STIs in Adolescents: An Update

1. STIs in Adolescents: An Update Mariam R. Chacko, M.D. Peds/Section of Adolescent and Sports Medicine

2. Goal The learner will understand: • The importance of recognizing common STI syndromes in adolescents • The challenges, changes and new approaches to STI testing and treatment in adolescents

3. Objectives Learner will be able to list key: • Clinical features of common sexually transmitted syndromes • Clinical features of common sexually transmitted rashes, genital lesions and ulcers • Diagnostic and screening tests for common STIs • Updates in treatment issues for STIs

4. Epidemiology • Gonorrhea (GC) and Chlamydia (CT) rates highest in 15 –19 year old women and 20 –24 year old men • CT more common than GC • Majority (74%) of new HPV infections in 15 – 24 year olds • Syphilis decreased but increased in Males who have Sex with Males (MSM) for all stages (HIV co-infection)

5. STIFemales who have Sex with Females • Overall at low risk for STIs • Risk based on variations in sexual identity and behavior • Low risk for chlamydia, gonorrhea, hepatitis and HIV • Risk for herpes almost the same as FSM • Risk for warts, trichomonas increases via touching, fondling or sharing sex toys

7. Chlamydia — Rates by Zip Code: Houston/Harris County, 2009 Note: Reflects zip code data available to City of Houston, 10.6% of zip code data missing

8. Gonorrhea — Rates by Zip Code: Houston/Harris County, 2009 Note: Reflects zip code data available to City of Houston, 11.7% of zip code data missing

9. Syphilis (P&S) — Rates by Zip Code: Houston/Harris County, 2009 Note: Reflects zip code data available to City of Houston

10. Common STI- Syndromes • Urethritis • Cervicitis • Vaginitis • Pelvic Inflammatory disease • Genital Ulcers/lesions

11. GC+ CT 15 - 25% Ureaplasma urealyticum 20 - 30% Mycoplasma genitalium 5-30% Trichomonas vaginalis 5% Purulent or mucoid, scant discharge, dysuria +/- First void urine leukocyte esterase > trace =/- Gram stain urethra > 5 WBCs x 1000 HPF Urethritis - Male

13. Clear mucoid discharge NGC Purulent discharge GC CDC

14. Urethral smear –Gram stain Gram negative Intracellular diplococci White blood cells CDC

15. Vaginal Discharge Vaginal infections • Trichomonas • Bacterial Vaginosis • Candida Cervical infection • Chlamydia • Gonorrhea

18. Inflamed mucosa with frothy discharge -Trich Homogenous white discharge - BV Inflamed vulva, Frothy Discharge Milky discharge, Fishy odor

19. Cottage cheese dischargeCandida CDC

21. Saline vaginal wet mount Trichomonads

22. Clue cells Saline vaginal wet mount

23. CT + GC 45 % Mycoplasma genitalium 2- 30% Other 10% - Trichomonas, HSV Asymptomatic Post coital bleeding Runny purulent cervical discharge Mucopurulent sticky cervical discharge Friable cervix Cervicitis

24. Normal Cervical Ectopy CDC

25. Mucopurulent cervicitis CDC

26. Severe Cervicitis CDC Courtesy of Sexually Transmitted Diseases Holmes, Sparling, Mardh et al.

27. PID and Cervicitis Clinical PID • Chlamydia trachomatis 10- 30% • Neisseria gonorrheae 10 –17% Subclinical or asymptomatic PID(histological endometritis) • Chlamydia trachomatis 27% • Neisseria gonorrheae 26%

28. PID -Minimal Criteria Pelvic or lower abdominal pain + >1 following criteria: Cervical motion tenderness or Uterine tenderness or Adnexal tenderness

29. PID Diagnosis - Additional criteria • Oral temperature>101 • Abnormal cervical discharge • Presence of WBC on wet mount • Elevated ESR or CRP • + N. gonorrheae or C. trachomatis (result in hand)

30. Rash, Lesions and Ulcers

31. Clinical Manifestations Secondary Syphilis— Generalized Body Rash Source: Cincinnati STD/HIV Prevention Training Center Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

32. Secondary Syphilis— Palmar/Plantar Rash Source: Seattle STD/HIV Prevention Training Center at the University of Washington, UW HSCER Slide Bank Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

34. Secondary syphilis Moist multiple gray white lesions Condyloma lata -Treponema pallidum CDC Het al.

35. Single or multiple, verrucous HPV types 6 and 11 Venereal WartsHuman papilloma virus CDC CDC ..

36. Tender, multiple, superficial, vesicular, ulcers, crusted lesions Tender inguinal nodes Herpes genitalisHSV 1 and 2 CDC

37. Chancre CDC

38. Chancre CDC CDC

39. When should you think Zebras? • Chancroid, LGV and Granuloma inguinale • Large genital ulcers • Large Inguinal lymph nodes - buboes • Males who have Sex with Males • Travel history • If you work in a tropical country

40. Lab Tests – Genital • Vaginal wet mount of discharge –most practical • Point-of-CareTests for Trichomonas • DNA probe for T.vaginalis, G. vaginalis (BV) and Candida sp. • Grams stain of urethral discharge in males

41. Lab Tests – Genital • Urine/vaginal GC and CT • Pharyngeal GC - NAAT or culture • Anal GC and CT - NAAT or culture • Dark field – no easily available

42. Nucleic Acid Amplification Tests (NAAT) FEMALES - Urine, Vagina, Cervix • GC – Sens 95-97% Spec 99 – 100% • CT – Sens 87 - 99% Spec 97 –100% MALES - Urine, Urethra • GC – Sens 100% Spec 97 – 100% • CT – Sens 90% Spec 97 –100%

43. NAAT GC/CT Pharynx - not been cleared by FDA*  • GC – Sens 72-84% Spec 99 – 100% Rectum -not been cleared by FDA * • GC – Sens 78-93% Spec 97 – 100% • CT – Sens 63 - 93% Spec 97 –100% * Unless the lab has established specifications for performance characteristics per CLIA

44. HPV testing • Women: - Not recommended > 30 years • Men: - Not recommended for genital warts - Not recommended in MSM

45. Lab Tests – Blood • RPR/EIA syphilis test • HIV • HBV screen for HBAsG – MSM • HCV in new HIV + or new unexplained elevated AST, ALT - MSM • HSV culture/ PCR - ulcer • HSV serology - ??

46. Role of HSV serology • Routine screening not recommended • To confirm clinical diagnosis with h/o lesions (typical and atypical) • Diagnose unrecognized infection • Diagnose asymptomatic infection during pregnancy • Manage sex partners of persons with genital herpes

47. Routine Screening – CTFemales who have sex with males Population-based approach • CT annually females < 25 years old – even if not engaging in high risk sexual behavior • Pregnancy • Exposure to CT past 60 days from an infected partner

48. Risk-factor Approach - GC • Annually when following risk factors: - Past h/o GC or Other STIs present - New or multiple partners - Inconsistent condom use - Commercial sex work - Drug use - Exposure to GC past 60 days from an infected partner

49. Vaginal Specimens in Females • Self-collected vaginal swabs are equivalent in sensitivity and specificity to those collected by a clinician 

50. Screening in Males- CT and GC Population-based Approach Males who have sex with females: • Annually in high prevalence settings • Correctional facilities, national job training programs, STD clinics, high school clinics, and urban adolescent clinics • Exposure to CT and GC past 60 days from an infected partner