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One of the visible and sometimes not so visible consequences of adolescent sexuality is the presence of sexually transmitted infections. These diseases are among the many challenges and landmines along the way of the development of normal healthy adolescent sexuality. It is important for health care providers to be aware of the adolescents developing sexuality, as well as helping the teen to reduce their risks associated with that sexuality including STIs and pregnancy. Screening for sexually transmitted infections can be a critical part of an annual examination in this age group.
There is a significant disease burden of STIs among adolescents. For example, in 1998, in the United States , adolescents 15-19 had the highest gonorrhea and chlamydia rates among any age group - this is particularly true if you include only sexually active individuals. Chlamydia rates can vary from 3% up to 18% among adolescent women. T. vaginalis rates can be as high as 14% in adolescent women and 3% to 5% in asymptomatic males. Serologic studies show positivity rates for Herpes Simplex up to 30% in some adolescent groups, although most do not have symptomatic infections. The disease with the highest prevalence is most likely human papilloma virus infections. However, there is some good news in that that gonorrhea rates are falling globally (see graph below - although rates in the United States are well above those of Europe and Canada ).
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Incident rates are not equal in all groups as the graph below demonstrates the significantly higher rate of gonorrhea among African-American youth.
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It is often asked why should adolescents have higher rate of STIs. While all of the reasons are not known, one suggestion has to do with the anatomy of the adolescent cervix. As can be seen in the next slide, the adolescent cervix usually has a lot of ectropion. There is much columnar epithelium (dark red) in the ectocervix of teens. The columnar squamous junction tends to occur in the ectocervix area. With age and after pregnancies, there is much squamous metaplasia converting columnar epithelium to squamous epithelium. The junction moves more to the endocervix. Gonorrhea and chlamydia have a predilection for columnar cells so with more columnar epithelium in the vaginal vault, teens may be at higher risk for a infection.
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Other explanations include the substantial rates of sex partner infections, and inconsistent or incorrect condom use.
A major revolution in STI management has been the development of nucleic acid amplification tests (NAAT). These tests have superior sensitivity and specificity compared to culture or other diagnostic tests such as direct fluorescent antibody (DFA) or DNA probe tests. They also allow for testing of urine and vaginal specimens in addition to cervical or urethral specimens.
It is important to have an approach to sexually transmitted infections. Perhaps a more useful approach then going disease by disease is to look at the symptom complexes that can occur. These include:
- Cervicitis/urethritis
- Vaginitis
- Abdominal pain
- Genital ulcers
- Genital growths
- Hepatitis
- Arthritis
- Epididymitis
- Perinatal/fetal infections
The discussion presented will focus on the first five.
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Neinstein LS: Adolescent Health Care: A Practical Guide, 4 th edition, 2002, Philadelphia , Lippincott Williams and Wilkins
Chapters:
26: Genitourinary Tract infections:
LJD Angelo and LS Neinstein
55: Vaginitis and Cervicitis:
M Haward and MA Shafer
60: Overview of Sexually Transmitted Diseases,
JD Fortenberry and LS Neinstein
61: Gonorrhea:
PK Braverman and LS Neinstein
62: Chlamydia trachomatis:
MA Shafer and A Countouriotis
63: Pelvic Inflammatory Disease:
JR Pletcher and GB Slap
64: Syphilis:
JD Fortenberry and LS Neinstein
65: Herpes Genitalis:
LE Schack and LS Neinstein
66: Human Papillomavirus and Molluscum Contagiosum:
A Joffe and LS Neinstein
68: Minor Sexually Transmitted diseases:
MS Jay and LS Neinstein
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