Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Sexually Transmitted Infection Syndromes


According to the Centers for Disease Control and Prevention (CDC), while youth age 15–24 account for only one-quarter of the sexually active population in the US, they are responsible for nearly half of the 20 million new sexually transmitted infections (STIs) that occur each year. In 2018, 61.8% of all reported chlamydia cases in the US were in persons age 15–24, and 21% of all new human immunodeficiency virus (HIV) diagnoses were in those between 13 and 24 years old. Behavioral, biological, and psychosocial factors contribute to this disproportionate burden. In an effort to improve health outcomes and decrease this heavy toll, providers caring for adolescents and young adults (AYA) must ensure that a thorough confidential sexual history and risk assessment is performed at all health care maintenance visits, and safe sexual practices and STI prevention should be discussed. ,

Prevention and Screening of Sexually Transmitted Infections

Multiple strategies exist for the prevention of STIs, including behavioral counseling, barrier protection, pre-exposure vaccination, pre- and post-exposure medication, and expedited partner treatment ( Box 49.1 ). , Routine screening is important to detect asymptomatic infection, ensure prompt treatment, and decrease further transmission in the community. ,

BOX 49.1
Prevention of Sexually Transmitted Infections a

a Not currently standard of care; further studies underway.

Barrier Contraception

  • Latex and polyurethane condoms provide the best available protection against sexually transmitted infections (STIs).

  • Spermicides that contain nonoxynol-9 do not protect against STIs, including infection with human immunodeficiency virus (HIV), and may increase the risk of acquiring HIV from an infected partner if used many times a day.

Vaccination

  • Hepatitis A vaccine: 2-dose series (minimum interval: 6 months) beginning at age 12 months

  • Hepatitis B vaccine: 3-dose series at 0, 1–2, 6–18 months (use monovalent HepB vaccine for doses administered before age 6 weeks)

  • Human papillomavirus vaccine (HPV): routinely recommended at age 11–12 years (can start at age 9 years); catch-up HPV vaccination recommended for all persons through age 18 years if not adequately vaccinated

Pre-Exposure Prophylaxis for Hiv Prevention (Prep)

  • Tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg (TDF/FTC; Truvada) is approved for PrEP for people weighing ≥35 kg (∼77 lb) at high risk of acquiring HIV.

  • Tenofovir alafenamide 25 mg/emtricitabine 200 mg (TAF/FTC; Descovy) once daily is an option for the prevention of HIV through sexual exposure in cisgender MSM and transgender women.

  • TAF/FTC as PrEP is preferred in cisgender MSM and transgender women who have preexisting renal disease or osteoporosis.

  • If daily dosing is a barrier to adherence or if episodic dosing is preferred, clinicians should evaluate the appropriateness of on-demand dosing of TDF/FTC as PrEP.

Nonoccupational Post-Exposure Prophylaxis (Npep) of Hiv

  • Recommended for HIV-negative persons who present within 72 hours after an exposure that has a substantial risk for HIV transmission.

  • The current preferred antiretroviral regimen for nPEP in adult and adolescent patients aged ≥13 years is TDF/FTC (Truvada) plus either raltegravir or dolutegravir × 28 days.

Prep and Pep for Syphilis and Other Bacterial Stis a

  • Doxycycline: 100 mg daily (PrEP) or 200 mg single-dose post–condomless sex event (PEP)

Expedited Partner Treatment (Ept) b

b Guidelines vary by state.

  • Clinical practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.

Sexually Transmitted Infection Syndromes

STI Syndromes in AYA can be divided into six clinical presentations: (1) discharge and dysuria, (2) anal discharge and gastrointestinal (GI) syndromes, (3) genital ulcer and lymphadenopathy, (4) pelvic or scrotal pain, (5) pharyngeal infection, and (6) anogenital warts and dermatologic syndromes ( Table 49.1 ).

TABLE 49.1
Sexually Transmitted Infection Syndromes: Pathogens and Diagnostic Studies
STI Syndrome Primary Organism Diagnosis a
Genitourinary Syndromes
Discharge and dysuria (e.g., cervicitis, urethritis) Neisseria gonorrhoeae
Chlamydia trachomatis
Mycoplasma genitalium
Trichomonas vaginalis
Ureaplasma spp.		 OFFICE:

  • Microscopic wet prep vaginal secretions, pH paper, whiff test, KOH, or Gram stain of urethral discharge; LET

  • Rapid tests for GC, CT, TV, BV

LABORATORY:

  • NAATs for GC, CT, MG, TV

Anal discharge and GI syndromes (e.g., proctitis, proctocolitis, enteritis) N. gonorrhoeae
C. trachomatis
Treponema pallidum
Herpes simplex virus 1,2
Giardia lamblia 		OFFICE:
Microscopy of anorectal exudate rapid tests for GC, CT
LABORATORY:

  • NAATs for GC, CT

  • See HSV and syphilis testing under genital ulcer

  • Stool microscopy, antigen detection, or NAAT for enteric organisms

Genital ulcer and lymphadenopathy Herpes simplex virus 1,2
T. pallidum
Haemophilus ducreyi
Klebsiella granulomatis
Chlamydia trachomatis (LGV serovars)		 OFFICE:

  • Darkfield microscopy for syphilis

LABORATORY:

  • PCR for HSV; serology for type

  • Qualitative treponemal serology plus quantitative nontreponemal serology (RPR)

  • PCR for H. ducreyi and K. granulomatis (though not widely available); Gram stain and culture for chancroid; staining for Donovan bodies on tissue culture

  • NAAT for C. trachomatis ; PCR to determine if LGV serovars

Pelvic pain (e.g., pelvic inflammatory disease) N. gonorrhoeae
C. trachomatis
M genitalium 		OFFICE:
Microscopic wet prep vaginal secretions, pH paper, whiff test, KOH:LET rapid tests for GC, CT, TV, BV
LABORATORY:

  • NAATs for GC, CT, MG

Scrotal pain (e.g., epididymitis) N. gonorrhoeae
C. trachomatis
M. genitalium 		OFFICE:
Gram stain of urethral discharge; LET rapid tests for GC, CT, TV, BV
LABORATORY:

  • NAATs for GC, CT, MG

Pharyngeal Syndromes
Infections of pharyngeal mucosa N. gonorrhoeae
C. trachomatis
Herpes simplex virus 1,2
T. pallidum
Human papillomavirus		 OFFICE:

  • Rapid strep test

LABORATORY:

  • NAATs for GC, CT

  • See HSV and syphilis testing under genital ulcer

  • Biopsy or PCR for HPV

Mucosal and Skin Infections
Anogenital warts (condyloma acuminatum) Human papillomavirus OFFICE:

  • Characteristic lesion on PE

LABORATORY:

  • Biopsy or PCR

Pubic lice Phthirus pubis OFFICE:

  • Identification of eggs, nymphs, and lice with naked eye or microscopy

Scabies Sarcoptes scabiei OFFICE:

  • Examination of skin and hair on PE or microscopy

BV, bacterial vaginosis; CT, Chlamydia trachomatis ; GC, Neisseria gonorrhoeae ; GI, gastrointestinal; HIV, human immunodeficiency virus; HSV-1, herpes simplex type 1; HSV-2, herpes simplex type 2; KOH, potassium hydroxide; LET, leukocyte esterase test of urine; LGV, lymphogranuloma venereum; MG, Mycoplasma genitalium ; NAATs, nucleic acid amplification tests; PCR, polymerase chain reaction; PE, physical examination; RPR, rapid plasma reagin; STI, Sexually Transmitted Infection; TV, Trichomonas vaginalis .

a When screening for any STI, testing for human immunodeficiency virus (HIV) should be performed simultaneously.

Discharge and Dysuria

Presentation

Vaginal or urethral discharge associated with STIs may be mucoid, mucopurulent, or purulent. Notable changes in color, odor, or frequency may be present. For young men, urethritis frequently presents with discharge, dysuria and or urethral pruritus, and, occasionally, orchalgia (testicular pain). Similar symptoms in women may represent urethritis or cervicitis, and symptoms may worsen with menses. Women may also experience abnormal vaginal bleeding, dyspareunia, and pelvic pain. Dysuria accompanied by detection of white blood cells (WBCs) in the urine and a negative culture (i.e., sterile pyuria) is suspicious for urethritis in men and cervicovaginal infection in women from either meatal irritation or urethral infection. Patients with these infections may also be asymptomatic and present for screening after a partner is diagnosed with an STI.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts