See also

Vulval ulcers
Vulval and vaginal conditions
Child abuse
Engaging with and assessing the adolescent patient

Key points

1. Many STIs are asymptomatic, but can cause serious complications
2. STI screening and counselling about prevention should be offered opportunistically to all sexually active adolescents who present for healthcare
3. Adolescents have a legal right to confidential care and adequate information in order to consent to investigation and management
4. Rarely, STIs may be an indication of sexual abuse. If concerns of sexual abuse, urgent referral to appropriate local services is needed, as time-critical samples may be required  

Background

• Young people aged 15-24 have the highest rates of chlamydia and gonorrhoea in Australia
• STIs are a major cause of infertility and pregnancy-related complications as well as pelvic inflammatory disease (PID)
• If an asymptomatic adolescent requests an STI screen, the investigations undertaken will depend on the information provided in their sexual history

Assessment

Adolescents have the legal right to confidential health care unless they cannot be considered mature minors and/or there is significant concern regarding risk ie harm to self or others, physical or sexual abuse

History

Undertake a risk assessment including

• Age at first sexual activity
• When / who / how (vaginal, anal, oral) of recent sexual activity
• Whether sexual partners are male, female, both (and partners’ partners, due to increased STI risk in men who have sex with men (MSM))
• Contraceptive use (always / sometimes / never) including barrier methods
• Associated risk factors (in young person and their partners) for transmission of STIs including intravenous drug use, sex work, body piercing, tattoos
• Past history of STIs and STI screening
• Assess:
• Risk of pregnancy and test where appropriate
• Need for emergency contraception
• Ongoing contraceptive needs
• HEEADSSS assessment

Chlamydia trachomatis

• Immunity to new infection is not provided by previous infection

Symptoms

• 50% of men and 75% of women have no symptoms
• Dysuria
• Urethral or vaginal discharge
• Testicular or pelvic pain
• Intermenstrual or postcoital bleeding
• Can also infect the eye, anus and rarely throat

Complications

• Epididymo-orchitis or PID
• Reactive arthritis
• Infertility or ectopic pregnancy

Investigations

• First pass urine OR self-collected vaginal swab OR clinician-collected endocervical swab for chlamydia Nucleic Acid Amplification Test (NAAT) using specific swab kit eg cobas®
• Anorectal and pharyngeal swabs for NAAT for MSM

Treatment

• Uncomplicated genital infection or asymptomatic rectal infection
• doxycycline 2 mg/kg (max 100 mg) PO bd for 7 days (generally not recommended for children ≤8 years)
  OR
  azithromycin 20 mg/kg (max 1 g) PO single dose
• Symptomatic anorectal infection requires treatment with doxycycline for 21 days OR azithromycin 1 g stat followed by repeat dose in 12-24 hours
• If high index of suspicion, treat without waiting for lab results
• No sexual contact for 7 days after treatment is administered
• No sexual contact with partners from the last 6 months, until the partners have been tested and treated if necessary
• Complete other STI screening
• Laboratory will notify department of health
• Follow-up after 1 week with GP or other health professional to confirm symptom resolution and contact tracing complete, provide sexual health education and prevention
• Test of cure not routinely recommended, however, re-testing to detect re-infection at 3 months is recommended

Neisseria gonorrhoeae

• Immunity to new infection is not provided by previous infection
• Co-infection with chlamydia is common

Symptoms

• Up to 80% of women and 10-15% of men have no genital symptoms
• Urethral or vaginal discharge
• Dysuria or dyspareunia
• Ano-rectal symptoms
• Conjunctivitis

Complications

• Epididymo-orchitis or PID
• Rarely: disseminated disease, meningitis or endocarditis

Investigations

• Always collect samples for gonococcal culture prior to treatment, however do not delay treatment to wait for these culture results
• First pass urine OR self-collected vaginal swab OR clinician-collected endocervical swab
• Asymptomatic: Neisseria gonorrhoeae NAAT
• Symptomatic: NAAT and MCS
• Consider urethral swab if discharge or other local symptoms
• Consider anal and pharyngeal swab for NAAT +/- MCS if MSM, anorectal symptoms (anal swab) or multiple sexual partners (pharyngeal swabs)

Treatment

• Uncomplicated genital and anorectal infection
• Ceftriaxone 50 mg/kg (max 500 mg) IM single dose
  AND
  Azithromycin 20 mg/kg (max 1 g) PO single dose (2 g in pharyngeal infection)
• If high index of suspicion, treat without waiting for lab results
• No sexual contact for 7 days after treatment is administered
• No sexual contact with partners from the last 2 months, until the partners have been tested and treated if necessary
• Complete other STI screening
• Contact tracing, factsheet, notify department of health (may be done by the laboratory)
• Follow-up after 1 week with GP or other health professional to confirm symptom resolution and contact tracing complete, provide sexual health education and prevention
• Test of cure (NAAT for each site of infection) should be performed 2 weeks after treatment is completed. Re-testing to detect re-infection at 3 months is recommended

Pelvic inflammatory disease

• Polymicrobial inflammatory condition
• Usually a complication of undiagnosed or improperly treated chlamydia or gonorrhoea infections, although non-STI related PID can occur
• Prompt treatment to prevent sequelae including ectopic pregnancy, infertility and chronic pelvic pain

Symptoms

• Range from asymptomatic to severe peritonitis and tubo-ovarian abscess formation
• Abdominal and pelvic pain (usually dull), fever, vaginal discharge, abnormal vaginal bleeding, uterine/cervical/adnexal motion tenderness on pelvic exam
• 50% will have gastrointestinal symptoms

Investigations

• Endocervical swabs for MCS, chlamydia, gonorrhoea and mycoplasma genitalium PCR NAAT
• Urine for urinalysis, MCS and pregnancy test
• FBE, CRP ± blood culture if septic

Treatment

• Refer to gynaecology
• Begin treatment without waiting for results
• Outpatient
• Ceftriaxone 50 mg/kg (max 500 mg) IM single dose
  PLUS
  doxycycline 2 mg/kg (max 100 mg) PO bd for 14 days
  PLUS
  metronidazole 10 mg/kg (max 400 mg) PO bd for 14 days
• Inpatient
• Indications: surgical emergency (such as appendicitis cannot be excluded), pregnancy, not responding or unable to tolerate to oral treatment regimen, severe illness/nausea/vomiting/high fever, tubo-ovarian abscess, immunodeficiency
• Ceftriaxone 100 mg/kg (max 2 g) IV daily OR cefotaxime 50mg/kg (max 2g) IV 8-hourly
  PLUS
  azithromycin 10 mg/kg (max 500 mg) IV daily
  PLUS
  metronidazole 12.5 mg/kg (max 500 mg) IV 12-hourly

Genital warts

• Caused by Human Papillomavirus (HPV) transmission via direct skin to skin contact with lesions or genital secretions
• Long latency period, does not imply recent sexual activity
• Reduced since introduction of HPV vaccination program

Symptoms

• Warty growths in and around genital skin with little discomfort, sometimes itchy

Complications

• Rarely malignancy, often detected on cervical cytology

Investigations

• No specific diagnostic test for HPV is available, diagnosis based on visual appearance

Treatment

• Prevention: HPV vaccination as per National Immunisation Program
• Treatment is cosmetic rather than curative
• Avoid shaving or waxing in the area as this may facilitate local spread by autoinoculation
• Refer to gynaecology for consideration of
• Podophyllotoxin or Imiquimod
• Cryotherapy, excision under local anaesthetic

Genital herpes

• Can be due to Herpes simplex virus (HSV) type 1 (>50%) or HSV type 2, and is often acquired without symptoms

Symptoms

• Initial episodes may be severe with extensive ulceration and systemic features
• Recurrent ano-genital ulcers or blisters
• Erythema with itching or tingling
• Urethritis or cervicitis

Complications

• Neuropathic bladder (initial episode)
• Increases risk of HIV transmission
• Risk of vertical transmission to neonate

Investigations

• HSV NAAT swab base of ulcer or deroofed vesicle (require visible lesions)
• Screening asymptomatic individual with serological tests is not recommended
• Consider other causes of vulval ulcers

Treatment

• Do not delay treatment waiting for lab results, particularly if severe
• Simple analgesia, salt baths, topical lignocaine, urinating in bath/shower
• First episode:

valaciclovir 20 mg/kg (max 500 mg) PO bd for 5-10 days
OR
aciclovir 10mg/kg (max 400 mg) PO tds for 5-10 days

• Recurrence episodic:

valaciclovir 20 mg/kg (max 500 mg) PO bd for 3 days
OR
famciclovir 1 g PO bd for 1 day (>12 years old)

• Recurrence suppressive:

valaciclovir 20 mg/kg (max 500 mg) PO daily for 6 months
OR
famciclovir 250 mg PO bd for 6 months (>12 years old)

• Contact tracing is not recommended
• Follow-up in 1 week with GP

Bacterial vaginosis

• While not an STI, it can be acquired through sexual activity and is the most common cause of abnormal vaginal discharge in people of childbearing age
• Polymicrobial syndrome due to a change in vaginal microbiota

Symptoms

• 50% asymptomatic
• Offensive “fishy” smelling, thin, white vaginal discharge
• Mild vulval irritation

Complications

• Increased risk of pregnancy complications, PID and STI acquisition

Investigations

• High vaginal swab MCS and Gram stain
• Vaginal secretion pH test using pH paper or urine dipstick (>4.5 indicative of bacterial vaginosis)

Treatment

metronidazole 10 mg/kg (max 400 mg) PO bd for 7 days
OR
metronidazole 0.75% gel, intravaginally nocte for 5 nights (not on PBS)
OR
clindamycin 2% vaginal cream, intravaginally nocte for 7 days (not on PBS)

Trichomoniasis

• Caused by Trichomonas vaginalis
• Uncommon in urban settings and may be asymptomatic

Symptoms

• Often asymptomatic, especially in males
• Diffuse, malodorous, yellow-green vaginal discharge
• Vulval itch / soreness

Investigations

• First pass urine or high vaginal swab NAAT
• MCS swab vaginal secretions

Treatment

• Metronidazole 2 g PO single dose (>12 years old)
  OR
  Metronidazole 10mg/kg (max 400 mg) PO bd for 7 days
• Topical treatment is not advised
• No sexual contact for 7 days after treatment
• Current sexual partner should be treated

Syphilis

• Caused by Treponema pallidum

Symptoms

• Latent infection (50%): no symptoms, detected by serologic testing
• Primary infection: painless ulcer or chancre with well-defined margin and indurated base. Can be multiple and have associated inguinal lymphadenopathy
• Secondary infection (incubation 2-24 weeks): fever, malaise, skin rash, mucocutaneous lesions and lymphadenopathy
• Tertiary infection: cardiac or ophthalmic manifestations, auditory abnormalities or gummatous lesions

Investigations

• Serology: enzyme immunoassay (EIA) with further confirmatory tests if positive (RPR/VDRL, TPHA)
• Swab of ulcer: syphilis NAAT (PCR)

Treatment

• Primary, secondary and early latent syphilis: Benzathine penicillin G 50 000 units/kg IM (max 2.4 million units) single dose given as 2 injections (max 1.2 million units each)
• Late latent syphilis (>2 years) or syphilis of unknown duration: Benzathine penicillin G 50 000 units/kg IM (max 2.4 million units) given as 2 injections (max 1.2 million units each), weekly for 3 doses
• Refer to infectious diseases
• Review with repeat RPR at 3 months, 6 months +/- 12 months after completing treatment

Prevention of STIs

• Education and counselling to address specific risk factors and effective changes in sexual behaviour
• Use barrier contraception together with other methods
• Identify adolescents unlikely to seek health care services and provide opportunistic counselling and testing
• Effective diagnosis and treatment
• Appropriate evaluation and treatment of sexual partners
• Pre-exposure vaccination of persons at risk for vaccine-preventable STIs
• Referral for follow up

Consider consultation with local paediatric team when

Consider consultation with local gynaecology team

Inpatient management of PID is required

If sexual assault is suspected, please refer to local guidelines. Early consultation with specialist services is vital

Consider transfer when

Care required beyond comfort level of local services

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Clear plan for follow up of testing results and any further treatment made

Parent information

Sexual health fact sheets available in multiple languages

Additional notes

ASHA: Australian STI management guidelines for use in primary care
STI Atlas: educational images
STI tools
Queensland Health Guide to Offering STI testing to people under 16

Last updated November 2022