STIs

Question 1

Epidemiology of STIs and Young People

Answer 1

• 19 million new cases per year: one half occur in people ages 15-24, most asymptomatic and undiagnosed
• new research: 1 in 4 teen has an STI
• 2006: one third of new infections were among people ages 13-29 (may be as high as 50%)
• economic costs- $17 billion/year

Question 2

Confidentiality and STIs

Answer 2

• confidentiality ensures better care
• ACOG ‘88 ( American College of Obstetrics and Gyn)
• Society for Adolescent Health and Medicine ‘92
• American Medical Association ‘92
• American Associated of Family Practititioners -89
• American Association of Pediatrics ‘89
• teenagers have the right to confidential care of STIs- diagnosis and treatment

Question 3

What is the differential diagnosis of dysuria (painful urination)

Answer 3

• urinary tract infection
• genital tract infection- cervicitis or vaginitis
• skin related abnormalities/ mucosal or perineal- herpes or trauma

Question 4

What additional information do you need in addition to dysuria symptom?

Answer 4

• onset and duration of symptoms
• description of symptoms
• associated symptoms: nausea/vomiting, fever/chills, abdominal pain, back pain, sores, lumps, bumps, dyspareunia (pain with sex)

Question 5

What are the Five Ps of Sexual History?

Answer 5

• Partners- Gender(s), Number (three months, lifetime)
• Prevention of pregnancy (Contraception, Emergency Contraception)
• Protection from STIs- Condom use
• Practices- Types of sex: anal, vaginal, oral
• Past history of STIs

Question 6

Female patient with history of dysuria, some vaginal itching, yellowish discharge, symptoms began a week ago. Several episodes of unprotected sex. DD?

Answer 6

• UTI- highly unlikely because symptoms don’t fit
• GTI- getting very likely with history
• Skin related problem- you’ll have to look on physical exam

Question 7

What is the differential diagnosis of vaginitis?

Answer 7

• trichomonas
• bacterial vaginitis
• candida vaginitis

Question 8

Trichomonas Infection

Answer 8

• Females: 50% symptomatic
• foul-smelling, frothy discharge, vaginal itching or redness, dyspareunia, urge to urinate and dysuria, post-coital bleeding, excessive or prolonged menses***
• strawberry cervix
• pH >4.5
• Male: most are asymptomatic and often missed
• if symptoms occur can present as NGU (non-gonococcal urethritis)
• consider trich in males with recurrent urethritis post adequate treatment

Question 9

Bacterial Vaginosis

Answer 9

• symptoms: odorous discharge, itching
• prevalence- found in 24-47% of STI clinic patients
• sequelae- pregnancy complications, possible increased in PID
• often positive KOH whiff test
• clue cells
• pH >4.5

Question 10

Candidiasis Symptoms

Answer 10

• Females: experience genital itching or burning, cottage cheese like discharge; fire-red tissue
• Males: itchy penile rash
• pH <4.5

Question 11

Trichomans Diagnosis

Answer 11

• Culture: Sensitivity 85-90%, Specificity 100%
• Antigen Detection: Sensitivity 83%, Specificity 97%, OSOM Rapid Test
• DNA Probe: Sensitivity 60-70%, Specificity: 100%, Affirm VP III
• Wet Mount: Senstivity 83%, Specificity 97%
• no good test for males so often unteted

Question 12

Candida Diagnosis

Answer 12

• largely a clinical diagnosis
• women can take themselves to any pharmacy and treat themselves
• DNA probe: Sensitivity 80%, Specificity 98%
• Wet Mount- Sensitivity 35-45, Specificity 97-99%

Question 13

Bacterial Vaginitis Diagnosis

Answer 13

• Amsel’s Criteria- Presence of at least 3/4
• whiff test positive for fishy or musty odor when alkaline KOH solution added to smear
• clue cells (bacteria attached to borders of epithelial cells, >20% of epithelial cells) (so gram stain is gold standard)
• vaginal pH > 4.5
• a homogenous non-inflammatory discharge

Question 14

Chlamydia Symptoms

Answer 14

• Females: Up to 75% asmymptomatic
• heavy or prolonged menses
• spotting
• dysmenorrhea
• dyspareuria
• vaginal discharge

-males: up to 50% asymptomatic- itchy penile rash

Question 15

Gonorrhea Symptoms

Answer 15

• Females: 50% are asymptomatic
• yellow or blood vaginal discharge
• painful urination
• dysmenorrhea

Males: up to 50% asymptomatic

• discharge from the penis with pain
• burning during urination
• swollen testicles

Question 16

Youth Risk Behavior Surveillance

Answer 16

• 43% of females and 45% of males have ever had sexual intercose
• 4% of females and 7% of males had sexual intercourse for the first time before age 13
• 14% of females and 15% of males had sexual intercourse with four or more persons during their life
• 35% of females and 33% of males had sexual intercourse within the last 3 months
• 40% of females and 30% of males did not use a condom during last sexual intercourse

Question 17

Diagnosing Cervicitis

Answer 17

• order Nucleic Acid Amplification Test- NAAT (GOLD STANDARD!)
• markedly amplifies target nucleic acids
• self collected vaginal swabs are preformed method unless the doctor is already doing a pelvic exam at cervical os
• all can be used on first 10-15 cc of urine specimens from men and women (must be >2 hours after last void)
• culture- used to be used for medical legal purposes

Question 18

What else do you do at STI visits?

Answer 18

• consider HIV and syphilis testing
• make sure vaccinated- Hep B and HPV
• counsel/ motivational interviewing about- protection against STIs, protection against pregnancy, consensual relationship