Internal Medicine 14: 18-year-old female for pre-college physical User: Ralph Marrero Email: [email protected] Date: May 9, 2022 8:42 PM

Learning Objectives

The student should be able to:

Describe and recall the HEEADSS mnemonic approach to adolescent counseling.

Obtain a history that differentiates among etiologies of dysuria.

Differentiate /distinguish signs and symptoms of lower versus upper urinary tract infection.

Recognize /recommend when to order diagnostic and laboratory tests in evaluation of dysuria, including urinalysis, wet prep, and KOH stain.

Recommend appropriate treatment for uncomplicated cystitis and pyelonephritis.

Describe current recommendations for cervical cancer screening.

Discuss safe sexual practices and efficacy of common methods of contraception.

Knowledge

HEEADSSS Approach to Adolescent Counseling

The HEEADSSS approach to adolescent counseling addresses the main categories of Home/health, Education/employment, Eating disorders, Activities, Drugs, Sexuality, Safety/violence, and Suicide/depression. View examples of screening questions for the HEEADSSS history. One of the nice qualities about the HEEADSSS approach is that it starts with less threatening issues and proceeds to more personal questions, so the interviewer has a chance to establish rapport before exploring sensitive, intrusive topics. Be sure to ask questions in a nonjudgmental way, and avoid questions that can be answered with "Okay" or with a "Yes/No" (i.e., "Do you get along with your mom and dad?"; "How are you doing in school?"; "Do you do drugs?"; "Are you sexually active?"). Remember to avoid making assumptions about a teen's behaviors. For example, don't assume that your patient is heterosexual, sexually active, or even dating.

Adolescent Interview—Safety

Violence

The leading causes of death in older adolescents are violent: suicide, injuries, and homicide. Bullying, family violence, sexual abuse, date rape, and school violence are all common. Data from the Center for Disease Control (CDC)’s Youth Risk Behavior Surveillance System (YRBSS) survey shows that in 2019, an average of 13% of high school students in the United States carried a weapon to school during the preceding 30 days. Family violence and dating violence cross all economic and social boundaries. Injuries

For some teens, school violence and guns are the major risks, and in others, sports injuries and injuries from wheeled vehicles are more likely. It is important to address the use of seat belts and bike helmets with every adolescent. Even though you address the safety issues most prevalent in the patient's community first, do not skip any part of the history based on assumptions about the patient's ethnic background or economic status.

Vaccination Recommendations for Adolescents and Teenagers

Vaccine Information

COVID-19 There are multiple manufacturers of COVID-19 vaccinations. Some are given in a two-shot series and some have approval for a third booster dose. They are highly effective at preventing COVID-19 and in preventing severe disease.

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Haemophilus influenzae type b

Haemophilus influenzae type b vaccine protects against meningitis, pneumonia, epiglottitis, and bacteremia in infants and young children, but it is not recommended after the age of five years.

Hepatitis A Hepatitis A vaccination is effective in preventing hepatitis A virus infection. The series of two to three injections (depending on the type of vaccine) is recommended for adolescents if they did not receive them when younger.

Hepatitis B Hepatitis B vaccination is effective in preventing hepatitis B virus infection and its sequelae of cirrhosis and hepatic carcinoma. The series of three injections is recommended for adolescents if they did not receive them when younger.

Human papillomavirus

There are two different human papillomavirus vaccines available. They vary in the number of strains of HPV they protect against, ranging from four to nine, and can prevent most cases of cervical cancer and genital warts. It is recommended for girls and females 9-26 years old.

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The Advisory Committee on Immunization Practices (ACIP) recommends the use of the HPV vaccine in males 11 or 12 years of age. ACIP also recommends vaccination in males ages 13-21 who have not been vaccinated previously or who have not completed the three-dose series. ACIP states that males aged 22-26 years may be vaccinated, but does not recommend routine vaccination in this age group.

Influenza

The influenza vaccine is recommended for everyone who is at least six months old. It is usually administered in September through December when the influenza season is imminent.

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The H1N1 strain, or "swine" influenza, the predominant strain circulating in the U.S. since 2009, has high rates of morbidity and mortality among children and adolescents.

Meningococcal The meningococcal vaccine is given to prevent meningococcal meningitis. It is commonly given once at age 11-12 years during the routine preadolescent immunization visit with a booster dose at age 16 and is recommended for all previously unvaccinated adolescents aged 11-18 years.

MMR MMR is recommended in adults who have not been previously vaccinated as children. An exception to this recommendation is the case of pregnant females, given concern for fetal transmission from a live virus vaccine.

Pneumococcal The pneumococcal vaccine is indicated for adolescents with certain chronic health conditions, including immunocompromised state (including HIV, transplant status, and cancer), functional or anatomic asplenia, CSF leaks or cochlear implants, diabetes, and conditions of the heart, lung, and liver.

Tetanus-diphtheria- acellular pertussis

The tetanus, diphtheria, acellular pertussis (Tdap) vaccine protects against tetanus, diphtheria, and pertussis. It contains acellular pertussis vaccine (ap), which is less reactogenic than the older whole-cell pertussis vaccine that caused high fever and neurologic symptoms when given to older children and adults. Tdap, which was licensed in 2005, is the first vaccine for adolescents and adults that protects against all three diseases.

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Adolescents should receive a single dose of Tdap as a booster between the ages of 11 and 18, with the preferred timing between 11 and 12 years. If a patient has received a Td booster, then waiting at least five years between Td and Tdap is encouraged because the incidence of side effects is lower.

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The exception to this rule is the case of type III hypersensitivity reactions*, where one should wait 10 years between booster doses.

Varicella/chickenpox

The varicella vaccine series, which is a live virus vaccine, should be given to adolescents who have never had chickenpox or have not received the vaccine.

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Two doses are required, with the first administered at 12-15 months of age and the second at 4-6 years of age. There is also a combination measles, mumps, rubella, and varicella vaccine (MMRV) available.

*Type III hypersensitivity reactions (Arthus reactions), which are characterized by immune complex deposition in blood vessels, can rarely be seen following receipt of vaccines containing tetanus toxoid or diphtheria toxoid. These reactions are characterized by severe pain, swelling, and sometimes necrosis at the injection site and occur between 4 and 12 hours following vaccination. It is recommended that patients who have had such a type III hypersensitivity reaction avoid receiving a tetanus toxoid-containing vaccine more frequently than every 10 years.

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When a Pelvic Examination Is Indicated

Cervical cancer screening should start at age 21 regardless of sexual activity and should continue through the age of 65. There is recent evidence that screening for cervical cancer in females less than 21 years of age leads to potentially unnecessary procedures and more harm than benefit. The frequency of cervical cancer screening with the Papanicolaou (Pap) test for immunocompetent individuals with previously normal tests is once every three years or, for females ages 30-65 years, screening with high-risk human papillomavirus (HPV) testing alone or in combination with cytology every five years.

STI Screening Recommendations

Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection. USPSTF also recommends screening all sexually active women and pregnant individuals age 24 years and younger for chlamydia and gonorrhea. This is a B recommendation. Test results for most STIs, such as gonorrhea, chlamydia, HIV etc. must be reported to the public health department.

Most Common Causes of Cystitis

E. coli causes a majority of all cases of uncomplicated urinary tract infections. Other common organisms include Klebsiella pneumonia, Proteus mirabilis and Staphylococcus saprophyticus.

Differentiating Cystitis from Pyelonephritis

It is important to make the distinction between cystitis and pyelonephritis because the treatment differs.

Cystitis Pyelonephritis

Clinical manifestations

dysuria, frequency, urgency, suprapubic pain, and/or hematuria

may or may not have symptoms of cystitis together with fever (> 38 C) and other systemic symptoms, such as chills, flank pain, costovertebral angle tenderness, and nausea/vomiting

Urinalysis pyuria pyuria, white blood cell casts (pathognomonic)

Treatment

short-course antibiotic therapy (three to five days for uncomplicated cystitis);

hospitalization usually not required

at least seven days of treatment;

hospitalization may be required

Dysuria in Males

Disease Presentation Diagnosis

UTI and cystitis

Isolated acute cystitis is rare in males because their longer urethra hinders bacteria from reaching the bladder, and prostatic fluid has antibacterial properties.

Most males with acute cystitis have functional or anatomic abnormalities, and need further evaluation.

Symptoms of lower and upper tract infections are the same in males and females.

Midstream culture and sensitivity of the urine

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Urethritis

Usually sexually transmitted gonococcal and/or chlamydial infection.

Gonococcal urethritis is more likely in males with acute symptoms and purulent urethral discharge.

Chlamydia is likely when dysuria is present alone or with minimal discharge. Males with chlamydia infection may be asymptomatic.

Recommended that patients be treated presumptively for both gonorrhea and chlamydia, pending results.

Herpes simplex virus is a rare cause of urethritis, but may be suggested by the history of penile lesions.

Diagnosis can be made on a Gram stain of a urethral swab.

Leukocytes and Gram-negative intracellular diplococci confirm the diagnosis of gonorrhea.

White cells without organisms suggest non-gonococcal urethritis (NGU) which is usually chlamydia but can also be Trichomonas vaginalis.

Because many outpatient offices are not equipped to do Gram stains, NAAT testing of the urethra or urine is becoming the preferred diagnostic test for gonorrhea and chlamydia.

Prostatitis

Acute prostatitis

Presents with UTI symptoms of fever, chills, dysuria, dribbling, and hesitancy, and is caused by Gram-negative rods (Enterobacteriaceae, Pseudomonas, Proteus), Gram-positive organisms (Enterococcus, S. aureus), and sexually transmitted agents such as Neisseria gonorrhoeae and Chlamydia trachomatis.

Prostate is edematous and very tender on digital rectal examination.

Chronic prostatitis

Characterized by lower urinary tract symptoms, perineal discomfort, pain with ejaculation, and occasionally deep pelvic pain that radiates to the back. The symptoms are often subtle and sometimes may be absent, and the physical exam may be normal.

This diagnosis should be considered in males with recurrent UTIs without risk factors.

Diagnosis can be difficult to make and may require submitting urine specimens gathered following prostatic massage for microscopic urinalysis and culture.

Epididymitis

Patients with epididymitis present with dysuria, frequency, urgency, and unilateral testicular pain.

Fever and rigors may be present and there may be redness and tenderness of the entire affected testicle.

Testicular torsion should be considered in all cases, especially when the patient is an adolescent and the onset is sudden.

Epididymitis in males < 35 years is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae; in those > 35, enteric Gram-negative rods (Escherichia coli) are the most common causes.

If the diagnosis is questionable, color duplex doppler scanning should be obtained immediately.

Factors that Contribute to Complicated Urinary Tract Infections

Anatomic or functional abnormalities of the urinary tract

Anatomic or functional abnormalities of the urinary tract lead to stasis and impede the free flow of urine, promoting bacterial growth and causing complicated infections.

Hospital-acquired Hospital-acquired urinary tract infections are considered complicated because patients are more susceptible to developing infections with antibiotic-resistant organisms that are found in the hospital environment.

Immunosuppressed or recently treated with antibiotics

Patients who are immunosuppressed or who recently have been treated with antibiotics are considered to have complicated infections.

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Male Urinary tract infections in males are complicated because they are commonly associated with bladder outlet obstruction, instrumentation, or other urologic abnormalities. However, a small number of adult males can develop uncomplicated UTIs. Risk factors associated with these infections are men having sex with men, intercourse with a urinary tract-infected female partner, and lack of circumcision.

Pregnant Urinary tract infections in pregnant females are considered complicated because they can progress to andcan induce preterm labor.

Urinary catheter or recent instrumentation

Urinary tract infections in patients with urinary catheters or recent instrumentation are considered complicated because they introduce external pathogens into the urinary tract and, in the case of indwelling catheters, provide a nidus for bacterial growth.

Birth Control Options

Percentage of females experiencing an unintended pregnancy within the first year of use: United States

Method Typical use Perfect use

No method 85 85

Spermicides 29 18

Withdrawal 27 4

Fertility awareness-based methods 25

Standard days method 5

Two day method 4

Ovulation method 3

Sponge

Parous females 32 20

Nulliparous females 16 9

Diaphragm 16 6

Condom

Female (Reality) 21 5

Male 15 2

Combined pill and progestogen-only pill 8 0.3

Evra patch 8 0.3

NuvaRing 8 0.3

Depo-Provera 3 0.3

Combined injectable (Lunelle) 3 0.05

IUD

ParaGard (copper T) 0.8 0.6

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Mirena (LNG-IUS) 0.2 0.2

Implanon 0.05 0.05

Female sterilization 0.5 0.5

Male sterilization 0.15 0.10

Adapted from WHO Medical eligibility criteria for contraceptive use (2015)

Male latex condoms: when correctly used with each episode of intercourse are the best protection against sexually transmitted infections.

IUDs: can be considered for females at low risk of acquiring sexually transmitted infections, since sexually transmitted infections may require removal of the IUD. Females with a history of PID can safely use the IUD with appropriate counseling. IUDs can be used as long as the female is not planning a pregnancy for at least one year, since attempting a pregnancy would require IUD removal. Females who have never been pregnant can safely use the IUD.

Post-coital contraceptives: (emergency contraception) initiated within 72 hours of unprotected intercourse reduce the risk of pregnancy by at least 75%.

Management

First-Line Empiric Therapy for Cystitis

In large part, empiric choice of antimicrobial agents for uncomplicated cystitis depends on regional susceptibility patterns.

In most regions of the U.S., rates of resistance of E. coli to ampicillin and amoxicillin exceed 20%, which makes amoxicillin a poor choice for empiric therapy.

In most areas, resistance rates for nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are less than 10%. Therefore, these have become recommended first-line empiric therapy in the U.S. However, the rates of resistance to these antibiotics vary by geographic region and can exceed 20% in some areas.

Fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin), in many areas, have favorable resistance profiles, but in some areas resistance rates exceed 20%. Even if the resistance rates are < 10%, fluoroquinolone use can select for multidrug-resistant organisms (sometimes referred to as "collateral damage") and there are several “black box” warnings on fluoroquinolones due to some serious side effects. Therefore, fluoroquinolones should be considered alternative therapy and reserved for patients who do not tolerate or are not eligible to receive recommended first-line agents. Selected beta-lactam agents may be reasonable choices as well when other agents cannot be used. However, there is less data with these agents. The beta-lactams that could be considered for treatment in select circumstances based on local susceptibility data include amoxicillin-clavulanate, second-generation cephalosporins (cefaclor), third-generation cephalosporins (cefdinir and cefpodoxime), and, in some instances first-generation cephalosporins (cephalexin and cefadroxil). In the end, the final choice of antibiotic should depend on a variety of factors, including local susceptibility patterns, patient allergies, potential drug-drug interactions, recent antibiotic use, and renal function, among others.

Recommended Dosing and Duration for Cystitis Therapy

Nitrofurantoin monohydrate or macrocrystals should be dosed at 100 mg twice daily for five days. The efficacy of this regimen has similar efficacy to that of a three-day regimen of trimethoprim-sulfamethoxazole in a randomized-control trial. However, other recommended first-line agents have different recommended durations. See the table below for recommended durations of first- line agents. First-line antimicrobial regimens for use in acute uncomplicated cystitis in the United States.

Drug Dose and interval Duration

Trimethoprim-sulfamethoxazole 160/800 mg q 12 hours 3 days

Nitrofurantoin monohydrate macrocrystals 100 mg q 12 hours 5 days

Fosfomycin trometamol 3 gm in a single dose 1 dose

Recommended Therapy for Pyelonephritis

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In patients with pyelonephritis, a urine culture with sensitivities should be sent in addition to a urine dipstick and microscopic urinalysis. Definitive antibiotic choice should be based on the results of the urine culture. For empiric therapy before the results of the urine culture are obtained, an oral fluoroquinolone is the first-line treatment if the local resistance rates are < 10%, as in this case. Fluoroquinolones provide high drug concentrations in the renal medulla. A longer course of at least seven days should be given for pyelonephritis. Trimethoprim-sulfamethoxazole should be used in pyelonephritis only if the culture and sensitivity results are available and if the infecting organism is known to be susceptible. Two-week regimens are generally advised when using trimethoprim- sulfamethoxazole. If trimethoprim-sulfamethoxazole is to be used prior to obtaining results of a urine culture, a single intravenous dose of a long-acting cephalosporin, such as ceftriaxone, should be given before starting the course of trimethoprim- sulfamethoxazole. Nitrofurantoin should not be used to treat pyelonephritis because adequate tissue levels in the kidney are not attained.

Who Should Be Hospitalized For Pyelonephritis

Patients who cannot maintain oral hydration or cannot take oral medicines should be hospitalized, as should those who have social circumstances or other factors that hinder adherence to therapy.

Patients who appear septic, who are hemodynamically unstable, and who have any complicating factors should also be hospitalized.

In many cases, people with diabetes should be hospitalized for parenteral therapy because they have worse outcomes, and diabetics have an increased risk of complications such as emphysematous pyelonephritis or abscess.

Pregnant females should be hospitalized, because pyelonephritis is associated with an increased incidence of fetal complications and premature delivery.

Preventing Recurrent UTIs

1. The first step in evaluating recurrent dysuria is to prove the patient is actually having urinary tract infections by urinalysis and urine culture. Dysuria could be due to atrophic vaginitis, genital herpes, interstitial cystitis, mechanical or chemical irritation, or urethritis.

2. The next step after proving recurrent cystitis is to ask the patient about risk factors and predisposing factors to complicating infections. These predisposing factors should be treated if present.

3. In patients without predisposing factors, some clinicians attempt behavioral and lifestyle modification. Because sexual activity is associated with recurrent infections, doctors often recommend that females void before and after sexual intercourse. This, and advice to wipe "front to back," increase fluid intake (including cranberry juice), and avoid full bladders, have not been proven to reduce the recurrence of infection, but they are benign maneuvers, and still make sense to many clinicians.

4. For post-menopausal females, topical estrogen normalizes the vaginal flora and reduces the risk of recurrent infection.

5. Especially if these conservative measures fail and the patient has at least three proven urinary tract infections per year or at least two in six months, antibiotic prophylaxis may be considered.

Potential strategies include continuous prophylaxis, post-coital prophylaxis, and self-treatment. Rates of urinary tract infections do not differ significantly between continuous and post-coital prophylaxis. Post-coital prophylaxis will result in less antibiotic use than continuous prophylaxis with similar efficacy, especially if the infections are temporally related to sexual intercourse. Likewise, patient-initiated treatment upon developing symptoms can represent a cost-effective management strategy if infections are not severe and not frequent. The ultimate choice of agent for prophylaxis or treatment should depend on local susceptibility patterns and susceptibility patterns of the patient's prior urine cultures. Generally, the recommended duration of continuous prophylaxis is six months followed by observation for reinfection.

Recommended Chlamydia Therapy

First-line chlamydia therapy is a one-time oral dose of azithromycin 1 gram or a seven-day course of oral doxycycline 100 mg twice daily. The one-time regimen of azithromycin is preferred because of better adherence. Levofloxacin and ofloxacin are considered alternative treatment agents and require seven days of therapy.

Studies

Cervical Cancer Screening Guidelines

Age Recommendation

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Under 21 Females under the age of 21 should not be tested, regardless of sexual activity.

21-29 Females between the ages of 21 and 29 should have a Pap test every three years with the liquid-based cytology technique.HPV testing should not be used in this age range unless it is prompted by an abnormal Pap result.

30-65 There are three options for screening females between the ages of 30 to 65: 1. "Co-testing" with the Pap test and a high-risk HPV test every five years, 2. Pap test alone every three years, or 3. High-risk HPV testing alone every five years.

Over 65

Females older than 65 who have had negative Pap tests and documentation of adequate prior screening for the past 10 years are unlikely to have abnormal Pap tests with repeat testing so should no longer be screened. Screening should occur for 20 years after a pre-cancerous lesion is detected, even if testing continues after the age of 65.

These guidelines apply to females without medical conditions or exposure that place them at a higher risk of cervical cancer. Females in the following groups should be screened more frequently (e.g. annually):

those with HIV infection

those who are immunosuppressed (i.e., patients with transplanted organs, on chemotherapy, or on chronic steroids)

those with diethylstilbestrol (DES) exposure before birth

Recommended Pelvic Exam Tests in the Setting of Suspected STIs

Microscopic examination of slide with drop of vaginal discharge and normal saline

The saline-prepped or "wet mount" slide allows for diagnosis of Trichomonas and bacterial vaginosis.

Microscopic examination of slide with drop of vaginal discharge and potassium hydroxide

The potassium hydroxide slide is used to visualize budding yeast and hyphae that are seen with Candida vaginal infections.

Nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis

The best way to test for Chlamydia and Gonorrhea during a pelvic exam is nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis. NAAT is a sensitive and specific assay and has replaced culture methods. It can be used on urine specimens as well.

Smelling a slide with a drop of vaginal discharge and potassium hydroxide

Placing a drop of potassium hydroxide on vaginal discharge is known as the whiff-amine test. The production of a fishy odor indicates a positive test. A positive whiff-amine test is seen in bacterial vaginosis.

Tests not indicated:

Gram stain in cervicitis is not sensitive enough to detect infection, although it is highly sensitive and specific for the detection of Neisseria gonorrhoeae in male urethral specimens. Culture of cervical specimens has largely been replaced by nucleic acid testing. Smelling a slide with normal saline is not useful.

What to Look for on Wet Mount Slides

In the case of trichomoniasis, wet mount slides reveal trichomonads, which are flagellated protozoans. The treatment is a single dose of 2 grams of metronidazole.

Clue cells can also be seen on a saline slide and are characteristic of bacterial vaginosis (BV). BV, the most common cause of abnormal vaginal discharge in females of childbearing age, is a condition characterized by reduced numbers of normal vaginal lactobacilli and overgrowth of other vaginal bacteria. Clue cells are epithelial cells entirely covered with these bacteria, giving the perimeter a "furlike" appearance. The treatment of BV is a course of metronidazole 500 mg twice daily for seven days.

It is also useful to measure the pH of vaginal discharge. A pH greater than 4.5 is seen in trichomoniasis, bacterial vaginosis, and atrophic vaginitis.

Diagnostic Tests for Cystitis

Microscopic urinalysis

Pyuria, defined as at least two to five leukocytes per high-powered field in a spun urine specimen, is present in almost all females © 2022 Aquifer, Inc. – Ralph Marrero ([email protected]) – 2022-05-09 20:42 EDT 8/11

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