Adolescents and Sexually Transmitted Infections – Part 2

Educational Objectives

The goal of this program is to improve management of sexually transmitted infections (STIs) in adolescents. After hearing and assimilating this program, the clinician will be better able to:

1. Identify risk factors for STIs in adolescents.
2. Counsel adolescents on strategies to reduce prevalence of STIs.
3. Perform a diagnostic workup for adolescents suspected to have STIs.
4. Develop management strategies for uncomplicated STIs.
5. Diagnose and treat sequalae of inadequately treated STIs.

Summary

Ulcerative diseases: differential diagnosis includes herpes simplex virus types 1 and 2 and syphilis; rare diseases include lymphogranuloma venereum and chancroid; viruses that are not sexually transmitted (eg, Epstein-Barr virus) can cause herpetic viral ulcerative disease in the genital area

Herpes simplex virus (HSV): single or multiple vesicles rupture to form shallow ulcers that are painful out of proportion to presentation; lesions heal without scarring; initial attack lasts 12 to 21 days; recurrences are milder in immunocompetent patients; HSV-1 and HSV-2 can present on any area of the body involved in sexual contact

Herpes simplex virus 2: incubation period is 7 to 12 days; first lesion is usually visible 4 days after exposure; appear as papular lesions that erode to shallow ulcers; swelling, inflammation, and adenopathy are significant for making diagnosis

Recurrence: has subtle appearance and may be asymptomatic; may appear as inflamed or eroded tissue that can be easily missed

Diagnosis: primarily made through history of underprotected sexual contact and physical findings; DNA amplification or PCR of the lesions are most sensitive tests; other less sensitive tests include Tzanck smear, culture in viral media, and serum antibodies/titers (nonspecific)

Treatment: first episodes — use acyclovir, valacyclovir, or famciclovir for 7 to 10 days until lesions are gone; recurrences — use higher doses of acyclovir or valacyclovir for shorter duration (start as soon as possible after symptoms appear); suppression of HSV recurrence — can reduce recurrence by ≤80% and reduce transmission to unaffected partner

Patient education: engage in discussion and answer all patient questions; explain the treatment protocol and expected outcomes; reassure patient that scars are unlikely; provide adequate pain control; explain that recurrence is likely and more frequent in the beginning; discuss strategies for the patient to discuss the condition with sexual partners; discuss asymptomatic viral shedding (particularly ≤1 yr after initial infection); obstetricians/gynecologists screen for HSV and have protocols for pregnant people with active lesions at the time of birth to reduce risk for perinatal transmission; educate on importance of barrier use to prevent transmission of HSV and other STIs; test for HIV and other STIs

Complications and sequelae: include neuralgia, ascending myelitis, meningitis, encephalitis, depression, and sexual dysfunction

Syphilis: has increased in all demographics and age groups; rates increased by ≈25% among adolescents 15 to 24 yr from 2014 to 2016; caused by Treponema pallidum (spirochete), which has an incubation period of 9 to 90 days (average 21 days)

Clinical presentation: primary syphilis — primary chancre occurs at site of inoculation; starts as a painless papule that erodes into an indurated ulcer, often without sensitivity; groin lymphadenopathy is often present; ulcer heals ≤6 wk and often goes unnoticed; secondary syphilis — occurs 6 to 8 wk after exposure; characterized by flu-like symptoms, eg, headache, lacrimation, nasal discharge, sore throat, joint pain, weight loss; skin rash appears on hands and feet; condylomata lata (secondary rash) may be present

Diagnosis: nontreponemal rapid plasma reagin (RPR) is highly sensitive (less specific) and typically given first; if positive, reflex testing with a treponemal test is given; some health care departments screen with the treponemal test first and then the nontreponemal test; dark field examination of chancre or condylomata lata identifies spirochete

Treatment: considered to be latent syphilis if infection was >1 yr ago; if chancre is visible, give single dose of intramuscular benzathine penicillin (2.4 million units); alternative protocols are available if benzathine penicillin is unavailable; for latent syphilis (4-fold increase in titer of previous RPR), benzathine penicillin is given weekly for 3 wk; refer to neurology or cardiology for evaluation of symptoms; repeat RPR at 6, 12, and 24 mo to ensure treatment success

Chancroid: rare and caused by Haemophilus ducreyi; clinical presentation includes single painful ulcer, erythematous halo, and unilateral adenopathy that forms buboes (inflamed abscess in the groin)

Human papillomavirus (HPV): HPV types 16 and 18 are high-risk variants that are responsible for ≈70% of HPV-related cancers; cause cervical inflammation and dysplasia; individuals infected with high-risk types should be monitored for progression but may not develop cancer; HPV types 6 and 10 are associated with genital warts; incubation period for skin-skin contact is 3 wk to 8 mo

Predisposing factors: include large number of sexual partners, conditions that affect immunity (eg, diabetes), other STIs, pregnancy, depression of cell-mediated immunity, and lack of HPV immunization

Vaccination: first dose is recommended at 10 yr; boys as young as 9 yr can be vaccinated; 9-valent vaccine includes high risk types; individuals 9 to 14 yr need 2 doses; individuals >15 yr need 3 doses if they have not started the series; vaccination was associated with decrease in cervical HPV infections by 71% and cervical precancers by 59%

Types of lesions: include classic soft sessile or pedunculated growths, small flat-topped warts, squared keratotic papules, and giant condyloma acuminata

Differential diagnosis of genital warts: pink pearly papules of the penis may appear as condyloma but are normal glandular tissue; Molluscum contagiosum are umbilicated small papules found in skin folds that can be passed through contact and water surfaces; condylomata lata are associated with secondary syphilis

Diagnosis: look at clinical appearance and location; perform Papanicolaou (Pap) test, colposcopy, biopsy; Pap test staging — corresponds with histologic changes in the epithelial tissue of the cervix; takes ≈5 yr to move from infection to cervical intraepithelial neoplasia (CIN) 2 or 3

Treatment of external condyloma: includes podophyllin or trichloroacetic acid, freezing agent, topical treatment (imiquimod or podofilox) for 16 wk, electrodessication, or laser

Prevention of STIs for adolescents: condom availability programs include high school distribution of condoms and free condoms from Departments of Public Health and federally funded family planning clinics; teach teenagers about condom negotiation with sexual partners

Readings

Suggested Readings

1. Auslander BA, Biro FM, Rosenthal SL. Genital herpes in adolescents. Semin Pediatr Infect Dis. 2005;16(1):24-30. doi:10.1053/j.spid.2004.09.008
2. Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, et al. Age of sexual debut among US adolescents. Contraception. 2009;80(2):158-162. doi:10.1016/j.contraception.2009.02.014
3. Cummings T, Zimet GD, Brown D, et al. Reduction of HPV infections through vaccination among at-risk urban adolescents. Vaccine. 2012;30(37):5496-5499. doi:10.1016/j.vaccine.2012.06.057
4. Mrug S, Elliott MN, Davies S, Tortolero SR, Cuccaro P, Schuster MA. Early puberty, negative peer influence, and problem behaviors in adolescent girls. Pediatrics. 2014;133(1):7-14. doi:10.1542/peds.2013-0628
5. Shannon CL, Klausner JD. The growing epidemic of sexually transmitted infections in adolescents: a neglected population. Curr Opin Pediatr. 2018;30(1):137-143. doi:10.1097/MOP.0000000000000578
6. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. doi:10.15585/mmwr.rr7004a1

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Ms. Bosnick's presentation includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.00 CE contact hours.

Lecture ID:

NP241003

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.