Sexually transmitted diseases (STDs) remain common in adolescents, with one in every four sexually active teens between the ages of 13 and 19 years being infected annually. This chapter reviews the evaluation, diagnosis, and management of the more common STDs in adolescence, including Chlamydia trachomatis infection, Neisseria gonorrhoeae infection, herpes simplex, syphilis, chancroid, and Trichomonas vaginalis infection. The recognition and management of physiologic leukorrhea, yeast vaginitis, and bacterial vaginosis are also reviewed because the presentation of each of these entities can be confused with those of the aforementioned STDs. Recent advances in testing strategies are discussed, including urine screening with DNA probes (nucleic acid amplification tests [NAATs], which have been found to be more sensitive than the previously used ligase chain reaction [LCR] and polymerase chain reaction [PCR]) and the appropriate use of culture versus other modalities.

STD rates are highest in the 15- to 24-year-old age group for a variety of reasons. Biologic factors include the prominent exocervix of adolescent girls, which involutes with age. During adolescence, this accessible transition zone serves as a magnet for STD organisms. Adolescents also have lower levels of protective antibodies because of a lesser degree of cumulative exposure to disease. Sperm can carry disease to the upper genital tract. Retrograde menstruation, which occurs in 25% of healthy women, spreads the infection to the fallopian tubes and contiguous areas.

Behavioral factors also increase the prevalence of STDs in adolescents, especially because risky behaviors in teenagers tend to be interrelated and clustered. The earlier teens begin sexual activity, the less likely they are to use a condom and the more likely they are to have multiple partners. In some cultures, it is normative for girls to date boys or young men much older than they are, so that condom negotiation is made difficult by the age and power differential. The use of alcohol or drugs also decreases the use of condoms. Furthermore, the adolescent mindset contributes to the acquisition of STDs; the personal sense of invulnerability of early to middle adolescence coincides with the concrete thought processes that impede an adolescent’s ability to see the consequences of behavior. The lack of education or awareness regarding STDs, the perceived lack of access to contraceptive services, fear of pelvic examination, and fear of disclosure to parents or other adults can serve as barriers to care and increase the risk for adolescent STD acquisition. Legally, with limited exceptions, all teens in the United States may consent to the confidential diagnosis and treatment of STDs. Moreover, teens can receive medical care for STDs without parental consent or knowledge, and adolescents may consent to human immunodeficiency virus (HIV) testing without parental consent in many states. Unfortunately, the lack of awareness among many teens and even healthcare providers of the adolescent and the adolescent’s right to confidential care for STDs further blocks access to care.

After confidentiality has been established, the primary care clinician should ask all teens the HEADS questions: home (Who lives at home? What happens when someone argues at home?); education (grades this year compared with those last year, grade level; recognizing that a slide in grades is a risk factor for various risk behaviors, including sexual activity); activities; drugs (including cigarettes and alcohol); depression/suicide; sex. The method of motivational interviewing allows for behavioral interventions to occur nonjudgmentally as questions are asked of the teen, helping them to shape healthier responses and finding motivation to change risk behavior patterns. Questions can move from less threatening to more invasive, allowing the teen to gain comfort and be empowered to make healthy choices using motivational interviewing. For example, when asking a teen who has admitted to having sex in the past, the clinician can
ask, “What methods of contraception did you use?” If she answers condoms, the clinician can ask if she uses them sometimes, most of the time, or all the time. The clinician can then move on to asking what second method of contraception she uses, and if this question is met with an inquisitive look, the clinician can remind the teen that condoms are only 85% effective at pregnancy prevention with typical teen usage, so that means that “15 out of every shots will find their mark.” The clinician can then discuss with the teen which second method the teen wishes to use if she has heterosexual sexual relations in the future. Adolescents should be asked about number of lifetime partners, and whether they have engaged in oral sex or anal sex, with motivational interviewing used to educate without having to step onto a soapbox, in a way that seems relevant to a specific teen’s life. For those girls who are younger, it is easy to ask questions about the menstrual cycle first: when the last menstrual period occurred; whether they have experienced dysmenorrhea and vaginal itching, discharge, or odor; whether they have noted any changes in their cycle. Girls and boys should be asked if they have ever had anyone do anything to them sexually that made them uncomfortable; careful phrasing can make it “safe” to answer questions about sexual abuse for the teen who has been in a coercive situation where she or he may have been put at risk but may not self define it as “abuse.” Teens should also be asked about sexual preference (“Are you attracted to guys, girls, or both?”); nonjudgmental phrasing can open doors for harm reduction in adolescents experimenting sexually in both same sex and opposite sex relationships. Boys should be asked about penile discharge, dysuria, and lesions and should be taught to perform a testicular self-examination.

Traditionally, the pelvic examination has been used to:

The question of who requires a pelvic examination continues to evolve. All sexually active teens require screening for STDs 3 to 6 months after acquiring each new partner; urine nucleic acid amplification strategies may be utilized for screening, with excellent sensitivity and specificity. With the ACOG recommendations of 2003, a pelvic examination should be first performed 3 years after coitarche, then annually in sexually active young people. For those who have not yet initiated sexual activity, the 2003 ACOG guidelines recommend a first pelvic at age 21 years, not at 18 years. Of note, adolescents tend not to differentiate the Pap smear from the pelvic examination; therefore, a teenager who underwent a pelvic examination in an emergency department setting, in which Pap smears are not performed, may not realize that the test was not done.