Use every episode of care with adolescent patients to assure genital health
Use every episode of care with adolescent patients to assure genital health: Excerpt from Avoiding Common Pediatric Errors
Author:
Madan Dharmar, MD
What to Do - Gather Appropriate Data
Adolescence is an important developmental period with regard to sexuality
andsexualbehavior.Adolescentsareatincreasedriskforsexuallytransmitted
diseases(STD)foravarietyofseveralbehavioralandbiologicalfactors.Ageat
first intercourseand timebetweenmenarche and firstintercourse, number of
sexualpartners,partnerswithmultipleotherpartners,inconsistentprotected
sex, and alcohol and drug abuse are some of the behavioral factors associated
with increased STDs in adolescents. Cervical ectopy or cervical immaturity
and low levels of secretary immunoglobulin A (IgA) in adolescent females
make them more susceptible to STDs.
When addressing the issue of STDs in adolescents, unique factors such
as consent for diagnosis and treatment, confidentiality, parental notification,
and mandatory reporting of sexual activity need to be kept in mind. Several of these issues, including behavioral and biological factors, should be
addressed by clinicians who provide services to adolescents. Clinicians can
also address the lack of knowledge and awareness about the risks and consequences of STDs and offer guidance, constituting true primary prevention,
to help adolescents develop healthy sexual behaviors and prevent patterns of
behavior that can undermine sexual health.
AssessingSexualHealthinanAdolescent: Clinicalpreventiveservicesprovided during an office visit must include screening for sexual behavior that
may result in unintended pregnancy and STD, and screening for STDs in a
sexually active patient. A great proportion of adolescents are not evaluated
for risk of acquiring STDs during their office visit. Owing to an increased
incidenceof someSTDs in adolescents,it is important for cliniciansto assess
the individual's sexual activity. Presenting symptoms and signs in a patient
can be useful for obtaining relevant history and appropriate examination
and tests to diagnose STDs. Common presentations of STDs are vaginal/
urethral discharge, skin lesions, genital ulcers, and pelvic inflammatory disease (PID).
Chlamydia Infection in Adolescents: The incidence of Chlamydia is highest among adolescent females aged 15 to 19 years. Though the number of
Chlamydiacasesreportedannuallyisincreasing,mostcasesareundiagnosed.
Chlamydia is a bacterial infection transmitted sexually. Chlamydia is more
commonly found in women than men, and is highest among adolescent females aged 15 to 19 years. The two most important risk factors are the age
of the woman (i.e., adolescent) and a risk of multiple sexual partners. Chlamydia infection is usually asymptomatic. Due to underdiagnosis and lack of
treatment, chlamydial infections can cause severe health consequences for
women, including PID, ectopic pregnancy, and infertility. Symptomatic patients present with vaginal discharge, poorly differentiated abdominal pain,
and increased frequency of urine and dysuria. Screening for chlamydial infection requires a pelvic examination that is usually uncomfortable, and is
considered a barrier for screening adolescents. Urine testing for Chlamydia
infection is more acceptable to patients and because of its ease of implementation,ismorelikelytodetectagreaternumberofcasesofPIDandinfertility.
Antibiotic therapy is curative for Chlamydia infection. Repeated acquisition
of STDs is common, with up to 40% of the annual incidence of chlamydial
or gonococcal disease occurring in adolescents previously infected with the
causative organisms. Many adolescents are re-infected within a few months
of an index infection. Annual screening for Chlamydia is recommended.
Vaginal discharge is the most common presenting symptom in STDs. It
canbeeitherphysiologicalorpathologicinorigin.Candidiasis,Trichomonas,
and bacterial vaginosis are three most common pathologic causes for vaginal discharge in adolescents. Trichomonas infection is classically associated
with a greenish-yellow purulent discharge; candidiasis with a thick, white,
adherent, "cottage cheeselike" discharge; and bacterial vaginosis with a thin,
homogeneous, "fishy smelling" gray discharge. Urethral mucopurulent discharge is a common presentation of gonorrhoeae. Skin lesions are commonly
caused by human papillomavirus (genital warts). Genital herpes is the most
common cause for genital ulcers in adolescents and are usually associated
with other genital lesions. Primary syphilis should also be considered in
adolescent patients involved in high-risk sexual behavior.
Suggested Readings
Anderson MR, Klink K, Cohrssen A. An evaluation of vaginal complaints. JAMA.
2004;291(11):1368–1379.
Centers for Disease Control and Prevention. STD Surveillance 2005. Centers for Disease Con
trol and Prevention. www.cdc.gov/std/stats/. Accessed December 18, 2007.
Ford CA, Best D, Miller WC. The pediatric forum: confidentiality and adolescents' will
ingness to consent to sexually transmitted disease testing. Arch Pediatr Adolesc Med.
2001;155(9):1072–1073.
Fortenberry JD. Adolescent substance use and sexually transmitted diseases risk: a review.
J Adolesc Health. 1995;16(4):304–308.
Halpern-Felsher BL, Ozer EM, Millstein SG, et al. Preventive services in a health maintenance
organization: how well do pediatricians screen and educate adolescent patients? Arch Pediatr
Adolesc Med. 2000;154(2):173–179.
McCormack WM, Rosner B, McComb DE, et al. Infection with Chlamydia trachomatis in
female college students. Am J Epidemiol. 1985;121(1):107–115.
Shafer MA, Pantell RH, Schachter J. Is the routine pelvic examination needed with the advent of urine-based screening for sexually transmitted diseases? Arch Pediatr Adolesc Med.
1999;153(2):119–125.
ShewML,FortenberryJD,MilesP,etal.Intervalbetweenmenarcheandfirstsexualintercourse,
related to risk of human papillomavirus infection. J Pediatr. 1994;125(4):661–666.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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