Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine), 4th Ed.

CHAPTER 88. Sexually Transmitted Diseases

George T. Koburov

HIGH-YIELD FACTS

• Chlamydia and gonorrhea are most common among 15- to 19-year-old women.

• Throughout the United States, medical care for sexually transmitted diseases (STDs) can be provided to all adolescents without parental consent or knowledge.

• HIV screening is recommended for patients seeking STD treatment in all health care settings. The patient should be notified that testing will be performed unless the patient declines (opt-out screening).

• Oral antibiotics are no longer the treatment of choice for gonorrhea but rather ceftriaxone parenterally.

• Many STDs occur concurrently. Therefore, evaluate and treat the patient appropriately at the initial examination. Do not forget to recommend treatment for sexual partners.

STDs constitute a broad range of over 25 infectious organisms.1 These include bacteria, parasites, and viruses. The morbidity and economic impact to our health care system as a result of these infections is significant. It is estimated that almost 25% of female adolescents between the ages of 14 and 19 years are infected with a pathogen.1 Many infections go untreated as a result of the patient being asymptomatic, barriers to access of care, or the stigma associated with these disease processes. The National Institute of Health (NIH) referred to STDs as the hidden epidemic. “They are hidden from public view because many Americans are reluctant to address sexual health issues in an open way and because of the biological and social factors associated with these diseases.”2

STDs are also referred to as sexually transmitted infections (STIs). This distinction is made to indicate that often times these processes are not symptomatic, that is they don’t result in an apparent disease process, thus they are silent carriers of a contagious illness. This reinforces the recommendation for routine STD screening for sexually active individuals.

CHLAMYDIA

image ETIOLOGY

Chlamydia, caused by a bacterium Chlamydia trachomatis, is amongst the most common STDs.3 It is the most common treatable STD in the United States, occurring in 10% or more of sexually active adolescent female patients with increasing rates of reported disease since the late 1980s.4 The burden of disease is likely at least double the 1,412,791 cases reported to the CDC in 2011. The reported rate is two and a half times higher in females than males, likely a result of screening rates. There is a higher prevalence in African American adolescents as well as in patients of lower socioeconomic status. Approximately 33% to 45% of patients with gonorrhea are coinfected with C. trachomatis. Patients with chlamydial infections are at increased risk of acquiring HIV infection.5

image CLINICAL MANIFESTATIONS

Presentation of symptoms is variable, but many patients are asymptomatic. Vaginal discharge, mild abdominal pain, dysuria, urinary frequency, or postcoital/intermenstrual bleeding is observed in women. Physical examination reveals pyuria without bacteruria, cervical edema, erythema, easily induced cervical bleeding, and mucopurulent discharge. In men, symptoms include dysuria, urethral itching, or clear to whitish urethral discharge. Often, the discharge may be slight and noted as stained underwear in the morning resulting from minimal overnight discharge. Physical examination in men demonstrates meatal edema, erythema, and a whitish/clear discharge. Pyuria is common.6

image DIAGNOSIS

Culture of cervical swabs from women and urethral swabs in men for C. trachomatis remain the standard for diagnosis, but are labor-intensive and have variable sensitivity. It is still preferred for cases with medicolegal implications (i.e., sexual assault). When obtaining specimens, do not use swabs with a wooden shaft as wood may contain substances toxic to Chlamydia. For prepubertal female patients, vaginal rather than cervical specimens should be taken. Specificity for this test is virtually 100%.

Nucleic acid amplification tests (NAAT) have largely replaced culture as the screening test of choice. The sensitivity of this test is superior to culture while maintaining excellent specificity.7 Specimen sources can include urine, endocervix, and vaginal. There is increasing evidence that for patients with receptive rectal intercourse, a rectal swab utilizing NAAT is both sensitive and specific.8,9

Using NAAT for STD surveillance and confirmation in sexual assault has become more accepted.9,10 There is a growing consensus in the field of child sexual assault that two separate positive NAAT tests constitute a conclusive positive test.

image TREATMENT

Treatment in adolescents and adults is a single oral dose of azithromycin or a 7-day course of oral doxycycline. Other options include a 7-day course of erythromycin, ofloxacin, or levofloxin. For preadolescent children, treatment includes oral erythromycin for 14 days in children weighing less than 45 kg, a single dose of azithromycin in children weighing at least 45 kg but younger than 8 years, and a single oral dose of azithromycin or a 7-day course of oral doxycycline in children 8 years or older (Table 88-1). Given the risks of noncompliance, single dose therapy is generally preferable.11 As with all STDs, it is important to recommend that the patient should abstain from sexual activity for 7 days and that all sexual partners seek care.

TABLE 88-1

Summary Table of Sexually Transmitted Diseases

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HUMAN PAPILLOMAVIRUS (HPV) INFECTION

image ETIOLOGY

HPV infections are a common cause of STDs. It is estimated that over 50% of sexually active individuals will acquire infection at some point in their lives.12 HPV is associated with genital warts as well as genital cancers. This is a DNA-containing virus, which is spread by skin-to-skin contact, causing external growths in the perigenital and perianal areas.12 The incubation period is 1 to 6 months. Treatment may not eradicate the HPV infection and recurrences are common. Other common names for genital warts are condyloma acuminata, anogenital wart, verruca acuminata, and venereal warts. HPV serotypes 6 and 11 commonly cause external genital warts. Types 16 and 18 cause endocervical wart infections and may predispose to cervical cancer.12

The prevalence of HPV is approximately 1% of the entire adult population.6 Ten to twenty percent of sexually active women are infected annually. It is three times more common than genital herpes. Its occurrence is most common in 15- to 30-year-olds and equally common in men and women. Perinatal transmission of HPV also occurs.3,6

image CLINICAL MANIFESTATIONS

Genital warts are the most easily recognized sign of HPV infection. However, the majority of people are asymptomatic carriers of the infection. Pain, itching, irritation, and bleeding may occur depending on the size and location of the warts. Difficulties in urination and defecation have been reported secondary to their local obstructive effects. In female patients, physical examination may reveal lesions on the external genitalia, cervix, vaginal wall, urethra, or perianal region (Figs. 88-1 and 88-2). In male patients, lesions are noted in the subpreputial area, on the coronal sulcus or penile shaft, and in the urethra. The conjunctiva, nose, mouth, and larynx may also be affected.13 Intra-anal warts are seen predominantly in male and female patients who have had receptive anal sex. The appearance of external genital warts is variable. They may be soft, pink or gray, occurring in clusters; flat, papular, cauliflower-like clusters or pedunculated growths. Keratotic papules are genital warts that have a thick horny layer and may resemble common warts or seborrheic keratosis.13

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FIGURE 88-1. Perianal human papillomavirus. (Used with permission from Matthew Cox, MD.)

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FIGURE 88-2. Prepubertal human papillomavirus. (Used with permission from Matthew Cox, MD.)

Other conditions that may be confused with genital warts include pearly penile papules, molluscum contagiosum, Bowenoid papules, and condyloma lata. Bowenoid papules are usually flat-topped papules and associated with HPV type 16, which predisposes to genital neoplasia. Condyloma lata are flat warty lesions secondary to syphilis. Often, they are adjacent to the previous chancre site. An aspirate of this lesion will show spirochetes on dark-field microscopy. Serologic tests for syphilis will be positive.13

image DIAGNOSIS

Diagnosis is visual examination. Biopsy can be used to confirm the diagnosis. There are no commercially available serologic tests and the organism cannot be grown in culture. However, diagnostic testing should include evaluation for other STDs, including serologic testing for syphilis (VDRL and RPR).13,14

image TREATMENT

The patient should be referred to a specialist who can provide definitive care. It is estimated that in immunocompetent children, three-quarters of anogenital warts will resolve within months to a few years. If lesions persist beyond 2 years, it is less likely they will resolve without treatment.14 Several options are available. Options for self-treatment include podofilox, a keratolytic and antimitotic that is applied to external genital warts. It is not indicated for treatment of mucous membrane warts. Imiquimod is an immunomodulator that enhances the immune response to viral infections and tumors by inducing immune system cells, cytokine, and interferon. This also is indicated for the treatment of external genital warts in patients 12 years of age or older. Other treatment options requiring professional administration include cryotherapy, podophyllin, intralesional interferon alfa-2b, surgical removal, and laser therapy.

Genital warts in children should raise suspicion of sexual abuse. Increasingly, however, there is evidence that a significant number of prepubertal children with anogenital warts did not acquire them through sexual contact.15,16Genital warts in adolescents should prompt questioning as to whether sexual contact was forced. Genital warts during pregnancy may increase in size and are always referred to obstetrics/gynecology for treatment.

GONORRHEA

image ETIOLOGY

Gonorrhea is an infection in the epithelium of the urethra, cervix, rectum, pharynx, or eyes by Neisseria gonorrhoeae a gram-negative, kidney-shaped diplococci. It is second only to chlamydia in the number of STD cases reported to the CDC.17 The incidence is highest in urban areas in persons younger than 24 years of age with multiple sex partners. Nontreatment may lead to bacteremia and septic complications. Disseminated gonococcal bacteremia can manifest as pustular lesions on the hands and feet, tenosynovitis, and polyarthritis. It can also cause septic arthritis and endocarditis. In male patients, orchitis and epididymitis are seen.18 Resistance to N. gonorrhoeae has continued to increase in the United States. Quinolone resistance has increased to 13.3% in 2011.4

image CLINICAL MANIFESTATIONS

In female patients, symptoms begin 7 to 21 days postexposure. Eighty percent of women are asymptomatic. Symptoms described include vaginal discharge, dysuria, urinary frequency, and abdominal/pelvic pain. Gonococcal pharyngitis is usually asymptomatic in both sexes. Gonococcal proctitis, however, may be very painful with purulent rectal discharge, pain, itching, and rectal spasm. Skin lesions and arthritis may occur in disseminated gonococcal infection, occurring in both male and female patients. On examination, the cervix may be red and friable with a mucopurulent discharge. A purulent discharge may be seen from the urethra, Skene ducts, or Bartholin glands. Salpingitis is a common complication18 (Fig. 88-3).

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FIGURE 88-3. Prepubertal gonorrhea. (Used with permission from Matthew Cox, MD.)

In male patients, symptoms occur 2 to 14 days post exposure. Symptoms described include dysuria, urethral discharge, urinary frequency, and urgency as the disease spreads to the posterior urethra. Although symptoms usually present earlier in men, the asymptomatic period may last up to 45 days. On examination, a purulent yellow–green urethral discharge is noted. The meatus may appear red and swollen.19Rectal gonorrhea in both sexes may be asymptomatic, or appear with pain, painful defecation, and rectal discharge. Gonococcal pharyngitis from orogenital contact may be asymptomatic or painful. The oropharyngeal area may be reddened and purulent.19 In preadolescent children with gonococcal disease, vaginitis is the most common manifestation of infection. Sexual abuse is the most common cause. Parents may give a history of dysuria or staining on underpants. On examination, irritation, erythema of the vulva, or purulent vaginal discharge may be noted.20

image DIAGNOSIS

Traditionally, diagnosis is made by culture of the urethra (men) or endocervix (women), rectum, and pharynx for N. gonorrhoeae. This requires special media for culture. This is the only method to test antibiotic sensitivity. In children, culture is the standard for diagnosis, as usually legal implications are present. Over the last few years, NAAT testing has largely replaced culture and is recommended for screening and diagnosis of gonococcal infection.21NAAT testing is recommended for rectal and oropharyngeal infections although not FDA approved.8,21 It is also recommended to perform syphilis and HIV testing for high-risk patients such as those with multiple partners and exposure to intravenous (IV) drug use.22

image TREATMENT

Over the last several years there has been increasing resistance of N. gonorrhoeae strains to cephalosporins. As a result, the CDC has changed its recommendation for treatment to combination therapy. This consists of a 250 mg dose of cetriaxone intramuscular (IM) plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days.23 Treatment failures should have a traditional culture and sensitivity performed to ascertain optimal treatment. The dose for children weighing less than 45 kg is ceftriaxone 125 mg IM as a single dose. Children weighing 45 kg or more should be treated with the adult regimen. For disseminated gonococcal infection, the adult dosing regimen is ceftriaxone 1 g IV or IM every 24 hours, continue until improvement is seen. Alternative regimens include cefotazime or ceftizoxime 1 g IV every 8 hours. A single dose of azithromycin 1 g should also be given or alternatively doxycycline 100 mg twice a day for 7 days.23 For disseminated gonococcal infections in children, treatment is ceftriaxone 25 to 50 mg/kg/dose IV (125 mg max dose) every 12 hours for 7 days.24 Treat for 14 days for meningitis. For ophthalmia neonatorum, treatment is ceftriaxone 25 to 50 mg/kg/day as a single dose.12 Flouroquinolones have not been recommended for patients less than 18 years of age.12 As with all STDs, it is important that any sex partners within the past 60 days be referred for evaluation and treatment.

TRICHOMONIASIS

image ETIOLOGY

Trichomoniasis is caused by the flagellated protozoan parasite, Trichomonas vaginalis.25 The incubation period is 3 to 28 days. Eight million new cases are reported annually in North America.3 It accounts for up to one-third of vaginitis cases in the primary care setting.26 This STI tends to affect the lower genital tract in females (vulva, vagina, and urethra) and in males, the urethra.27 Women are more likely to be infected than males and in males the infection tends to be transient and often resolves within 10 days.28

image CLINICAL MANIFESTATIONS

Thirty to fifty percent of women are symptomatic. The classic presentation in women is frothy white or green foul-smelling thin vaginal discharge, pruritus, and erythema. These “classic” findings are found in fewer than 10% of symptomatic women.26 Abdominal pain, dyspareunia, and urinary urgency may also occur. On examination, the classic strawberry cervix and vulva are noted in 1% to 2%,29 in addition to a malodorous discharge. In male patients, the infection is often asymptomatic, but can produce urethritis.29

image DIAGNOSIS

The wet prep has been and largely remains the standard diagnostic technique. Diagnosis is made by viewing the flagellated organism on microscopy of saline preparations (wet prep) of vaginal discharge or urine. This has a sensitivity of 50% to 70%.26 Other available diagnostic tests include culture, nucleic acid amplification, and rapid antigen tests.26 Cultures often take days before results are available making it a less than desirable choice in the ED setting. NAAT and rapid antigen tests are available in less than 1 hour and many have excellent sensitivity and specificity.26 Comparatively, the sensitivity of a wet prep is significantly lower than these alternatives.

image TREATMENT

Metronidazole, 2 g orally as a single dose, is the standard of treatment. It is curative in 95% of the cases.12 It is safe in the second trimester of pregnancy. Treatment of the partner is necessary to prevent recurrence. An abstinence period of 1 week following the last dose of antibiotic is necessary. Treatment failures are retreated with metronidazole 500 mg twice daily for 7 days.12,30

SYPHILIS

image ETIOLOGY

Syphilis is caused by the spirochete Treponema pallidum. It is solely a human pathogen. Transmission is primarily from sexual activity and occurs via penetration through mucous membranes and abrasions on epithelial surfaces. It can also be acquired via placental transmission and blood transfusions.31 The average incubation time is about 3 weeks but ranges from 10 to 90 days. It is more common in men, particularly men who have sex with other men. In 2011, 72% of primary and secondary syphilis occurred among men who have sex with men.32 Tertiary syphilis develops in 8% to 40% of untreated patients over several decades following primary infection.3

image CLINICAL MANIFESTATIONS

Syphilis continues to cause considerable morbidity and facilitates HIV transmission.33 The primary lesion of syphilis is the chancre developing within 3 weeks after contact. Symptoms of syphilis in adults can be divided into stages.34 Chancres are usually round, painless, and firm ulcerations. These are seen primarily on the genitals, anus, or lips of affected individuals. Since they are painless they usually go unrecognized especially if they occur in the anus or vagina. During this primary stage, spirochetes can be isolated from the surface of the ulcer. Whether treated or not, healing of the chancre lesion occurs in 3 to 12 weeks. Commonly nontender bilateral inguinal/regional lymphadenopathy may be present.10 Figure 88-4 demonstrates a primary syphilitic penile chancre. Latent syphilis, defined as those patients without clinical manifestations, is detected by serological testing.3

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FIGURE 88-4. Primary syphilitic penile chancre. (Reproduced with permission from Centers for Disease Control Public Health Image Library.)

Secondary syphilis occurs anywhere from the time of the primary lesion healing to months after its resolution. It is characterized by the development of a rash and lymphadenopathy (Fig. 88-5). The rash is usually generalized, nonpruritic, maculopapular beginning on the trunk/arms and spreading to the palms and soles.35 Mucous membrane involvement includes oral lesions and condyloma lata (cauliflower-like growths that are infectious) usually occurring in the anogenital region (Fig. 88-6). Patchy alopecia may develop. Systemic symptoms of fever, malaise, anorexia, arthralgias, hepatitis, and generalized lymphadenopathy are described.32 As with primary syphilis, this stage will resolve with or without treatment. Without appropriate treatment, the infection will progress to the latent and possibly late stages of the disease.

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FIGURE 88-5. Exanthem of secondary syphilis. (Reproduced with permission from Centers for Disease Control Public Health Image Library.)

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FIGURE 88-6. Vaginal ulcer from secondary syphilis. (Reproduced with permission from Centers for Disease Control Public Health Image Library.)

Latent Syphilis The latent, or asymptomatic phase, may last from a few years to as many as 25 years. Affected patients may recall symptoms of primary and secondary syphilis. They are asymptomatic during the latent phase, and the disease is detected only by serologic tests.

Latent syphilis is divided into early and late. The early latent period is the first year after the resolution of primary or secondary syphilis. During this time, individuals are asymptomatic but still considered infectious. Late latency syphilis is generally not considered infectious; however, women in this stage can spread the disease in utero leading to congenital syphilis. These individuals are only identifiable by serologic testing. If untreated, patients may progress to the more destructive tertiary phase of syphilis.

Tertiary Syphilis Tertiary (late) syphilis is slowly progressive and may affect any organ. It is thought that about 15% of untreated individuals will progress to this stage.32 The disease is generally not thought to be infectious at this stage. Tertiary syphilis can affect virtually any organ including the skin, lungs, cardiovascular, central nervous system, ocular, and musculoskeletal.31,32 When the nervous system is affected it is referred to as neurosyphilis. Clinical manifestations include headache, dementia, problems with coordination, altered behavior, and movement disorders.

Congenital Syphilis Congenital syphilis is transmitted vertically, from a pregnant woman to her fetus. It is relatively rare with 377 cases reported in 2010.4 Infection results in a wide spectrum of disorders. Clinically, only the most severe cases are recognized at birth making prenatal screening imperative.

Early clinical findings usually become apparent by 3 months of age and include hepatomegaly, syphilitic rhinitis (snuffles), lymphadenopathy, and rash. Other symptoms may include fever, myocarditis, pneumonia, pseudoparalysis of Parrot (failure to move an extremity secondary to pain), ophthalmologic and gastrointestinal manifestations.36 Late congenital syphilis is characterized by facial features, interstitial keratitis, hearing loss, skeletal, dental (Hutchinson teeth), and cutaneous abnormalities.37 Diagnosis is usually made serologically with other options including dark-field microsopy and histopathologic examination.

image DIAGNOSIS

Diagnosis in the first or second stage is by dark-field and direct fluorescent antibody (DFA) of the treponemes from the chancre of condyloma lata or oral lesions. This technology is generally not available so it is rarely performed. Serologic tests include nontreponemal VDRL or RPR and treponemal FTA-ABS and treponemal enzyme and chemiluminescence immunoassays (EIA/CIA). Sensitivity is 78% for RPR and 86% for VDRL in primary syphilis and 100% in secondary syphilis.4 The recommended testing for syphilis is screening tests with “nontreponemal” assay (VDRL, RPR) and confirmation with the treponemal test.38 These tests become negative 1 year after treatment. The treponemal tests stay positive for life and do not correlate with disease activity.4

image TREATMENT

Penicillin G, administered parenterally, is the preferred drug for treatment of all stages of syphilis.12 Benzathine penicillin G 2.4 million units IM as a single dose remains the treatment of choice for the primary and secondary uncomplicated infections. Patients with latent or tertiary syphilis are also treated with Penicillin G although the duration and frequency is different. Doxycycline, tetracycline, and ceftriaxone remain alternatives (Table 88-1). Children with syphilis should have CSF examination to detect asymptomatic neurosyphilis. Treatment for children is benzathine penicillin G 50,000 units/kg IM up to the adult dose as a single injection (Table 88-1).12 Again, for latent and tertiary syphilis additional doses are required.12

HERPES SIMPLEX INFECTION

image ETIOLOGY

The herpes simplex virus (HSV) is the most common cause of genital herpes. The epidemiology is changing from a predominance of HSV type 2 to now approaching a 50:50 split between HSV 1 and HSV 2.35 HSV-1 is much less likely to be subclinical and recurrent outbreaks are uncommon. Thus, distinguishing the two types has an impact on the prognosis and counseling/education that a patient receives.5Nongenital infections of HSV-1 during childhood may be protective to some extent against subsequent genital HSV-2 infections in adults.35

image CLINICAL MANIFESTATIONS

Most individuals who become infected will be relatively asymptomatic and are never aware they have acquired a herpes infection. The incubation period is about 1 week. At that time, painful ulcers or vesicles may develop on the genitalia and anus. Tender inguinal lymphadenopathy and constitutional systemic symptoms of fever and myalgias may also develop. Dysuria, dyspareunia, and urinary retention may occur. Aseptic meningitis occurs in 30% of patients. Resolution occurs within 3 weeks with crusting of the ulcers. With recurrent infections, symptoms are milder4,12 (Figs. 88-7 and 88-8).

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FIGURE 88-7. Herpes simplex penile lesion in adult. (Used with permission from Matthew COX, MD.)

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FIGURE 88-8. Prepubertal herpes simplex. (Used with permission from Matthew COX, MD.)

image DIAGNOSIS

The diagnosis should be confirmed by viral culture. Glycoprotein specific antibody assays that identify antibodies to HSV glycoprotein G-1 and G-2, which evoke a type-specific antibody response, have been FDSA approved.11Point of care testing can provide results for HSV-2 antibodies from capillary blood or serum during a health care visit.3

image TREATMENT

Acyclovir, valacyclovir, and famciclovir are the antivirals recommended for treatment. Recurrence can be treated with episodic or suppressive approaches. Daily suppressive therapy has been shown to prevent 80% of recurrences (Table 88-1).3,5

HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED IMMUNODEFICIENCY DISEASE SYNDROME

image ETIOLOGY

Acquired immunodeficiency disease syndrome (AIDS) is caused by the human immunodeficiency virus (HIV). Modes of transmission include homosexuality, heterosexuality, bisexuality, IV drug use, needle sticks, blood transfusion before 1985, and maternal–neonatal transmission. It is estimated that there are 1.2 million individuals living with HIV in the United States. Of these, 240,000 do not know they are infected. Screening for HIV in patients presenting for evaluation of STDs is recommended.40 The majority of adolescents and adults infected remain asymptomatic for a median time period of 10 years.5 Viral replication continues during all stages of infection. Prompt diagnosis will allow early treatment and hopefully prevent further spread.

Most HIV infections in the United States are HIV-1. HIV-2 infections are endemic in West Africa. Therefore, risk factors of receiving blood transfusions, unsterile needle sticks, or sex partners from West Africa may alert the physician to perform appropriate testing.5

image CLINICAL MANIFESTATIONS

The disease spectrum is variable from primary infection, asymptomatic carrier, to AIDS with life-threatening complications. Fever, malaise, lymphadenopathy, and skin rash occur within several weeks of infection.5 Other manifestations include adenopathy, failure to thrive or weight loss, hepatosplenomegaly, opportunistic infections, and malignancies.

image DIAGNOSIS

The diagnosis is made with testing for antibodies against HIV-1 using EIA or rapid test, usually within half an hour. If positive, confirmatory testing with either western blot or immunoflourescence assay (IFA) is performed. Referral to a health care provider knowledgeable in HIV management is recommended. Combination testing for HIV-2 and HIV-1 variants is also available.5 Make sure to complete a thorough investigation for the etiology of fever, if it is a presenting symptom. It is recommended to perform testing for other STDs at this time as they can occur concomitantly.

image TREATMENT

Available retroviral medications include zidovudine, didanosine, zallcitabine, stravudine, indinavir, and ritonavir. However, newly diagnosed patients need to be referred to a specialist at this time for appropriate counseling, treatment strategy, and psychosocial evaluation.5 Up-to-date information is available online at http://aidsinfo.nih.gov/contentfiles/lvguidelines/ped_appb.pdf.

CLINICAL PRESENTATIONS OF STD

image GENITAL ULCERS

Both primary syphilis and herpes simplex will present with genital ulcers.

image URETHRITIS, EPIDIDYMITIS, AND CERVICITIS

Urethritis is the inflammation of the urethra, most commonly caused by N. gonorrhoeae and C. trachomatis. Other causes include Ureaplasma urealyticum and Mycoplasma genitalium, Trichomonas, herpes, and papillomavirus. Noninfectious causes may be symptoms of systemic diseases, topically applied agents, foods, and others that cause irritation.14

In men, dysuria, mucopurulent, or purulent penile discharge may be seen. Hematuria is uncommon. Women often are asymptomatic, but dysuria, urinary frequency, and vaginal discharge or cervicitis may exist.14 In men, finding gram-negative diplococci on Gram stain makes the diagnosis of gonococcal urethritis. Also consider use of nucleic acid amplification methods. Treatment should be per recommendations of STD guidelines outlined in Table 88-1.

Epididymitis is inflammation of the epididymis. Causative agents vary with patient age. The most common infectious etiologies in prepubertal boys are due to Escherichia coli or Hemophilus influenzae and in men younger than 35 years due to STDs (N. gonorrhoeae and C. trachomatis).15 Noninfectious causes include trauma, vigorous physical activity leading to an inflammatory response to sterile urine refluxing through the ejaculatory ducts and vas deferens into the epididymus.16 Scrotal pain may be dull or sharp. Swelling, edema, reactive hydrocele, a palpable abnormality or systemic signs of fever, and tachycardia may be identified.4,16 Testicular torsion must be first ruled out by Doppler ultrasound if indicated.

Laboratory diagnosis includes the presence of pyuria, bacteriuria, positive urine culture, and leukocytosis. The CDC recommends that evaluation of epididymitis in men is similar to the evaluation of urethritis including Gram stain of urethral secretions with >5 WBC/oil immersion field or positive leukoesterase on first-void specimen or first-void urine with >10 WBC/oil immersion field.3,5 Gonococcal infection is confirmed by finding gram-negative diplococci on the smear. Also consider use of nucleic acid amplification methods. Treatment should be as per recommendations of STD guidelines. Additionally, analgesia, rest, scrotal elevation, and warm tub baths to ease pain are recommended (Table 88-1).

Cervicitis, defined as inflammation of the cervix with a mucopurulent endocervical discharge, is most commonly caused by an STD. On speculum examination, a friable bleeding cervix, mucopurulent or purulent endocervical discharge is seen. Evaluate for STDs using culture or nucleic acid amplification testing.3,14 Treatment should be as per recommendations of STD guidelines (Table 88-1).

PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease (PID) refers to infection of the upper genital tract. Infection is usually due to C. trachomatis and N. gonorrhoeae. The infection ascends the female genital tract to involve the uterus, fallopian tubes, ovaries, and pelvic peritoneum leading to pelvic abscesses.17 The vaginal flora becomes infected resulting in a polymicrobial infection with facultative organisms such as E. coliBacteroides spp., anaerobic cocci, H. influenzae, Group A strep, M. hominis, and U. urealyticum. Therefore, treatment must be with broad-spectrum antibiotic coverage. Twenty to thirty percent of cases are in sexually active adolescents with the peak incidence in 15 to 24 year olds.17

The clinical presentation is with pelvic pain, vaginal discharge, abnormal uterine bleeding, dysuria, and dyspareunia. Some women are asymptomatic. Fever, mucopurulent endocervical discharge, adnexal and cervical motion tenderness on palpation are considered the “classic” examination findings.17,18

Diagnosis is difficult as the presentation is variable. Diagnostic criteria include fever >38.3°C (101°F), abnormal cervical or vaginal discharge, elevated ESR and C-reactive protein, confirmed gonococcal or chlamydial infection of the cervix, saline microscopy of vaginal fluid with increased WBCs. Definitive criteria for diagnosis include ultrasound showing tubo-ovarian abscess, laparoscopic abnormalities consistent with PID, or endometrial biopsy.5,12,40Ectopic pregnancy must always be excluded.

Oral antibiotics are recommended for mild to moderately severe acute PID. Patients usually respond within 72 hours. Outpatient oral treatment recommended by the CDC is a single dose of a third-generation cephalosporin (ceftriaxone or cefoxitin) plus oral doxycycline plus oral metronidazole to complete a 14-day course.1240

image RECOMMENDED REGIMEN

Ceftriaxone 250 mg IM in a single dose

PLUS

Doxycycline 100 mg orally twice a day for 14 days

WITH or WITHOUT

Metronidazole 500 mg orally twice a day for 14 days

OR

Cefoxitin 2 g IM in a single dose and probenecid, 1 g orally administered concurrently in a single dose

PLUS

Doxycycline 100 mg orally twice a day for 14 days

WITH or WITHOUT

Metronidazole 500 mg orally twice a day for 14 days

OR

Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)

PLUS

Doxycycline 100 mg orally twice a day for 14 days

WITH or WITHOUT

Metronidazole 500 mg orally twice a day for 14 days

Inpatient treatment is reserved for patient presenting with high fever, ill appearing, patients with uncertain diagnosis (i.e., appendicitis), those who cannot tolerate or comply with oral medication, failed outpatient management, and pregnancy or tubo-ovarian abscesses. Parenteral management includes cefotetan or cefoxitin plus oral or intravenous doxycycline. An alternative treatment option is clindamycin plus gentamicin. IV treatment is continued until there is clinical improvement for 24 hours, then switch to an oral outpatient regimen.5,12

REFERENCES

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