TABLE 3-16. COMMON SEXUALLY TRANSMITTED DISEASES IN ADOLESCENTS

TABLE 3-16. COMMON SEXUALLY TRANSMITTED DISEASES IN ADOLESCENTS
NAME	PATHOGENESIS	COMMON SYNDROMES	DIAGNOSIS	TREATMENT^a	COMMENTS
I. Bacterial
Neisseria gonorrhoeae (Gonorrhea) Gram (-) diplococcus ()	Genetic ability to frequently change antigenic surface structures	Uncomplicated Urethritis Endocervicitis Pharyngitis Proctitis Conjunctivitis Complicated Disseminated gonococcal infection PID Epididymitis	Male: Urethritis Gram stain [Gram (-) intracellular diplococci] Culture Female: Cervicitis Endocervical culture Gram stain but ↓ sensitivity DNA probe and NAATs applied to genital and FCU specimens^d	See Table 3-17^b	Many asymptomatic infections in men and women Screen all gonorrhea patients for syphilis, chlamydia; R/O HIV
Chlamydia trachomatis (Chlamydia) ()	Obligate intracellular bacteria that cause cell damage directly at end of their growth cycle and indirectly by stimulation of inflammatory host immune response	Uncomplicated Endocervicitis Urethritis Proctitis Conjunctivitis Complicated PID Pharyngitis Epididymitis	Male: Nongonococcal urethritis (NGU) Negative gonococcal culture and/or Gram stain ≥ 4 PMNs/oil (mean of 5 hpf × 1000×) immersion and no GNID Urethral culture (+) Nonculture tests Female: Endocervicitis Mucopus and/or ≥ 10-30 PMNs/hpf on Gram stain (confirm with specific chlamydia test) DNA probe and NAATs applied to genital and FCU specimens	See Table 3-17^b	Many asymptomatic infections in men and women; most common cause of urethritis in adolescent boys and cervicitis in adolescent girls
Treponema pallidum (Syphilis)	Enters through small abrasions in mucosa during intercourse and stimulates a local immune response and spreads hematogenously (secondary)	Primary: chancre Secondary: generalized skin rash especially palms and soles Early, late latent, and tertiary: rare in adolescents	Primary: treponemes on dark-field microscopy Secondary: VDRL or RPR, confirmed by FTA-ABS or MHA-TP	Benzathine^b Pen G: 2.4 × 10⁶ UI IM or, if penicillin allergy, Doxycycline 100 mg PO BID or Tetracycline 500 mg PO qid × 14 days	Screen with VDRL or RPR if contact history, at diagnosis of any STD, or in population with high syphilis rate; penicillin in pregnancy; screen for HIV.
II. Viral
Herpes simplex virus (HSV) HSV type 1 HSV type 2	Enters host through mucosa or abraded epithelium Replicates in host cell nucleus Predilection for sensory autonomic nerve cells Latency, reactivation states Host immune response related to disease severity	Genital herpes Primary (systemic) Recurrent (local) Vulvovaginitis Cervicitis Proctitis Penile lesions Urethritis Oropharyngitis	1. Based on symptoms and signs at presentation 2. HSV culture with fluorescent antibody	1. Primary: acyclovir 200 mg PO 5 × day for 7-10 days or until resolved 2. Recurrent: see CDC Treatment Guidelines	Infection in clinical presentation in adolescents often primary disease
Human papillomavirus (HPV)	Requires direct access to basal epithelial cells, eg, transformation zone of the cervix and active cellular replication to sustain viral replication which result in the cytohistologic manifestations	Condyloma acuminata Visible genital skin wart Subclinical HPV Flat condylomas invisible to unaided eye that occur anywhere in anogenital tract	Condyloma acuminata Visible inspection of genital skin Subclinical HPV Pretreat area—3% acetic acid wash Colposcopic (magnify) examination: dense, white areas: HPV HPV DNA detection (hybridization techniques)	Based on type, location, extent condyloma acuminata: TCA Podophyllin, liquid nitrogen TCA (85% trichloroacetic acid) Extensive/recalcitrant: topical 5-FU, interferon, laser Subclinical HPV (LGSIL/HGSIL): Refer for TCA, 5-FU, cryotherapy, laser, LEEP	Condyloma acuminata Liquid nitrogen: pain on application Podophyllin: systemic toxicity, teratogenicity precludes use on mucosa and pregnancy TCA: Safe with mucosa and pregnancy; local sensitivity LGSIL/HGSIL: Refer all patients with visible warts for evaluation and treatment
III. Fungal/protozoal
Candida albicans	Unclear mechanisms: Host factors Disease states Medications	Vulvovaginitis Balanitis	1. Symptoms of vulvovaginitis 2. Presence of pseudohyphae in KOH preparation or Gram stain (only 40% accurate) 3. Vaginal pH < 4.5 4. Culture prn	Clotrimazole,^b two 100-mg vaginal tablets hs for 3 doses or 500-mg vaginal tablet once	Controversy over diagnosis of disease when Candida present and asymptomatic
Trichomonas vaginalis	Unclear mechanisms: Host factors Local environment Asymptomatic carrier	Vaginitis Cervicitis Urethritis	1. Symptoms of vulvovaginitis 2. Vaginal pH > 5.0 3. Trichomonads (motile) on NaCl wet mount, PAP smear, direct culture, or by direct monoclonal antibody technique	Metronidazole: 2.0 g PO once (nonpregnant)^b or 500 mg BID for 7 days	Classic frothy yellow-green discharge found in only 12%, and "strawberry cervix" or punctate hemorrhages on exocervix seen in only 2%
^a Screen and treat all partners and encourage use of condoms.
^b STD treatment guidelines, Centers for Disease Control, 1993.
^c Other comparable medications include butoconazole, miconazole, tioconazole, and terconazole; most creams are oil-based and may weaken latex condoms; over-the-counter preparations are available, but self- medication by the adolescent is not encouraged because of the risk of other STDs causing symptoms.
^d NAATs = nucleic acid amplification tests, eg, ligase or polymerase chain reactions
FCU = first-catch urine (first 10-20 mL urine) 5-FU = 5-fluorouracil GNID = gram-negative intracellular diplococci LGSIL = low-grade squamous intraepithelial lesion HGSIL = high-grade squamous intraepithelial lesion LEEP = loop electrosurgical excision procedure

TABLE 3-16. COMMON SEXUALLY TRANSMITTED DISEASES IN ADOLESCENTS
NAME	PATHOGENESIS	COMMON SYNDROMES	DIAGNOSIS	TREATMENT^a	COMMENTS
I. Bacterial
Neisseria gonorrhoeae (Gonorrhea) Gram (-) diplococcus ()	Genetic ability to frequently change antigenic surface structures	Uncomplicated Urethritis Endocervicitis Pharyngitis Proctitis Conjunctivitis Complicated Disseminated gonococcal infection PID Epididymitis	Male: Urethritis Gram stain [Gram (-) intracellular diplococci] Culture Female: Cervicitis Endocervical culture Gram stain but ↓ sensitivity DNA probe and NAATs applied to genital and FCU specimens^d	See Table 3-17^b	Many asymptomatic infections in men and women Screen all gonorrhea patients for syphilis, chlamydia; R/O HIV
Chlamydia trachomatis (Chlamydia) ()	Obligate intracellular bacteria that cause cell damage directly at end of their growth cycle and indirectly by stimulation of inflammatory host immune response	Uncomplicated Endocervicitis Urethritis Proctitis Conjunctivitis Complicated PID Pharyngitis Epididymitis	Male: Nongonococcal urethritis (NGU) Negative gonococcal culture and/or Gram stain ≥ 4 PMNs/oil (mean of 5 hpf × 1000×) immersion and no GNID Urethral culture (+) Nonculture tests Female: Endocervicitis Mucopus and/or ≥ 10-30 PMNs/hpf on Gram stain (confirm with specific chlamydia test) DNA probe and NAATs applied to genital and FCU specimens	See Table 3-17^b	Many asymptomatic infections in men and women; most common cause of urethritis in adolescent boys and cervicitis in adolescent girls
Treponema pallidum (Syphilis)	Enters through small abrasions in mucosa during intercourse and stimulates a local immune response and spreads hematogenously (secondary)	Primary: chancre Secondary: generalized skin rash especially palms and soles Early, late latent, and tertiary: rare in adolescents	Primary: treponemes on dark-field microscopy Secondary: VDRL or RPR, confirmed by FTA-ABS or MHA-TP	Benzathine^b Pen G: 2.4 × 10⁶ UI IM or, if penicillin allergy, Doxycycline 100 mg PO BID or Tetracycline 500 mg PO qid × 14 days	Screen with VDRL or RPR if contact history, at diagnosis of any STD, or in population with high syphilis rate; penicillin in pregnancy; screen for HIV.
II. Viral
Herpes simplex virus (HSV) HSV type 1 HSV type 2	Enters host through mucosa or abraded epithelium Replicates in host cell nucleus Predilection for sensory autonomic nerve cells Latency, reactivation states Host immune response related to disease severity	Genital herpes Primary (systemic) Recurrent (local) Vulvovaginitis Cervicitis Proctitis Penile lesions Urethritis Oropharyngitis	1. Based on symptoms and signs at presentation 2. HSV culture with fluorescent antibody	1. Primary: acyclovir 200 mg PO 5 × day for 7-10 days or until resolved 2. Recurrent: see CDC Treatment Guidelines	Infection in clinical presentation in adolescents often primary disease
Human papillomavirus (HPV)	Requires direct access to basal epithelial cells, eg, transformation zone of the cervix and active cellular replication to sustain viral replication which result in the cytohistologic manifestations	Condyloma acuminata Visible genital skin wart Subclinical HPV Flat condylomas invisible to unaided eye that occur anywhere in anogenital tract	Condyloma acuminata Visible inspection of genital skin Subclinical HPV Pretreat area—3% acetic acid wash Colposcopic (magnify) examination: dense, white areas: HPV HPV DNA detection (hybridization techniques)	Based on type, location, extent condyloma acuminata: TCA Podophyllin, liquid nitrogen TCA (85% trichloroacetic acid) Extensive/recalcitrant: topical 5-FU, interferon, laser Subclinical HPV (LGSIL/HGSIL): Refer for TCA, 5-FU, cryotherapy, laser, LEEP	Condyloma acuminata Liquid nitrogen: pain on application Podophyllin: systemic toxicity, teratogenicity precludes use on mucosa and pregnancy TCA: Safe with mucosa and pregnancy; local sensitivity LGSIL/HGSIL: Refer all patients with visible warts for evaluation and treatment
III. Fungal/protozoal
Candida albicans	Unclear mechanisms: Host factors Disease states Medications	Vulvovaginitis Balanitis	1. Symptoms of vulvovaginitis 2. Presence of pseudohyphae in KOH preparation or Gram stain (only 40% accurate) 3. Vaginal pH < 4.5 4. Culture prn	Clotrimazole,^b two 100-mg vaginal tablets hs for 3 doses or 500-mg vaginal tablet once	Controversy over diagnosis of disease when Candida present and asymptomatic
Trichomonas vaginalis	Unclear mechanisms: Host factors Local environment Asymptomatic carrier	Vaginitis Cervicitis Urethritis	1. Symptoms of vulvovaginitis 2. Vaginal pH > 5.0 3. Trichomonads (motile) on NaCl wet mount, PAP smear, direct culture, or by direct monoclonal antibody technique	Metronidazole: 2.0 g PO once (nonpregnant)^b or 500 mg BID for 7 days	Classic frothy yellow-green discharge found in only 12%, and "strawberry cervix" or punctate hemorrhages on exocervix seen in only 2%
^a Screen and treat all partners and encourage use of condoms.
^b STD treatment guidelines, Centers for Disease Control, 1993.
^c Other comparable medications include butoconazole, miconazole, tioconazole, and terconazole; most creams are oil-based and may weaken latex condoms; over-the-counter preparations are available, but self- medication by the adolescent is not encouraged because of the risk of other STDs causing symptoms.
^d NAATs = nucleic acid amplification tests, eg, ligase or polymerase chain reactions
FCU = first-catch urine (first 10-20 mL urine) 5-FU = 5-fluorouracil GNID = gram-negative intracellular diplococci LGSIL = low-grade squamous intraepithelial lesion HGSIL = high-grade squamous intraepithelial lesion LEEP = loop electrosurgical excision procedure