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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
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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
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TAKING A SEXUAL HISTORY
• Utilize a non-judgmental open manner
• Discuss confidentiality
• Avoid medical jargon
• 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?”
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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
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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
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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
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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
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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 4x/day for 7 days
• Abstinence for 7days after treatment and until all partners have
been treated
Treatment of sexual partners of last 60 days and most recent
partner if > 60 days
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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
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TREATMENT
• Ceftriaxone 250 mg IM Once PLUS Azithromycin 1
gm orally in a single dose
• Alternative
• Cefixime 400mg orally once
Also treat for CT due to the frequency of coinfection
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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
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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
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TREATMENT OF PID
• Ceftriaxone 250 mg IM PLUS Doxycycline 100mg
orally twice daily for 14 days
• May require hospitalization for severe symptoms or
to rule out a surgical emergency such as an
ectopic pregnancy
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DISEASE CHARACTERIZED BY
VAGINAL DISCHARGE
• Bacterial Vaginosis (BV)
• Trichomoniasis (trich)
• Vulvovaginal Candidiasis (yeast
infection)
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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
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TREATMENT
• Intravaginal creams or suppositories
• Oral Fluconazole
• Male partners do not need treatment if
asymptomatic
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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
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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”
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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
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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
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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)
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TREATMENT
• First Clinical Episode
• Acyclovir 400 mg orally TID for 7-10 days
• Episodic Therapy
• Acyclovir 400mg orally TID for 5 days
• Valacyclovir 500 mg BID for 3 days
• Suppressive therapy for recurrent genital herpes
• Valacyclovir 500mg to 1 gm orally once a day
• Acyclovir 400mg orally twice a day
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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
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COUNSELING POINTS (continued)
• The effectiveness of latex condoms to help reduce
(but not eliminate) transmission
• The risk of neonatal transmission
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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, anal, and oropharyngeal cancers
• Types 6 and 11 cause genital warts
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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
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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
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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
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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.
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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
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BARRIERS
• Lack of knowledge of STI’s
• Cost
• Inconvenient services, inability of student driving
themselves
• Shame
• Lack of understanding of confidentiality
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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
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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
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