCF must be notified of a positive STD test if the minor is 12 years of age or younger. • Care and treatment of this minor must remain confidential, although DCF may proceed with their own investigation. 33

MANDATORY DCF REPORTING • DCF Reporting Guidelines: • Child under 13 - must report to DCF/police • Child b/t 13 -15 engaged in consensual sexual relationship w/partner 21 & over - must report to DCF/police • Child under 18 in non-consensual/coerced sexual activity - must report to DCF/police • Child b/t 13 -15 engaged in consensual sexual relationship w/partner under 21 – (not mandated to report per se) • Child under 18 engaged in sexual relations with family member 34

BARRIERS • Lack of knowledge of STI’s • Cost • Inconvenient services, inability of student driving themselves • Shame • Lack of understanding of confidentiality 35

ROLE OF THE SCHOOL NURSE • Nurses need to advocate that sexual health should be given priority as part of the health curriculum. Nurses need to have cultural awareness and knowledge and gain competence to understand beliefs in different schools and adjust accordingly to that • Remain non-judgmental and approachable • Knowledge of community resources for screenings and treatment 36

REFERENCES • https: //medlineplus. gov/ency/article/000886. htm • https: //www. cdc. gov/ • MMWR/ Sexually Transmitted Diseases Treatment Guidelines. June 5, 2015/vol. 64/No. 3 • Jay E. Sicklick, Esq. Presentation March 27, 2014, CT AAP School Health Conference 37