Sexually Transmitted Diseases E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: GIP - Gynaecology in Practice
- Sprache: Englisch
Sexually Transmitted Diseases present a major public health challenge. Over 25 diseases can be transmitted through sexual activity, and effective treatment, especially where long term infection can lead to further health problems, and in women infertility, requires good diagnostic skills and understanding of the best treatment methods. This book aims to give a practical guide to diagnosis and treamtent in a patient-centred framework, with care at the heart of the book.
The aim of the Gynecology in Practice Series is to provide a clinical 'in the office' or 'at the bedside' guide to effective patient care for gynecologists. The tone will be practical, not academic. The working assumption is that readers want to know what (and what not) might or should be done, without over emphasis on the why. That said, it is important to review the crucial basic science necessary for effective diagnosis and management, and to provide reminders in the context of the practical chapters.
The books will not be heavily referenced, in line with a more practical approach. This allows for smoother reading (and also relieves the burden of comprehensive citing from authors). Key evidence (clinical trials, Cochrane or other meta analyses) should be summarized in 'Evidence at a Glance' boxes and key references such as reviews, major papers can be provided in the 'selected bibliography' at the end of each chapter.
Practical guidance will be provided through:
- the use of algorithms and guidelines where they are appropriate
- 'Tips and Tricks' boxes – hints on improving outcomes perhaps via practical technique, patient questioning etc
- 'Caution' warning boxes – hints on avoiding problems, perhaps via contraindications
- 'Science Revisited' – quick reminder of the basic science principles necessary for understanding
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Seitenzahl: 424
Veröffentlichungsjahr: 2012
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Contents
Cover
Title Page
Copyright
Dedication
List of Contributors
Series Foreword
Preface
Chapter 1: Standard Clinical Evaluation
Introduction
Clinical Evaluation
Conclusion
Chapter 2: Specific Considerations for Pediatric and Adolescent Patients
Introduction
The Physical Examination
Vaginal Discharge in Prepubertal Girls
Sexual Assault in Children and Adolescents
Adolescent Testing for N. Gonorrheae, C. Trachomatis, and Other Vaginitis
Management of Specific Prevalent Infections
Conclusion
Bibliography
Chapter 3: Cervicitis and Pelvic Inflammatory Disease
Introduction
Pathophysiology
Diagnosis
Treatment
Sequelae
Prevention
Bibliography
Chapter 4: Genital Herpes Simplex Infections in Women
Epidemiology
Pathophysiology
Clinical Presentation
Management of Genital Herpes
Counseling
HSV in Pregnancy
Bibliography
Chapter 5: Syphilis Infection in Women
Epidemiology
Clinical Presentation
Diagnosis
Treatment
Response to Therapy
Partner Management
Special Cases
Summary
Bibliography
Chapter 6: Chancroid and Lymphogranuloma Venereum
Chancroid (Haemophilus Ducreyi)
Lymphogranuloma Venereum
Bibliography
Chapter 7: Bacterial Vaginosis
Introduction
Clinical and Microbiologic Characteristics of BV
Complications Associated With BV
Diagnosis
Recurrent BV
Prevention of BV
Conclusion
Bibliography
Chapter 8: Trichomonas Vaginalis
Introduction
Epidemiology and Risk Factors
Pathology
Clinical Presentation
Diagnosis
Management
Conclusion
Bibliography
Chapter 9: Vulvovaginal Candidiasis, Desquamative Inflammatory Vaginitis, and Atrophic Vaginitis
Introduction
Candida Vulvovaginitis
Atrophic Vaginitis
Desquamative Inflammatory Vaginitis (DIV)
Pathogenesis
Bibliography
Chapter 10: Human Papillomavirus
HPV the Virus
HPV Oncogenic Potential for Cervical Disease
Recurrent Respiratory Laryngeal Papillomatosis
Natural History of HPV Infection
Immunology
Vulvar and Vaginal Cancers
Anal Cancer
Bibliography
Chapter 11: Ectoparasites: Pediculosis Pubis and Scabies
Pediculosis Pubis
Scabies
Bibliography
Chapter 12: Dermatological Conditions and Noninfectious Genital Ulcers
Introduction
Symptoms and Evaluation
Patient Concerns
Medications for Vulvar Disorders
Specific Conditions
Summary
Bibliography
Chapter 13: Vulvodynia
Introduction
Background and Nomenclature
Incidence
Etiology
Diagnosis
Treatment
Vestibulectomy
Conclusion
Bibliography
Chapter 14: Vulvar Cancer
Introduction
Epidemiology
Clinical Evaluation and Staging
Anatomy/Pattern of Spread
Treatment
Prognosis
Summary
Bibliography
Chapter 15: Different Manifestations and Implications of Sexually Transmitted Infections and Vagnitides in Pregnancy
Introduction
Sexually Transmitted Infections
Bibliography
Chapter 16: Treatment of Sexually Transmitted Infections in Pregnancy
Introduction
Genital Herpes
Syphilis
Gonorrhea
Chlamydial Infections
Human Papillomavirus
Trichomonas Infections
Bacterial Vaginosis
Summary
Bibliography
Chapter 17: Prevention of Sexually Transmitted Diseases
Background
Conceptualizing Prevention
STD Prevention Counseling
Prevention Methods
Special Populations
Women Who have Sex with Women
Conclusions
Bibliography
Index
This edition first published 2012, © 2012 by John Wiley & Sons, Ltd.
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Library of Congress Cataloging-in-Publication Data
Sexually transmitted diseases / edited by Richard H. Beigi.
p. ; cm. – (Gynecology in practice)
Includes bibliographical references and index.
ISBN 978-0-470-65835-2 (pbk. : alk. paper)
I. Beigi, Richard H. II. Series: Gynecology in practice.
[DNLM: 1. Sexually Transmitted Diseases–diagnosis. 2. Sexually Transmitted Diseases–therapy. WC 140]
616.95′1–dc23
2012002551
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
This book is dedicated to all of my excellent mentors and to my family for their ongoing support.
List of Contributors
Richard H. Beigi, MD, MSc
Department of Obstetrics, Gynecology and Reproductive Sciences,
Magee-Womens Hospital of the University of Pittsburgh Medical Center
Pittsburgh, PA 15213, USA
Carolyn Gardella, MD, MPH
Department of Ob/Gyn
Division of Women's Health
University of Washington
Box 356460
Seattle, Washington 98195-6460, USA
Suzanne M. Garland
Department of Microbiology and Infectious Diseases, The Royal Women's Hospital,
Parkville, Victoria 3052, Australia
Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
Murdoch Children's Research Institute, Parkville, Victoria, Australia
Alice Goepfert, MD
Professor
Department of Obstetrics and Gynecology
Division of Maternal-Fetal Medicine
619 19th Street South, 176F 10270N
Birmingham, AL 35249-7333, USA
Ravi Gunatilake
Duke University Hospital
Durham, North Carolina, USA
R. Phillip Heine
Duke University Hospital
Durham, North Carolina, USA
Lisa M. Hollier, MD, MPH
Professor, Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Sciences
University of Texas Houston Medical School
LBJ General Hospital
5656 Kelley Street
Houston, TX 77026, USA
Katherine M. Holman, MD
Instructor
Department of Medicine
Division of Infectious Diseases
University of Alabama at Birmingham
1900 University Blvd, THT 229
Birmingham, AL 35294, USA
Oluwatosin Jaiyeoba, MD
Department of Obstetrics and Gynecology
Medical University of South Carolina
Charleston, South Carolina, USA
Noor Niyar N. Ladhani, MD MPH FRCSC
Fellow, Maternal Fetal Medicine
University of Toronto
Toronto, Canada
2108-1055 Bay St
Toronto, Ontario M5S 3A3, Canada
Eduardo Lara-Torre, MD, FACOG
Associate Professor of Obstetrics and Gynecology
OBGYN Residency Program Director
Virginia Tech Carilion School of Medicine
1906 Belleview Ave
Roanoke, VA 24014, USA
Tracy L. Lemonovich, MD
Instructor of Medicine, Division of Infectious Disease and HIV Medicine
University Hospitals Case Medical Center, Case Western Reserve University
11100 Euclid Ave, Cleveland, OH 44106, USA
Silvia T. Linares, MD
Assistant Professor
Department of Obstetrics, Gynecology & Reproductive Sciences
University of Texas Houston Medical School
LBJ General Hospital
5656 Kelley Street
Houston, TX 77026, USA
Jeanne M. Marrazzo, MD, MPH
Professor of Medicine, Division of Allergy & Infectious Diseases
Harborview Medical Center, Division of Infectious Diseases
325 Ninth Avenue, Mailbox #359932
Seattle, WA 98104
And
Medical Director, Seattle STD/HIV Prevention Training Center
University of Washington, Seattle, WA, USA
Michelle H. Moniz, MD
Department of Obstetrics, Gynecology and Reproductive Sciences,
Magee-Womens Hospital of the University of Pittsburgh Medical Center
Amber Naresh, MD, MPH
Department of Obstetrics, Gynecology & Reproductive Sciences
Division of Reproductive Infectious Diseases
University of Pittsburgh
300 Halket Street
Pittsburgh, PA 15213, USA
Robert A. Salata, MD
Professor of Medicine, Division of Infectious Disease and HIV Medicine
University Hospitals Case Medical Center, Case Western Reserve University
11100 Euclid Ave, Cleveland, OH 44106, USA
Ashlee Smith, DO
Gynecologic Oncology Fellow
300 Halket Street
Magee-Womens Hospital
Division of Gynecologic Oncology
Pittsburgh, PA 15213, USA
Jack D. Sobel, MD
Division of Infectious Diseases Harper University Hospital 3990 John R
Detroit, MI 48201, USA
David E. Soper, MD
Medical University of South Carolina
Department of Obstetrics and Gynecology
96 Jonathan Lucas Street, Suite 634
P.O.Box 250619, Charleston, SC 2942, USA
Glenn Updike, MD, MMM
Assistant Professor
Department of Obstetrics, Gynecology, and Reproductive Sciences
University of Pittsburgh
Suite 0892
Magee-Womens Hospital
300 Halket Street
Pittsburgh, PA 15232, USA
Mark H. Yudin, MD MSc FRCSC
Associate Professor, University of Toronto, Department of Obstetrics and Gynecology
Attending Physician, St. Michael's Hospital, Department of Obstetrics and Gynecology
Toronto, Canada
30 Bond Street
Toronto, Ontario M5B 1W8, Canada
Kristin K. Zorn, MD
Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences
300 Halket Street
Magee-Womens Hospital
Division of Gynecologic Oncology
Pittsburgh, PA 15213, USA
Series Foreword
In recent decades, massive advances in medical science and technology have caused an explosion of information available to the practitioner. In the modern information age, it is not unusual for physicians to have a computer in their offices with the capability of accessing medical databases and literature searches. On the other hand, however, there is always a need for concise, readable, and highly practicable written resources. The purpose of this series is to fulfill this need in the field of gynecology.
The Gynecology in Practice series aims to present practical clinical guidance on effective patient care for the busy gynecologist. The goal of each volume is to provide an evidence-based approach for specific gynecologic problems. “Evidence at a glance ” features in the text provide summaries of key trials or landmark papers that guide practice, and a selected bibliography at the end of each chapter provides a springboard for deeper reading. Even with a practical approach, it is important to review the crucial basic science necessary for effective diagnosis and management. This is reinforced by “Science revisited” boxes that remind readers of crucial anatomic, physiologic or pharmacologic principles for practice.
Each volume is edited by outstanding international experts who have brought together truly gifted clinicians to address many relevant clinical questions in their chapters. The first volumes in the series are on Chronic Pelvic Pain, one of the most challenging problems in gynecology, Disorders of Menstruation, Infertility, and Contraception. These will be followed by volumes on Sexually Transmitted Diseases, Menopause, Urinary Incontinence, Endoscopic Surgeries, and Fibroids, to name a few. I would like to express my gratitude to all the editors and authors, who, despite their other responsibilities, have contributed their time, effort, and expertise to this series.
Finally, I greatly appreciate the support of the staff at Wiley-Blackwell for their outstanding editorial competence. My special thanks go to Martin Sugden, PhD; without his vision and perseverance, this series would not have come to life. My sincere hope is that this novel and exciting series will serve women and their physicians well, and will be part of the diagnostic and therapeutic armamentarium of practicing gynecologists.
Aydin Arici, MDProfessorDepartment of Obstetrics, Gynecology, and Reproductive SciencesYale University School of Medicine New Haven, USA
Preface
Sexually transmitted diseases (STDs) have been recognized for centuries, are the subject of many ancient writings, and have likely been present for at least as long as humans, given the necessity of human reproduction. Early descriptions of syphilis, gonorrhea, herpes simplex virus, and other STDs (and their associated clinical syndromes) have been found in both medical and nonmedical documents. On a global scale, STDs remain one of the most prevalent infectious diseases among the human race. Despite numerous technological advances in the past century, including the introduction of effective antimicrobial agents, STDs persist, and even thrive in varied locales.
There are numerous obstacles internationally to the successful control of STDs, including, in many instances, social, financial, and political underpinnings complicating control efforts. The health threats posed by many STDs also frequently extend to unborn fetuses and/or neonates, increasing their global importance. Because of the substantial prevalence of many of these clinical entities, as well as the significant toll on health and associated societal costs, clinicians caring for girls and women of all ages should have a thorough working knowledge of STD recognition, diagnosis, and management.
For the typical women's health provider, STDs and their associated morbidities represent a sizable portion of the daily efforts directed at improving and maintaining health, in addition to treating acute ailments. Also, many clinical efforts focus on STDs as a part of the larger goal of promoting disease prevention among women. In addition to the well-known STDs, the infectious vulvovaginitis syndromes are a major cause of discomfort, remain one of the main reasons women seek care and use antimicrobial agents, and are thus discussed thoroughly. Given significant overlap in clinical presentation, many noninfectious conditions of the female genital tract are also commonly seen by busy women's health providers and are occasionally misdiagnosed as STDs and/or infectious vulvovaginitis. This is also true for the relatively rare, but clinically apparent, vulvovaginal cancers. The awareness of these noninfectious clinical entities has increased in recent years, and burgeoning research has demonstrated the relatively high frequency of many of these conditions. Thus, special attention is given in this text to some of these more common entities.
Taken together, these conditions require a thorough understanding and disciplined approach to the evaluation and management in order to optimize women's health globally. Importantly, human immunodeficiency virus (HIV), while a sexually transmitted pathogen, is not discussed directly in this text, primarily because its scope and breadth warrants an entire text unto itself.
It is my sincere hope that this text provides a thorough yet user-friendly guide to the common STDs, vaginitides, and the gynecologic noninfectious syndromes that are frequently encountered in clinical practice. I also hope and believe that the combination of excellent contributors, along with the unique chapter selections, will serve as an invaluable resource for busy women's health providers across the world.
Richard H. Beigi, MD, MSc
Chapter 1
Standard Clinical Evaluation
Richard H. Beigi
Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Women's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA
A thorough and reproducible approach is required for every patient being evaluated for any lower genital tract complaints to assure an objective and complete clinical evaluation. The following chapter serves as a guide to performing such an evaluation.
Introduction
The clinical evaluation of women presenting with genital tract complaints requires a standard approach that leads to an objective, reproducible evaluation. This is a critical point to understand given the diverse conditions that are being evaluated. These diverse conditions, however, often have very closely overlapping clinical presentations, requiring the standard approach to maximize diagnostic accuracy and optimize outcomes. In general, the evaluation of women with lower genital tract complaints without physical examination and/or laboratory testing has been demonstrated to be suboptimal. Self-diagnosis has also been demonstrated to be inaccurate, and is generally discouraged. The syndromic management of women, based on subjective presentation alone, has been used in developing countries (and still is in certain settings) where a health infrastructure is lacking. However, thorough and careful history-taking, physical examination, and selected laboratory methods can significantly improve objectivity and, whenever possible, are strongly recommended in developed nations with an existent healthcare infrastructure. A recommended and reproducible approach to all women with lower genital tract complaints is described below.
Clinical Evaluation
A thorough understanding of the vulvar, vaginal, and internal female genital tract anatomy is the key first step in assessingvulvovaginal complaints among women. As noted in Figure 1.1, the vulva is bound by the genitocrural folds laterally, the anus posteriorly, and the upper mons pubis superiorly. Importantly, hair follicles (coarse) are present on the inferior, lateral, and superior tissues of the vulva, but are lacking from the inner labia majora, labia minora, and the vaginal vestibule. The vaginal vestibule is separated from the inner labia minora by an artificial anatomic line, called the Hart line. This is an important landmark because it separates the nonmucous-secreting outer skin from the inner, mucous-secreting moist tissues of the vaginal vestibule and the hymenal ring. The vaginal vestibule is where the Bartholin and minor vestibular glands are located and produce lubricating fluids, where the vaginal orifice begins, and where the urethra opens at its meatus. Delineating and appreciating the exact anatomical location of physical findings is very important in deciphering the underlying etiology as well as administering effective treatment of sexually transmitted diseases (STDs) and the associated vulvovaginal syndromes/conditions.
Figure 1.1 Female external genitalia. (Reproduced from Rogstad KE, et al., ABC of Sexually Transmitted Infections, 6th edn. Blackwell Publishing: Oxford, 2011, with permission.)
The standard position for most gynecological examinations is the dorsal lithotomy (on back, with knees flexed, thighs flexed and apart, feet resting in stirrups). This positioning (Figure 1.1) allows in most scenarios the best physiologic view of the female anatomy and optimizes specimen collection for most laboratory analyses. Occasionally, due to anatomic restrictions, lack of mobility, or other factors, different positioning may be necessary or undertaken. This may be especially true for young women or girls who have never had pelvic examinations performed or are reticent for such an examination (covered more extensively in Chapter 2).
It is likewise essential for practitioners caring for women to have a thorough understanding of the internal female genital tract anatomy (Figure 1.2). This cross-section demonstrates the relationship of the vagina, cervix, uterus, and adnexae to each other as well as the relationship to the two other important organ systems in the pelvis – the gastrointestinal tract (large bowel) and the urinary system (urethra and bladder). Distinguishing signs and/or symptoms attributable to the genital tract versus the other adjacent organ systems is often challenging but occasionally very important to successful management.
Figure 1.2 Female internal genitalia. (Reproduced from Rogstad KE, et al., ABC of Sexually Transmitted Infections, 6th edn. Blackwell Publishing: Oxford, 2011, with permission.)
With this basic understanding of the female anatomy, history-taking becomes the next key step (as in nearly all clinical evaluations). Focusing on specific symptomatology, exact timing of the onset of symptoms and length of time, alleviating and exacerbating factors, recent therapies (including self-chosen and nonprescription remedies) and presence/absence of partner(s) symptoms will help to narrow the differential diagnoses. The Centers for Disease Control and Prevention (CDC) has recommended an approach to sexual history-taking (5 Ps), which is covered more extensively in Chapter 17 (Prevention of Sexually Transmitted Diseases). This approach is strongly recommended to assist providers' ability to obtain key information in these evaluations that will lead to the correct diagnosis and management, thus improving clinical outcomes. Use of nonjudgmental, open-ended questions is suggested when eliciting a sexual history as this approach is more likely to produce meaningful and accurate information about sexual practices and risk factors.
After taking a thorough history and with a thorough understanding of the anatomy, all evaluations begin with an inspection of the vulvar area. Close attention to all elements of the external genital anatomy, the presence of any lesions, appearance and color of the skin, labia majora and minora, as well as any atypical findings is required. Obvious large lesions or other major findings should be noted and captured in a drawing for future reference. More subtle findings such as fissuring, labial agglutination, or small ulcers should also be sought, as they often give direct insight into the etiology of symptoms. Lymph nodes in the inguinal region should be routinely palpated for enlargement and/or tenderness (or rarely, fluctuance). For some of the vaginitides (i.e. vaginal candidiasis) and especially the noninfectious and/or dermatologic conditions, vulvovaginalinspection is often a high-yield component of the examination. After a thorough examination of the vulvar tissues (specific attention to color, tissue appearance, lesions, scaling, etc.), the vaginal introitus should be inspected for color changes, the presence of lesions, and vaginal tissue rugosity (as a sign of endogenous estrogen stimulation).
Subsequent to the thorough inspection of the external anatomy and vaginal introitus, anappropriately sized speculum should be placed into the vaginal vault, and the vaginal tissues and cervix inspected. Again, attention to tissue color, texture, presence of discharge, anatomic origin of the discharge (vaginal vs. cervical os), and other signs should be noted on every patient. Origin of discharge is a key point, as cervical discharge has a vastly different etiology, evaluation, and management compared to discharge emanating from the vaginal tissues. Evaluation of discharge microscopically is also a very important component of nearly all genital tract evaluations (when considering infectious conditions) and can often yield highly valuable information. The specifics of these techniques will be discussed in ensuing chapters. Close attention to the cervical appearance is also a key to this part of the examination. Once this is performed (and any appropriate specimens obtained for testing), the speculum is removed.
Internal bimanual pelvic examination is then carried out in the usual fashion using two fingers in the posterior vagina to palpate and move the cervix, while placing the other hand on the lower abdomen to simultaneously palpate the internal genital organs. This component of the examination is done with specific attention to the findings of pelvic tenderness on motion of the cervix (i.e. cervical motion tenderness) and any adnexal and/or uterine findings. This too is an important part of the examination that can often give vital information about upper genital tract infection that requires specific (often prolonged) therapy. Rectovaginal examination is also an often used method to help to discern further the nature of any findings on pelvic examination, as well as specific findings in the anorectal canal itself, and should be used liberally.
Conclusion
Use of this standard and reproducible approach on every patient will improve the ability of the provider to objectively determine the cause of the symptomatology. This in turn will improve the management and patient outcomes from these often physically and psychologically debilitating conditions.
Chapter 2
Specific Considerations for Pediatric and Adolescent Patients
Eduardo Lara-Torre
Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
The evaluation and management of children and adolescents with exposure or infection with sexually transmitted disease requires special considerations and care. The difference in examination techniques and instruments to facilitate these examinations will assist the providers in performing the age appropriate examination and minimizing trauma. Prophylaxis for sexual assault cases as well as screening and treatment for certain diseases requires special considerations for children and adolescents. The Centers for Disease Control and Prevention (CDC) updated the recommendations in December, 2010 and provides a great resource for practitioners caring for this population.
Introduction
The management of sexually transmitted infections (STIs) in children and adolescents requires the practitioner to apply a different approach from the one used for adult women.
To understand the screening and treatment algorithms, one must understand some basic epidemiology and behaviors that differentiate these patients from their counterparts. It is also important to understand the indications, techniques, and alternative methods of screening utilized with this population, especially because these patients may be hesitant to be screened and examined in the traditional way. When dealing with children and adolescents, understanding local law and state statutes regarding the confidentiality of their reproductive healthcare is also important as it dictates the type of services they can receive without parental notification and also determines the rules and regulations for reporting. This is not only noted in the presence of certain infections such as chlamydia, but more importantly among those patients who might have been victims of sexual abuse.
In general, children are screened and treated for STIs related to involuntary intercourse or genital contact. Examples of these inappropriate contacts may include sexual abuse with penetration or simply the placement of male genitals in contact with the child's vulva. The management of children with STIs requires a multidisciplinary approach and should include collaboration between the governmental agencies (such as child protective services), laboratory, and clinicians. Some infections acquired after the neonatal period are consistent with sexual abuse (i.e. gonorrhea), while other diseases such as HPV may not be. A full understanding of the management of victims of sexual abuse is important for those caring for this population and is beyond the spectrum of this chapter.
Adolescents, on the contrary, are more commonly screened and treated for acquired infections due to consensual sex. The approach to each of these scenarios is different, and the evaluation and management for each patient and conditions will be presented in separate sections.
The Physical Examination
Prepubertal Girls
The initial step in the examination of children is to obtain the cooperation of the child. While explaining the examination to the patient, allow her to have some say in the process (e.g. give the child a choice of examination gown to wear). Starting with an overall assessment of the child before initiating the genitalia examination is recommended as it will provide an opportunity for the patient to become comfortable with the examiner and proceed with the genital examination.
In order to be able to visualize the genitalia of children, positioning plays a key component to the success of the examination. Multiple positions have been described to allow adequate visualization, and, in some situations, more than one position may be required to complete an adequate genital examination. The frog-leg is the most commonly used position in the younger patient, allowing her to have a direct view of the examiner and herself (Figure 2.1). The knee–chest position is adjunctively helpful in some cases in visualizing the lower and upper vagina with the use of an otoscope or other low-power magnification. This position may be especially helpful in those patients for whom a vaginal discharge may be a complaint (Figure 2.2). As the child grows older, the use of stirrups and the lithotomy position may provide the best visualization of the area. Having the mother hold her daughter on her lap may also be of assistance. In certain instances, even the most experienced examiner will be unable to complete the examination because the child will not fully cooperate. In these patients, the emergent nature of the complaint and the clinical consequence of the pathology must be considered. A multivisit examination or an examination under anesthesia may be warranted.
Figure 2.1 A 5-year-old child demonstrating the supine “frog-leg” position. (Reproduced from McCann JJ, Kerns DL. The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference, Intercort, Inc.: St. Louis, MO, 1999 with permission.)
Figure 2.2 Technique for examination of female genitalia in prone knee–chest position. (Reproduced from Finkel MA, Giardino AP (eds.). Medical Examination of Child Sexual Abuse: A Practical Guide, 2nd edn. Sage Publications: Thousand Oaks, CA, 2002; pp. 46–64, with permission.)
The use of gentle traction with lateral and downward pulling may improve visualization while maintaining the integrity of the normal prepubertal genitalia (Figures 2.3 and 2.4). The examiner must be careful not to cause any trauma or pain in the area, as it will promptly make the patient uncomfortable and possibly lead to a premature termination of the examination. In the prepubertal female, the unestrogenized nature of the hymenal tissue makes it sensitive to touch and easily torn.
Figure 2.3 Labial traction technique for examination of female genitalia in the supine frog-leg position. (Reproduced from Finkel MA, Giardino AP (eds.). Medical Examination of Child Sexual Abuse: A Practical Guide, 2nd edn. Sage Publications: Thousand Oaks, CA, 2002; pp. 46–64, with permission.)
Figure 2.4 Labial separation technique for examination of female genitalia in the supine frog-leg position. (Reproduced from Finkel MA, Giardino AP (eds.). Medical Examination of Child Sexual Abuse: A Practical Guide, 2nd edn. Sage Publications: Thousand Oaks, CA, 2002; pp. 46–64, with permission.)
Although the evaluation of the internal pelvic organs may not be easy, the use of a recto-abdominal examination may assist in the palpation of the internal organs as well as possible pelvic masses. Proper nomenclature of the female genitalia should be used when reporting a pediatric genital examination to prevent confusion between examiners. Components of such an examination include assessment of pubertal development (Tanner stage), visualization and measurement of the clitoris, and description of the labia majora and minora including any discoloration, pigmentation, or lesion. The appearance of the urethra, meatus, and hymen (including type or shape, estrogen status, and abnormalities) should be detailed. Estrogenization at puberty thickens the hymen, which becomes pale pink and is often more redundant in its configuration, but in the prepubertal patient the hymen is thin, red, and unestrogenized. If the cervix is visualized in the knee–chest position, it is important to document its appearance.
Using Special Techniques to Obtain Specimens
The hymenal opening is small in this age group, and traditional cotton swabs create discomfort. When vaginal specimens for culture must be collected, moistened small Dacron swabs (male urethral size) may be used as they are thin and easy to insert without touching the hymen. While making the collection of the sample less traumatic, the accuracy of the test does not change. Another helpful method is a catheter-within-a-catheter technique in which a 4-inch intravenous catheter is inserted into the proximal end of a No. 12 red rubber bladder catheter. This is then connected to a fluid-filled syringe passed carefully into the vagina. The fluid is then injected and aspirated multiple times to allow a good mixture of secretions. These specimens may be sent for culture as needed without affecting the sensitivity or specificity of the tests (Figure 2.5).
Figure 2.5 Assembled catheter-within-a-catheter aspirator, as used to obtain samples of vaginal secretions from prepubertal patients. (Reproduced from Pokorny SF, Stormer J: Atraumatic removal of secretions from the prepubertal vagina. Am J Obstet Gynecol 1987; 156: 581–582, © 1987 Mosby with permission.)
As some children age, they may be able to tolerate more office procedures without the need for sedation. In this case, a pediatric feeding tube connected to a 20-mL syringe filled with warm water or saline may be used to irrigate the contents of the vagina and collect the secretions for culture or wash out small pieces of foreign body material such as toilet paper. This can make the need for specula unnecessary in these prepubertal patients who have a small hymenal aperture that would be injured with the insertion of a speculum.
When documenting the findings of the examination and anatomical variations one should merely described the findings and not make diagnosis in the examination portion of the documentation. This process of documenting prevents the assumption of abuse and limits the record to a description of the findings.
Vaginal Discharge in Prepubertal Girls
One of the most common complaints in girls seeking gynecological evaluation at this age is vaginal discharge. Vulvovaginitis in children has very different etiology than in adolescents/adults. The main difference in these patients is the etiology of the discharge. While most of the discharge in reproductive-age women is secondary to a specific cause (i.e. yeast, bacterial vaginosis, etc.), the most common etiology in children is a “nonspecific vaginitis.”
Local irritation and immaturity of the mucosa probably play a role in the development of the discharge. Its appearance is commonly clear to yellow and may or may not present with itching and odor. Many patients do not even complain about it, but is noticed by the parent in their underwear, leading to concern. Detergents, toilet paper, moisture, perfume, even tight clothing have all been associated with the discharge and discomfort. Hygienic measures in general resolve the problem and no further intervention is necessary. Interventions for the management of nonspecific vaginitis can be found at www.naspag.org.
Bacterial colonization is also a common agent in this condition. Unlike the adult, yeast is rarely encountered in these patients and is present only in those immunosuppressed or on chronic treatment with steroids or antibiotics. Fecal (E. coli) or upper respiratory flora (Group A streptococci or Hemophilus. influenzae) are the most common bacteria encountered in culture. When hygienic maneuvers fail, a trial of antibiotic treatment for 10 days using such products as amoxicillin or trimetropin/sulfamethoxazole is indicated. If a bloody discharge is present, suspicion for shigella should be considered and an appropriate culture taken. Failure to resolve the symptoms should alert the practitioner to other causes such as foreign body or perhaps organisms associated with sexual abuse.
Adolescent
The adolescent patient may present a challenge for the examining practitioner. The patient's self-consciousness about her own body and the extreme variation in psychosocial and sexual development at this age may make the examination even more difficult to perform. As teenagers develop at varying rates, careful interviewing and counseling should precede an examination. The use of educational videos that explain the examination process and the common reasons why it is done may improve the provider–patient relationship. Delaying the genital examination, even if sexually active, may prevent the patient from having reservations about her examiner. These preferences should be taken into account to make the experience as minimally traumatizing as possible. The examination can be delayed until an indication is present, such as a vaginal discharge or abnormal bleeding or the need for cervical cancer screening has been reached (age 21). Performing an external examination may be undertaken annually as part of the patient's preventive visit. Developing rapport with the teens during their first few visits will allow them to feel ready for this part of their physical examination but the timing will vary from patient to patient.
With adolescents, if possible, it is important to meet initially with the teen and her parents/guardian together to explain the concept of confidentiality and privacy. After the initial history form is completed with parent and teen together, take the sensitive/confidential part of the history with the teen without the presence of the parent (e.g. alcohol, drug and substance use, dating, and sexual history). Remember, when screening, begin with less sensitive issues like safety (e.g. seat belt use) before psychological and sexuality issues.
Before completing the initial gynecologic examination, take time to explain the general process. Patients may choose to delay their pelvic examination when asymptomatic, but the proper examination equipment for this age group should be available if needed. The use of tampons prior to the examination in the presence of menses may facilitate the use of a speculum, as the patient may be more comfortable with vaginal manipulation. A Huffman speculum (1/2 inch wide × 4 inches long) or a Pederson speculum (7/8 inch wide × 4 inches long) may be used with those who are sexually active. Care should be undertaken to utilize the appropriate size speculum for the patients. Teenagers often receive their first-time examination in an urgent or emergency room care setting, where the availability of these smaller instruments may be limited and larger instruments are used, such as the Graves speculum. This practice can lead to an increase in trauma to the patient and apprehension for the pelvic examination, leading adolescents to be reluctant to seek reproductive services for fear of another examination.
Use of the “extinction of stimuli” approach may be of benefit in those undergoing their first pelvic examination. Using a finger to apply pressure to the perineal area, away from the introitus or thigh, will lessen or diffuse the sensation from the examiner's finger at the vaginal opening. Once a finger has been placed in this area, the insertion of a speculum may be easier and the cervix and vagina can be visualized adequately. Once access to the cervix is obtained, cultures may be collected if indicated.
All adolescents should be reassured that the examination, while uncomfortable, is not painful, and will not alter their anatomy. This will reassure those who may believe that the examination will alter their “virginity.” After the examination, it is helpful to meet again with the family and patient to explain the findings of the examination and to plan further management. If confidentiality is a concern with the sexually active teenager, first discuss findings with the patient alone while in the examination room.
Sexual Assault in Children and Adolescents
Among patients in whom sexual abuse is suspected, screening and management should include an initial examination at the time of the assault followed by a repeat evaluation 2 weeks after the event. This would allow for those organisms not detected in the original examination to accumulate enough concentration to be detected. Inspection of the genitalia and other possible areas of genital contact from a perpetrator should be undertaken. Suspicious areas of discharge, odor, or lesions must be assessed and samples collected for laboratory analysis. Only specific tests should be used in children as most of the evidence collected will be used in court to pursue criminal charges, and requires little room for misinterpretation.
Initial and 2-week post-event screening should include testing for Neisseria gonorrheae and Chlamydia trachomatis from the anus, vagina, and pharynx. The use of culture-specific media for the organism is preferred and the use of DNA amplified techniques is discouraged. The Centers for Disease Control and Prevention in 2010 described utilizing Nucleic Acid Amplification Tests (NAATs) as an alternative to C. trachomatis culture, with specimens obtained from urine instead of the vagina, potentially minimizing trauma during the examination. At this point, there is insufficient data to support NAAT for N. gonorrheae for this indication, and discussion with the local authorities before collection of the specimens is advised to minimize retesting. Collecting a vaginal swab for Trichomonas vaginalis culture and bacterial vaginosis is also advisable. During the initial evaluation, collection of serum for human immunodeficiency (HIV), syphilis, and Hepatitis B virus baseline status is recommended. This test can be later compared to samples at 6 weeks, 3 months, and 6 months to detect seroconversion and form an association with the assault.
Prophylaxis after assault is different in children than in any other population. The immature nature of the female anatomy appears to be protective for ascending infection. When making the decision to use prophylactic medications to prevent the acquisition of disease, especially for HIV, it should be in consultation with the parents after an accurate assessment of the risk of acquisition from the perpetrator has been made, and after obtaining consultation from a clinician specializing in infectious diseases in children. Routine prophylaxis without first obtaining verification via accepted testing modalities is not recommended for any disease.
In contrast, prophylaxis for an adolescent who has been the victim of sexual abuse is recommended. Protection against trichomonas, chlamydia, and gonorrhea infections, as well as pregnancy preventions, is advised. Post-exposure use on anti-HIV medications may be indicated but still requires the expertise of those specializing in infectious diseases.
Adolescent Screening Guidelines
In order to optimize care, understanding the indications and testing methodology utilized to screen for STIs in adolescents is important. Having an understanding as to the incidence of certain diseases in this age group justifies the need for asymptomatic screening. High risk-taking behaviors also tend to occur in this age group; in fact adolescents age 15–19 have the highest rates of chlamydia and gonorrhea infections. Adolescents frequently lack access to healthcare. Serial monogamy (i.e. having one partner at the time, but changing partners frequently) and lack of consistent use of barrier methods, increases their overall risk. There also appears to be an increase in susceptibility of the genital tract to acquire some sexually transmitted infections, possibly because of an inherent biological immaturity of these tissues.
An additional complicating issue is that adolescents often seek strict confidentiality when seeing providers for STI management. Although the 50 states and D.C. allow for confidential testing without the need to notify parents of the care or results of the testing, true confidential services are difficult to provide. While the visit information can be kept strictly confidential, the billing resulting from the provider's fee and laboratory testing likely will reach their care givers and/or parents. These invoices will interfere with the confidentiality of the service provided. Some agencies that provide free services to teenagers may be better equipped to handle true confidential services, as no billing is generated for those visits.
Examples of such facilities may include certain planned parenthood clinics and health department STI clinics. These locations may be an ideal option for those teenagers truly concerned about parental discovery. Screening recommendations are listed in Table 2.1.
Table 2.1 CDC screening recommendations for adolescents.
• Annual routine screening for C. trachomatis on all sexually active patients 25 years old or younger.• Annual routine screening for N. gonorrheae on all sexually active females at risk for STDs at any age.• HIV risk should be discussed and assessed with all patients at least annually and testing encouraged on all sexually active teens and those with history of injection drug use at least once.• Routine testing for asymptomatic patients for syphilis, Hepatitis B and C, human papilloma virus (HPV), herpes and trichomonas is not recommended. Pregnant adolescents may benefit from testing for some of these infections as part of their prenatal care.• All teens should be screened and counseled on high-risk behavior that leads to the acquisition of any of these infections.• Primary prevention of HPV, Hepatitis A and B through vaccination should be encouraged.Adolescent Testing for N. Gonorrheae, C. Trachomatis, and Other Vaginitis
Adolescents present a challenging population to screen utilizing traditional pelvic examination. While in the adult the practice of an internal vaginal examination is acceptable, for many teenagers this practice is unacceptable, threatening, and may prevent them from seeking medical care for fear of the examination. The available alternative methods of screening for certain STI using alternative body fluids and collection techniques has allowed for an increase in the utilization of screening services.
NAATs has increased the ability not only to detect, in a reliable manner, organisms that are present in low concentrations, but has also allowed the use of other body fluids instead of endocervical or urethral specimen collection. NAATs has been approved for the use in urine specimens in men and women, but proper specimen collection is critically important (Table 2.2).
Table 2.2 Urine specimen collection requirements.
• Allow one hour from the last void.• Not a clean catch specimen.• Collect the first 5–10 mL (max) of urine in a sterile container.• May be left for 24 hours at room temperature.As technology has improved, new specimen collection kits are available that allow patients to undergo self-testing by collecting their own vaginal specimen. The sensitivity of self-vaginal swab testing is comparable to urine or endocervical swabs and facilitates patient screening. Recent data suggests that adolescents prefer this method, which may potentially increase the effectiveness of the screening programs. As the technology improves, self-testing for other pathogens such as herpes, trichomonas, and bacterial vaginosis may become available.
The use of NAAT technology for nongenital sites has not undergone FDA validation, but the CDC recommends its use in those centers where a validation study has been done with their technique. Further information on laboratory requirements needed to fulfill validation can be found at www.cdc.gov/std.
In some cases, using point-of-care testing for certain infectious agents is feasible and cost effective. For example, traditional testing for T. vaginalis or bacterial vaginosis involves a pelvic examination, preparation of a wet mount, and direct observation under the microscope. This traditional point-of-care test has poor reliability and interobserver accuracy. Most studies would quote a sensitivity of 30–60% for either condition, making the diagnosis difficult. New rapid DNA-based technology (15 minutes) has increased the accuracy of the test without the need for visual direct interpretation with sensitivities of 95% and specificities close to 100%. Utilization of these techniques in the office may increase accuracy in the diagnosis of these conditions and improve treatment at the time of the visit.
Management of Specific Prevalent Infections
The treatment of specific pathogens is described in other chapters, but special considerations in children and adolescents will be reviewed in this section to facilitate the practitioners' management of some of these conditions, as well as serving as a quick reference for agents and dosing.
Herpes Simplex Virus
Neonatal herpes: patients with potential exposure during birth to maternal herpes genital infection should be managed in conjunction with a pediatric infectious disease specialist. The use of intravenous acyclovir on suspected or diagnosed cases post-delivery is recommended at a dose of 20 mg/kg every 8 hours for 14–21 days, depending on the location of the infection.
Diseases Characterized by Urethritis and Cervicitis
Chlamydia treatment in adolescents and children over the age of 8 follows the same guidelines as the adult. In children, once again, management in collaboration with child protective services is critically important to assure a thorough and proper sexual abuse evaluation. Regimens effective for treatment include:
Recommended regimen for children who weigh less than 45 kg: Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days.Recommended regimen for children who weigh 45 kg or more than 45 kg but who are less than 8 years of age: Azithromycin 1 g orally in a single dose.Gonorrhea treatment in adolescents and children who weigh more than 45 kg is the same as the adult. In 2010, the CDC increased the dose of ceftriaxone to 250 mg IM single dose to increase its efficacy. Because of an increase in resistant strains, the use of fluoroquinolones is no longer indicated.
Recommended regimen for children who weigh less than 45 kg: ceftriaxone 125 mg IM single dose.Pelvic inflammatory disease (PID) treatment guidelines in adolescents are the same as for adults. Although the incidence of PID in children is very low, it does occur and may have an origin predominantly in endogenous flora. Of importance in this age group is the need for early diagnosis and the aggressive treatment of suspected cases. The long-term effects related to infertility secondary to tubal occlusion, especially with chlamydia, make this intervention a very important healthcare issue. Patients suspected of having PID should be treated and followed carefully, and frequently, to document the effectiveness of treatment. The results of the testing collected at the time of diagnosis should be followed and patients counseled appropriately about the results. Adolescents are a group with a significant risk of noncompliance with medical treatment and sometimes qualify for intrahospital management of their disease rather than as an outpatient, although this “requirement” has been removed from the formal CDC recommendations for PID treatment.
Patients who have been treated for gonorrhea or chlamydia may not require a “test of cure” (repeat NAAT testing at 4 weeks post-treatment) unless they are pregnant, there is a suspicion of reinfection, noncompliance, or persistence of symptoms. Patient with high-risk behavior and frequent partner change may benefit from testing for these infections every 6 months, or with every new partner. If a “test of cure” is performed, sufficient time should be allowed for the infectious material to dissolve, and should not be performed sooner than 4 weeks after treatment to prevent false-positive testing from dead organisms being detected by the highly sensitive NAAT methodology.
Conclusion
Caring for young patients requires a different set of skills than those used for adults. Concentrating in minimizing trauma and maximizing education should be the main focus of all those involved in the care of children and adolescents. Patience, appropriate documentation, and confidentiality play mayor roles in the successful examination of this population. Using alternative fluid testing for screening, such as urine, may improve compliance with future reproductive healthcare. Utilizing these techniques and the resources listed in the bibliography section, may allow the providers to perform the screening and treatment of these patients.
Bibliography
ACOG. Tool Kit for Teen Care (2nd edn.). American College of Obstetricians and Gynecologists, Washington, D.C., 2010.
Changes in the 2010 STD Treatment Guidelines: What Adolescent Health Care Providers Should Know from the American College of Obstetricians and Gynecologists. Adolescent Healthcare Division. Accessed on 5/11/2011 at: http://www.acog.org/departments/dept_notice.cfm?recno=7&bulletin=5545
Finkel MA, Giardino AP. (eds.). Medical Examination of Child Sexual Abuse: A Practical Guide (2nd edn.). Sage Publications: Thousand Oaks, CA, 2002; pp. 46–64.
Lara-Torre E. The physical examination in pediatric and adolescent patients. Clinic Obstet Gynecol 2008;51: 205–213.
McCann JJ, Kerns DL. The Anatomy of Child and Adolescent Sexual Abuse: A CD-ROM Atlas/Reference. MO, Intercort, Inc.: St. Louis, 1999.
North American Society of Pediatric and Adolescent Gynecology at www.naspag.org.
Pokorny SF, Stormer J: A traumatic removal of secretions from the prepubertal vagina. Am J Obstet Gynecol 1987;156: 581–582.
Sanfilippo JS, Lara-Torre E, Edmonds K, Templemand C (eds.). Clinical Pediatric and Adolescent Gynecology. Informa Healthcare USA, Inc., New York, NY, 2009.
Sanfilippo JS, Lara-Torre E. Adolescent gynecology. Clinical Expert Series: Obstet Gynecol 2009;113: 935–947.
Sexually Transmitted Diseases Treatment Guidelines 2010. MMWR December 17, 2010. Accessed on 5/11/2011 from http://www.cdc.gov/std/treatment/2010/default.htm
Chapter 3
Cervicitis and Pelvic Inflammatory Disease
Oluwatosin Jaiyeoba and David E. Soper
Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
