Cervicitis and Sexually Transmitted Infections in the Adolescent ...

Weber-LaShore and Biro
If there is a high rate of gonorrhea in the
patient population, concurrent treatment for
gonorrhea should be considered. All sexual
partners within the previous 60 days require
treatment. Performing a test of cure is not
recommended for nonpregnant adolescent
females. However, due to the high rate of reinfection,
a repeat test is recommended 3 to 5
months after treatment.
GONORRHEA
Gonorrhea, caused by the bacteria Neisseria gonorrhoeae
(GC), is the second most commonly
reported STI in the United States. In 2006, there
were more than 358,000 cases of gonorrhea
reported, which is believed to represent about
half of the actual cases that year. 3 Similar to chlamydia,
gonorrhea is prevalent in the adolescent
population and disproportionally affects minority
groups. The rate of gonococcal infections in
black women is 18 times higher than in white
women. 3 Symptoms associated with infections
include vaginal discharge, dysuria, metrorrhagia
and postcoital bleeding. A significant number of
gonorrheal infections are asymptomatic and if
untreated can develop into PID, and rarely, disseminated
GC.
The USPSTF recommends annual screening of
all women 25 years old and younger. 7 Screening
options include culture, nucleic acid hybridization
test, and NAAT. Again, either cervical swab
or urine can be used as the specimen for NAAT.
In 2006, more than 13% of gonorrhea isolates
showed resistance to fluoroquinolones and thus,
that class of antibiotics has been removed as a
recommended treatment option. 8 The current
CDC recommended treatment options are ceftriaxone
125 mg IM–single dose, or cefixime
400 mg orally–single dose.
Patients with gonorrhea are often also infected
with chlamydia, and thus dual treatment might
be warranted. If a NAAT test was performed and
is negative for chlamydia, there is no need to
treat for chlamydia. However, if a non-NAAT test
was negative for chlamydia, or a test for chlamydia
was not done, then the patient should also
receive treatment for chlamydia. 6 Sex partners
also require treatment. There is no recommendation
as to whether a patient should be tested
for re-exposure after initial treatment.
TRICHOMONIASIS
Trichomonas vaginalis is a protozoan characterized
by flagellated motility. An estimated 7.4 million
cases are seen annually in the United States. 1
Rate per 100,000 sexually active women
7,000
6,000
5,000
4,000
3,000
2,000
1,000
0
1,409
6,224
Infection with trichomoniasis
has been shown to increase
the risk of HIV transmission.
Patients may complain of a
vaginal discharge that is often
frothy and yellow-greenish in
nature with an odor. They may
also have vaginal irritation, dysuria,
and dysparunia. On exam,
small red ulcerations in the
vagina or on the cervix (strawberry
cervix) may be seen. The
vaginal pH is usually >5.
Trichomoniasis can be diagnosed
by viewing the motile
trichomonads from the vaginal
secretions on a wet prep. It
681
3,143
15-19 20-24 25-29
Age group (y)
can also be detected by performing the rapid
trichomoniasis test (results available in 10
minutes), or by performing the Affirm VP III
test (results available in 45 minutes). The most
sensitive and specific method of diagnosis of
trichomoniasis is by performing a culture. 6 The
recommended treatment options are metronidazole
2gm orally–single dose, or tinidazole
2 gm orally–single dose.
Patients should be instructed to avoid alcohol
for 24 hours after taking metronidazole or
for 72 hours after taking tinidazole to prevent a
disulfiram-like reaction. No follow-up is necessary
for patients who were initially asymptomatic
or who became asymptomatic after
treatment. Sex partners should also be treated
to prevent reinfection.
GC
CT
1,189
307
FIGURE. CDC 2006 sexually transmitted diseases surveillance: gonorrhea
and chlamydia rates.
GC = gonococcus; CT = chlamydia trachomatis.
FOCUSPOINT
The majority
of chlamydial
infections are
asymptomatic,
a fact not known
by most
adolescents.
The Female Patient | VOL 34 JUNE 2009 35