Adolescent Medicine



Adolescent Medicine


Sarah Mermelstein

Sarah Tycast

Kathryn L. Plax





  • Adolescence is the time of transition from childhood to adulthood. Typically, it begins at 10-14 years of age. It is characterized by rapid physical, cognitive, and emotional growth, as well as sexual development (puberty).


  • Adolescents start to develop independence and separation from their parents. Less willing to participate in family activities, many concentrate on peer relationships and challenge parental authority.


  • Adolescents are increasingly concerned about their developing body, peer opinion, independence, and sexual exploration.


  • Tips for the adolescent clinical interview:



    • Interview the adolescent and the parent(s) together and then the adolescent alone.


    • Early in the interview and in front of the parent(s), discuss patient confidentiality. Be sure to say that you will keep your findings and all discussions confidential unless the patient is at risk of hurting himself or herself or others, or someone has hurt the patient.


    • Encourage the adolescent to discuss problems with his or her parents, and encourage parents to create a time in the day to be with their child.


    • The adolescent psychosocial history often includes a HEADSS assessment:

      Home dynamics

      Education: school performance

      Activities, Aspirations

      Drugs, Depression

      Sex, Suicide, Safety, Strengths


    • Offer anticipatory guidance on diet, maturation, sexuality, injury prevention, and good health habits.


    • Other advice includes the following:



      • Before the physical examination, give the adolescent the option of being examined alone or accompanied by the parent. Respect the patient’s modesty.


      • When formulating a plan, it is important to reinforce the strengths and achievements of the adolescent both to the patient and to the parent.


      • Use a shared decision-making strategy and youth-directed priorities if behavior change is needed.


SEXUALLY TRANSMITTED DISEASES


Definition and Etiology



  • Sexually transmitted diseases (STDs) can present as urethritis, vulvovaginitis, cervicitis, genital ulcers or growths, pelvic inflammatory disease (PID), epididymitis, abdominal pain, enteritis or proctitis, hepatitis, arthritis, pharyngitis, rash, or conjunctivitis.



SCREENING AND PREVENTION



  • Condoms, when properly used, can greatly decrease the spread of STDs and should be encouraged with all sexual activity.


  • CDC screening recommendations (2015):



    • Annual screening for gonorrhea and chlamydia in sexually active females


    • Consider screening heterosexual men for chlamydia in high prevalence clinical settings or in populations with high burden of infection.


    • Annual screening for human immunodeficiency virus (HIV) between the ages of 13-64 for anyone who is sexually active or is an intravenous drug user (IVDU).


    • Annual screening for syphilis, gonorrhea, chlamydia, and HIV in sexually active gay, bisexual men, and other men who have sex with men (MSM). Screening in this population should include extragenital sites of contact (rectum, pharynx). Consider more frequent screening (every 3-6 months) in MSM who have multiple or anonymous partners.


    • Hepatitis C testing should be offered to all HIV-infected patients, people with hepatitis C-infected partners, and patients who abuse intravenous (IV) drugs or who have partners that do.


  • Human papillomavirus (HPV) is a cause of genital warts and cervical cancer. HPV vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP) between 11 and 12 years of age; however, it can be given as young as 9 and as old as 26. A three-injection series is administered over 6 months. Three HPV vaccines have now been approved by the U.S. Food and Drug Administration (FDA)—Cervarix, Gardasil-4, and Gardasil-9. All three provide protection against HPV serotypes 16 and 18 (cause of 70% of cervical and oropharyngeal cancers). The quadrivalent vaccine and 9-valent vaccine also protect against HPV serotypes 6 and 11 (cause of 90% of genital warts). The 9-valent vaccine protects against five additional serotypes—31, 33, 45, 52 and 58 (cause of an additional 20% of cervical cancers not previously covered). Only Gardasil has been approved for males. Papanicolaou (Pap) smear screening recommendations still apply because the vaccine does not protect against all types of HPV.



    • Initiation of Pap smears should occur when the patient is 21 years old, regardless of age of onset of sexual activity. A pelvic exam and Pap smear is not required for initiation of birth control.


Diagnosis and Treatment



  • Table 10-1 summarizes the characteristics and treatment of the various STDs.


  • Adolescents can consent for evaluation and treatment of STDs without parental consent and notification in most states.


  • Evaluation should include complete history and physical examination. In symptomatic females, a pregnancy test, wet prep, assay for Neisseria gonorrhoeae and Chlamydia trachomatis, Trichomonas, and HIV testing should be performed if there is concern for STD. Consider rapid plasma reagin (RPR), depending on syphilis prevalence in your community. In males, a urine specimen or urethral swab should be taken for diagnosis of infection with N. gonorrhoeae and C. trachomatis, and HIV and RPR testing should also be completed. In MSM, oral and rectal testing for N. gonorrhoeae and C. trachomatis are also recommended if they are having oral and anal sex.


  • If an STD is suspected and follow-up not certain, treat presumptively for at least gonorrhea and chlamydia.












TABLE 10-1 Characteristics and Therapy for Sexually Transmitted Diseases











































































Disease

Characteristics

Therapy


Gonorrhea


  • Caused by N. gonorrhoeae



  • Patients are often coinfected with Chlamydia, so treat for both regardless of chlamydia result



  • Sexual partners should be treated



  • May cause mucopurulent cervicitis



  • Widespread resistance to quinolone exists


  • Uncomplicated urogenital, rectal, or pharyngeal:


    Ceftriaxone 250 mg IM single dose and 1 g of azithromycin PO times single dose


    OR if beta-lactam allergic:


    Azithromycin 2 g in a single oral dose PLUS test-of-cure


Chlamydia


  • Caused by C. trachomatis



  • Asymptomatic infection is very common among men and women



  • Sexual partners should be treated



  • May cause mucopurulent cervicitis



  • Sexual abuse must be considered in preadolescent children with chlamydia


  • Uncomplicated urogenital:


    Azithromycin 1 g PO single OR


    Doxycycline 100 mg PO b.i.d. for 7 days



  • Pregnancy: azithromycin 1 g PO single dose or amoxicillin 500 mg PO t.i.d. for 7 days with retesting 3 months after treatment


Syphilis


  • Caused by Treponema pallidum



  • Primary: painless ulcer or chancre



  • Secondary: rash, mucocutaneous lesions, and adenopathy



  • Early latent syphilis: within a year of prior negative evaluation, patient has seroconversion or unequivocal symptoms of primary or secondary syphilis, or sex partner with primary, secondary, or early latent syphilis



  • All others should be considered to have late latent syphilis


  • Primary and secondary or early latent:


    Benzathine penicillin G 50,000 U/kg, 2.4 million units IM in a single dose (pregnant or not)



  • Penicillin allergy:


    Doxycycline 100 mg PO b.i.d for 14 days OR


    Tetracycline 500 mg PO q.i.d. for 14 days



  • Late latent:


    Benzathine penicillin G 2.4 million units IM every week for 3 weeks



  • Penicillin allergy:


    Doxycycline 100 mg PO b.i.d. for 28 days OR


    Tetracycline 500 mg PO q.i.d. for 28 days


  • Tertiary: CNS, cardiac, or ophthalmic lesions, auditory disturbances, gummas



  • Diagnosis: VDRL or RPR (positive = fourfold change in titers)




    • Cannot compare one to the other—may turn negative after treatment



    • Treponemal serologic test to confirm infection (FTA-ABS)—stays positive for a lifetime



  • Sexual partners should be treated


  • Tertiary syphilis:


    Benzathine penicillin G 2.4 million units IM every week for 3 weeks



  • Neurosyphilis:


    Aqueous crystalline penicillin G 4 million units IV q4h for 10-14 days followed by


    Benzathine penicillin G 2.4 million units IM every week for 3 weeks at the completion of IV therapy


Trichomoniasis


  • Caused by Trichomonas vaginalis



  • Malodorous yellow-green discharge and irritation but may be asymptomatic



  • Diagnosis: wet prep and rapid antigen testing



  • Sexual partners should be treated

Metronidazole 2 g PO single dose OR tinidazole 2 g PO single dose


If previous treatment fails:


Metronidazole 500 mg PO b.i.d. for 7 days


Epididymitis


  • Usually caused by chlamydia or gonorrhea



  • Epididymal swelling, tenderness, discharge, fever, dysuria

Ceftriaxone 250 mg IM single dose PLUS


Doxycycline 100 mg PO b.i.d. for 10 days


For acute epididymitis most likely caused by enteric organisms, add levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice a day for 10 days.


Follow up in 72 hr to ensure response to therapy


Herpes


  • Recurrent, lifelong viral infection



  • May manifest as painful genital or oral ulcers, cervicitis, or proctitis or be asymptomatic



  • Pregnant women who acquire infection near time of delivery have a higher risk of perinatal infection (30%-50%)

First episode:


Acyclovir 400 mg PO t.i.d. for 7-10 days OR


Famciclovir 250 mg PO t.i.d. for 7-10 days OR


Valacyclovir 1 g PO b.i.d. for 7-10 days OR


Herpes


  • Condoms reduce, but do not eliminate, risk of transmission



  • Asymptomatic shedding can occur



  • Treatment may shorten duration of lesions but does not eradicate the virus

Recurrent episodes:


Acyclovir 400 mg PO t.i.d. for 5 days OR


Acyclovir 800 mg PO t.i.d. for 2 days OR


Famciclovir 125 mg PO b.i.d. for 5 days OR


Valacyclovir 500 mg PO b.i.d. for 3 days


Daily suppressive therapy if six recurrences or more per year (↓ frequency of recurrences by 75%):


Acyclovir 400 mg PO b.i.d OR


Valacyclovir 500-1,000 mg PO once daily


Chancroid


  • Caused by Haemophilus ducreyi and very rare in the United States



  • One or more painful ulcers and tender suppurative regional lymphadenopathy



  • All patients should be tested for HIV at time of diagnosis and 3 months after (it is a cofactor for HIV)



  • Partners must be treated

Azithromycin 1 g PO single dose OR


Ceftriaxone 250 mg IM once OR


Ciprofloxacin 500 mg PO b.i.d. for 3 days OR


Erythromycin 500 mg PO t.i.d. for 7 days




  • If treatment is successful, ulcers improve symptomatically in 3 days; complete healing may require >2 weeks


Genital warts or Condyloma acuminatum


  • Caused by human papillomavirus



  • May manifest as visible genital warts or uterine, cervix, anal, vaginal, urethral, or laryngeal warts (types 6, 11)



  • Associated with cervical dysplasia (types 16, 18, 31, 33, 35)



  • Condoms reduce but do not eliminate risk of transmission



  • Patient might remain infectious even though warts are gone



  • Cervical and anal mucosa warts management should be by expert


  • External warts:


    Patient administered:


    Podofilox 0.5% topical solution b.i.d. for 3 days and then 4 days off; may repeat 4 times this cycle, OR


    Imiquimod 5% cream apply at bedtime 3× per week then wash off in AM for up to 16 weeks


    Provider applied:


    Cryotherapy OR


    Podophyllin resin 10%-25% OR


    Trichloroacetic acid OR surgical or laser removal


  • Treatment may induce wartfree periods but does not eradicate virus



  • HPV vaccine now recommended for all children at 11-12 years of age


Pediculosis pubis


  • Lice or nits on pubic hair



  • Patients consult because of pruritus or visual nits

Permethrin 1% cream: apply for 10 min and rinse


Pyrethrins with piperonyl butoxide: apply for 10 min and rinse


Scabies


  • Caused by Sarcoptes scabiei



  • In adults may be sexually transmitted but not in children



  • Pruritus and rash



  • Treat partners and household contacts, plus household decontamination

Permethrin 5% cream: apply to body from neck down, and wash off after 8-14 hr OR


Ivermectin 200 µg/kg PO × 1 and then can repeat after 2 weeks


Lindane 1% lotion*


Vaginitis



Bacterial vaginosis


  • Caused by G. vaginalis



  • Most prevalent cause of pathologic vaginal discharge



  • Symptoms may include vaginal discharge and odor, vulvar itching, and irritation, although up to 50% are asymptomatic



  • Partners do not need treatment

Metronidazole 500 mg PO b.i.d. for 7 days OR


Metronidazole gel 0.75%: 5 g applicator intravaginally for 5 nights OR


Clindamycin cream 2%: 5 g applicator intravaginally for 7 nights†


Candidiasis


  • Symptoms include pruritus, erythema, and white discharge



  • Partners do not need treatment

Fluconazole 150 mg PO once


Clotrimazole 100 mg


tablet: 2 intravaginal daily for 3 days or 1 daily for 7 days


Clotrimazole 1% cream 5 g intravaginally for 7 nights


Miconazole 200 mg vaginal suppository for 3 days


* Do not use in patients <2 years of age due to neurotoxicity. Only use in cases of treatment failure or if patients cannot tolerate first-line treatments.


† Clindamycin cream is oil based and might weaken latex condoms and diaphragms for 5 days after use.





Complications



  • Long-term sequelae of STDs include PID, chronic pelvic pain, ectopic pregnancy, cervical dysplasia, infertility, and cancer.


PELVIC INFLAMMATORY DISEASE


Definition and Etiology



  • PID is a spectrum of inflammatory disorders of the upper female genital tract, including endometritis, salpingitis, and oophoritis. Complications may include tuboovarian abscess (TOA), perihepatitis, pelvic peritonitis, formation of scar tissue, increased risk for ectopic pregnancy, and infertility.


  • The most common causal organisms are N. gonorrhoeae and C. trachomatis. Other organisms isolated are Gardnerella vaginalis, Haemophilus influenzae, enteric gramnegative rods, Streptococcus agalactiae, Bacteroides fragilis, and Mycoplasma genitalium.



Diagnosis

Lower abdominal pain in a sexually active female with no other identifiable cause and:

Tags:
Jun 5, 2016 | Posted by in PEDIATRICS | Comments Off on Adolescent Medicine

Full access? Get Clinical Tree
Get Clinical Tree app for offline access