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Chapter 3 Index
A. General
B. Skin
C.
Orthopedics
D.
Genitourinary:
--Hormonal
Contraception for Adolescents
--Dysmenorrhea
--Dysfunctional
Uterine Bleeding |
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Sexually Transmitted Diseases (STDs)
Reda Bassali, MD
Incidence: One of six
sexually active adolescents gets 1 STD a year.
Risk Factors: Alcohol the most associated with STDs;
multiple partners; drugs; no barriers.
Prevention and treatment: All sexually active adolescents
should have yearly exam. Many of the STDs can be asymptomatic and
need to be diagnosed on exam:
- females: pelvic exam with cultures and pap smear
- males: genital exam and urinalysis; if pyuria without bacteria,
consider STD
1. Vaginitis: Candida, Trichomonas Vaginalis, BV (Gardnerella), HSV
a. Candida Albicans: Colonization does not mean infection; 10-15%
of women colonized with this organism. Not necessarily sexually
transmitted.
- symptoms: itching with scant curd-like discharge;
area can be red or eroded
- diagnosis: KOH prep shows budding yeast; pH is
normal (3.5 to 4.5)
- treatment: Topical meds usually suffice:
Clotrimazole (Mycelex), Miconazole (Monistat 7), Terazole (once a day); if
too painful to treat topically, use oral Fluconazole (150 mg po once).
b. Bacterial Vaginosis (BV): (Gardnerella vaginalis, anaerobes, and
mycoplasma)
- incidence: 40-60% of sexually active adolescents
have this organism
- symptoms: thin discharge with fishy odor (positive
whiff test)
- diagnosis: Clue cells: > 20% epithelial cells
covered with rods; pH > 4.5
- treatment: Flagyl 500 mg BID x 7 days po (preferred)
or Flagyl 2 grams x 1 dose
c. Trichimonas Vaginalis: 10-15% are asymptomatic; very common
infection
- symptoms: itching, dysuria, frothy white discharge
- diagnosis: clinical: strawberry spots on red cervix
laboratory: wet prep: motile flagellated trichomonads; pH > 4.5
- treatment: Flagyl 2 gm po x 1 dose (do pregnancy
test on all prescribed this med). If infection is resistant, use Flagyl
250 TID. Always treat partner.
Clinical differentiation of these three causes of vaginitis:
| |
pH (nl 3.5-4.5) |
Itching |
Whiff test |
|
Candida |
Normal |
Yes |
No |
|
Trichomonas |
> 4.5 |
Yes |
Possible |
|
BV |
> 4.5 |
No |
Yes |
2. Cervicitis: caused by Gonorrhea, Chlamydia, HPV and Trichomonas,
HSV
a. Gonorrhea (Neisseria gonorrhea): Most common reportable infectious
disease in US
- symptoms: mucopurulent discharge, bleeding, dysuria,
proctitis, pharyngitis, and arthritis epididymitis, pustules.
- diagnosis: gram stain: gram negative intracellular
diplococci; culture; PCR replaced LCR: must use endocervical swab; results
in 2 days
- treatment: Rocephin (ceftriaxone) 125 mg IM or
Suprax (cefixime) 400 mg x 1. If disseminated disease: use Rocephin 1 gm
IV/day x 7-10 days.
Note: If patient is treated for GC, s/he should also be treated
for Chlamydia.
b. Chlamydia (Chlamydia Trachomatis):
- incidence: most common bacterial STD: up to 40% of
sexually active teenagers
- symptoms: 80% are asymptomatic; can have cervicitis
with d/c and bleeding some (8%) progress to PID/infertility/chronic pelvic
disease
- diagnosis: culture, fluorescent antibodies, ELISA,
PCR
- treatment: of choice: Azithromycin 1 gm x 1 dose;
doxycycline 100 mg BID
Note: even though treat all GC patients for Chlamydia, treat
only Chlamydia if make that diagnosis. Don’t reculture.
3. Viral STDs: HSV, HPV
a. Herpes Simplex: must differentiate between types 1 and 2: if
find 2: sexual abuse
- incidence: 75% are asymptomatic, but 35 million have
this infection in the US and there is a 90% recurrence of type HSV 2.
- symptoms: painful blisters, ulcers; can be systemic
with fever, myalgia, headache
- transmission: 85% of contacts will contract this
infection
- diagnosis: Tzanck prep: multinucleated cells;
fluorescent antibody test; culture
- treatment: Acyclovir 400 mg po TID x 7-10 days;
Local: sitz baths, lidocaine gel. Recurrent infection: Acyclovir 200-400
mg BID long-term (> 5 episodes/yr)
b. HPV (human papilloma virus):70 subtypes; types 16 and 18
associated with cervical ca
- incidence: fairly common, but no statistics available; present with
condylomas. 70 subtypes; types 16 and 18 associated with cervical cancer
- symptoms: warts associated with early sexual activity and with
multiple partners.
- diagnosis: presence of warts, pap smear can diagnose: squamous
intraepithelial lesions; (SIL) - formerly called cervical intraepithelial
neoplasia. (CIN)
- treatment: difficult: can use chemical treatments: podophyllin, acetic
acid, lasers; creams: aldara(imiquimod)
4. Pelvic Inflammatory Disease (PID) caused by many
different organisms: Gonorrhea, Chlamydia, Bacteroides, E. Coli,
Mycoplasma Hominis, Peptostreptococcus, Peptococcus, and Ureaplasma
Urealyticum): A clinical diagnosis
- symptoms: must have systemic symptoms along with
local symptoms: lower abdominal pain, increased vaginal discharge,
irregular bleeding, dysuria, emesis
- signs: marked adnexal tenderness (90%), fever,
cervical motion tenderness
- diagnosis: history and physical exam. If suspect a
tubo-ovarian abscess: ultrasound; Gold Standard if diagnosis is in doubt:
laparoscopy. Often confused with appendicitis; must always rule out
ectopic pregnancy (do pregnancy test on all PID patients)
- treatment: hospitalize all patients. Cefoxitin 2 gm
IV every 6 hours plus Doxycycline; If must treat as outpatient: Rocephin
250 IM + Doxycycline 100 po bid x 10-14d
- complications: Infertility: after one episode: 13%;
two: 50%; three episodes: 75%.
Rewritten 5/01
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