GENITOURINARY/GYNECOLOGICAL DISORDERS

URINARY TRACT INFECTION (UTI) most Risk factors include: premature & low birth weight due to immature kidneys,
common pediatric urinary problem
: the presence of bacterial congenital urological abnormalities (reflux, neurogenic bladder), females except during infancy
→more common in males
infection of the urinary tract involving the (shorter urethra, close to anus), dysfunctional voiding (urinary stasis,
bladder (cystitis), urethra (urethritis) or kidney incomplete bladder emptying), functional obstruction (constipation, pregnancy),
(pyelonephritis). trauma/irritants (catheterization, bubble baths, intercourse, sexual abuse, pinworms)
ETIOLOGY SIGNS/SYMPTOMS DIAGNOSTICS MANAGEMENT
Escherichia coli May be asymptomatic Urine analysis not diagnostic (UA): Parenteral antibiotics: used to treat newborns,
(80-95% of all Newborns: irritability, ✚ leukocyte esterase, ✚ nitrate, infants, or older children with severe, systemic
childhood UTI’s) poor feeding, weight loss, ✚blood symptoms, fever, or unable to take fluids
Enterobacter, diarrhea, fever, vomiting, Urine culture: identified Oral antibiotics: 10-day regimen is standard (can
Klebsiella, Infants/preschoolers: presence of CFU/mL of specific be extended to 14-days for complicated infections)
Staphylococcus diarrhea, vomiting, fever, organisms identified (2nd culture →TMP/SMX (1st line for infants > 2 mo): TMP 6-
rd
saphrophyticus poor feeding, strong/foul- 72 hrs after & 3 culture 1 week 10 mg/kg/day, SMX 30-60 mg/kg/day bid
(common in males)
smelling urine after starting antibiotic) →Amoxicillin: 30-50 mg/kg/day tid
School-age/ Blood culture: collected in →Augmentin: 40 mg/kg/day tid
adolescents: infants <12 months with →Sulfisozazole: 150 mg/kg/day qid
fever, suspected sepsis →Cephalexin: 50 mg/kg/day tid
vomiting, Radiological studies: only →Nitrofurantoin: 5-7 mg/kg/day in ÷ doses (best
strong/foul indicated if child has symptoms for bladder infections)
smelling of pyelonephritis, is < 3 months Prophylactic antibiotic (very controversial) – not
urine, supra- old, males w/ 1st infection & indicated for infants 2-24 months but there are
pubic or females w/ 2nd infection. case-by-case circumstances that warrant
urethral exceptions (i.e. vesicoureteral reflux (VUR) which
pain, can be treated with ½ dose of TMP/SMX at
frequency, bedtime). VUR usually resolves on its own with
dysuria, growth unless child had dysfunctional voiding or
incontinence eliminating.
Random voids/bagged urine: not used due to high probability of false positives from contamination
Clean-catch midstream: reliable for circumcised males and older females with mild symptoms (✚ if 50,000-100,000 CFU/mL)
Straight catheterization: infants & children who cannot void voluntarily w/ moderate to severe symptoms (✚ if >10,000 CFU/mL)
Supra-pubic aspiration: infants & children who cannot void voluntarily & need urgent culture due to severity (✚ if >1,000 CFU/mL)
PATIENT EDUCATION: ↑fluid intake, frequent voiding, complete bladder emptying, good perineal hygiene, front to back wiping, avoid
urethral irritants and bubble baths

BLADDER RENAL ULTRASOUND → first step in

evaluating for structural and developmental anomalies

VOIDING CYSTOURETHROGRAM (VCUG) → detects

reflux of urine after diagnosis to exclude cause (continue
antibiotic till after test completion)

INTRAVENOUS PYELOGRAM OR NUCLEAR RENAL

CORTICAL SCANS → used to detect scarring and examine
renal function conducted if VCUG is ✚)

ACUTE DMSA (dimercaptosuccinic acid) →done during

time of infection to assess renal inflammation and/or uptake
defects
ENURESIS: Involuntary urination after a child has reached age when bladder control is usually attained during the day (diurnal) or at
night (nocturnal). Considered abnormal if problem persists beyond 7th birthday.
ETIOLOGY SYMPTOMS MANAGEMENT
TYPE Familial •Bedwetting Primary nocturnal: limit fluids after dinner, double voiding before
predisposition or daytime bedtime, avoid punishment, Usually resolves on its own
Primary Enuresis Small bladder urine leakage Motivational therapy: verbal praise for dryness, reward system,
most common
: child has capacity, toilet- •Odor of dryness calendar (not usually successful if done by itself)
never gained control training problems, urine on Conditioning therapy: enuresis alarm triggered by urine awakens child
delayed maturational clothing or at night (expensive, takes 2-6 mo, high relapse rates, disrupts others)
voiding inhibitory bedding Pharmacologic treatment:
reflexes, sleep •Withdrawn → Desmopressin acetate: 0.2-0.6 mg PO 1hr before bed → Synthetic
problems (“deep & isolated ADH analog that works in 1-2 wks (titrate based on effectiveness, high
sleeper”), lack of self from relapse rates, SE: headache, congestion, nasal irritation, epistaxis)
inhibition of ADH, peers → Imipramine: 0.9-1.5 mg/kg/day, 1-2 hrs before bed (max 25-
ingestion of too much •Dribbling 50mg/day) → tricyclic antidepressant thought to ↓ bladder
fluid, inattention or occurs during contractions & works in ≈2 wks. Treat for 3-6 mo
too busy to void physical before taper off (controversial due to possible ASE
exam like depression, seizures, arrhythmias, dry mouth,
sedation – best to obtain EEG before starting
therapy, high relapse rates.
Secondary Enuresis: Diseases (UTI, DM, Hypospadias Determine
reoccurrence of GU abnormalities) Epispadias underlying
incontinence Medications Labial fusion etiology &
following a period of (theophylline, treat
at least 6 month of diuretics) according
dryness Family or other stress

CRYPTORCHIDISM (undescended testes): absences of one or both testes in scrotal sac due to failure of
normal descent from abdomen during fetal development.
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Premature infants (born before testes May be asymptomatic Routine assessment of testicles at
descend into scrotum at 28-36 wks) Testes may or may not be palpable every well visit during 1st year
Hormonal imbalance Palpable: may be Refer to urologist if undescended
Chromosomal abnormalities retractile or ectopic by 1 year (for hormonal therapy
Structural disorders Non-palpable: may be or surgical orchiopexy between
Familial predisposition abdominal or absent 12-18 mo)
PATIENT EDUCATION: increased risk of infertility especially if bilateral, testicular malignancy, & hernia

HYDROCELE most common cause of painless scrotal swelling: painless scrotal swelling due to collection of peritoneal fluid within the tunica vaginalis
surrounding the scrotum
TYPE ETIOLOGY SYMPTOMS MANAGEMENT
Scrotal swelling or asymmetry (appears tense but scrotal skin is normal) Refer if persists beyond 1 year
Non-tender (except some discomfort with coughing or straining)
Translucent with trans-illumination
Non-communicating: tunica Size of hydrocele constant or fixed Most of the time resolves without intervention
vaginalis is closed, limiting Refer if there is a significant increase in size, or
fluid collection to scrotum, causes discomfort
Communicating: tunica Incomplete Size of hydrocele changes with activity Occasionally resolves spontaneously
vaginalis remains open closure of & rest, gets larger over through the day Often develops into a hernia that requires
allowing fluid to flow processes Often associated with a hernia (obtain surgical intervention
between peritoneum & vaginalis abdominal ultrasound to differentiate)
hydrocele sac
HYPOSPADIAS: Congenital defect w/ urethral meatus on the ventral surface of the penis (most common in Caucasians westerners)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Urethral folds along midline Can be located all along the ventral shaft of penis (glans, corona, Avoid circumcision (foreskin
fail to fuse due to genetic & anterior shaft, midshaft, scrotal, penoscrotal junction, posterior shaft) will be used for repair)
environmental factors Chordee = Ventral curvature of penis due to fibrous band of tissue Refer to pediatric urology →
early repair (6-18 mo) for
better outcomes

PHIMOSIS: Narrow, non-tractable foreskin of childhood to limit glans exposure (may not be fully retractable till age 10)
Primary phimosis in the newborn is normal Secondary phimosis not normal (scarring after bilantitis)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Inflammation/ infection Foreskin can not be retracted Maintain good hygiene
under foreskin May be asymptomatic Gently stretch the foreskin during bath
Congenital narrowing & Painful & weak urination without force
tightness Foreskin may balloon out when urinating Circumcision if urinary obstruction occurs
PARAPHIMOSIS: inability to replace foreskin over glans after retraction
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Forcible retraction of Pain & tenderness GOAL: to ↓ foreskin swelling
foreskin for “cleaning” Visible Ice, application of granulated sugar to the penis, wrap distal
purposes edema/discoloration of penis in saline soaked gauze & apply pressure for 5-10 mins
foreskin & glans May inject hyaluronidase beneath band to release it

MEATAL STENOSIS: Narrowing of the distal end of the urethra

ETIOLOGY SIGNS/SYMPTOMS
Only seen in a circumcised penis Penile pain & discomfort w/
(mechanical diaper irritation, urination
frenular artery damage during Glans inflammation
procedure leading to ischemia, Slit like or narrowed meatus
inflammation from dermatitis of Narrow, dorsally diverted urine
skin) stream
High-velocity urine stream
Occasional bleeding post-void
MANAGEMENT
Exposure to air
Warm soaks/baths
Frequent diaper changes
Meatotomy is certain cases
Cover glans with petrolatum g
after circumcision & monitor

TESTICULAR TORSION: Torsion of the spermatic cords (emergency → can lead to gangrene of testes).
Most common in adolescent males
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Abnormal fixation of Acute painful swelling, redness, and warm of scrotum of Medical emergency →
the testis to the the affected side requires immediate
scrotum (allows testis Enlarged, highly tender testis referral for surgery within
to twist/rotate Nausea, vomiting, anorexia the first 6 hours of onset to
ultimately impeding Anxious patient resistant to movement preserve fertility &
lymphatic and blood Minimal fever prevent atrophy/abscess
flood) Urinary symptoms absent formation
 Can also occur after Lifting of testes does no relieve the pain (Phehn’s sign) If left untreated, can lead
scrotal trauma Solid mass visualized with trans-illumination to testicular loss

LABIAL ADHESIONS (labial fusion, synechia valvae, labial agglutination): Benign fusion of labial minora – not seen much in
newborns due to maternal estrogen. Usually occurs after 2 mo old (mostly b/w 3 mo – 6 yrs)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Thought to be result of tissue Generally asymptomatic Dribbling of urine Most cases involve parental reassurance and close
irritation (trauma, superficial Difficulty voiding throughout the day observation without intervention
infection, poor hygiene & General discomfort Thin, flat midline Mechanical lysis no longer recommended due to high
damp skin, sexual abuse), Enuresis due to pooling membrane frequency of re-fusion
inflammation and of urine behind adhesion extending from Observed for UTI symptoms
hypoestrogenization of labial after voiding (depending clitoris to posterior Topical application of conjugated estrogen cream
minora on degree of obstruction) fourchette → apply sparingly bid for 2-3 weeks will result in
Complete Fusion: entire vestibule Partial fusion: most of the genital separation within 8 weeks 90% of the time
covered w/ only small pinpoint opening structure visible → overuse of cream will lead to precocious puberty i.e.
breast buds, which resolve with discontinuation
→transient hyperpigmentation of labia may occur during
treatment
→Maintain good hygiene
→ follow up with topical application of bland creams or
petroleum

VULVOVAGINITIS: Perineal inflammation and/or infection of the vulva (vulvitis) or vagina (vaginitis) often associated with vaginal
discharge, odor, itching, & irritation
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Sources can be Infectious or Non- Vaginal discharge, discomfort, itching, Pelvic exam should be preformed in pubescent
infectious dysuria, burning, erythema, edema, odor female who complains of abdominal pain**
Physiologic Leukorrhea: normal think, clear, or white discharge from vagina Improvement of perineal hygiene first
Non-specific vaginitis usually resolves on it’s
beginning at the onset of puberty
own

Noninfectious
ETIOLOGY SIGNS MANAGEMENT **if pelvic exam is not successful or
Chemical irritation White-yellow Discontinue use
discharge of any irritants child uncooperative, refer out for
(bubble bath, powder,
detergents, soaps, douches) vaginal exam under anesthesia
Mechanical irritation White-yellow Wear cotton underwear & loose fitting cotton lined clothes
(tight clothing, nylon discharge
underwear)
Foreign body irritation Brown, If Pre-pubertal: irrigate w/ warm saline using small feeding tube
(toilet tissue retained tampon) bloody, foul If Post-pubertal: preform pelvic exam to locate object & remove
odor w/ moistened cotton-tip applicator**
Trauma/sexual abuse Treat any associated STD/STI
Masturbation
Allergy to latex condoms Non-latex condoms or another form of contraception

Infectious
ETIOLOGY SIGNS MANAGEMENT
Nonspecific bacterial thin-white frothy discharge, Metronidazole 1 g/day PO in two divided doses for 7 days
(Bacterial vaginosis) clue cell on wet mount, (adolescents), 15 mg/kg/day (child <45 kg) (max 1g/day
fishy odor on “whiff test” Metronidazole gel, 0.75%, 5 g intra-vaginally qd for 5 days
→ overgrowth due to pH > 4.5 (acidic) (adolescents)
poor hygiene Clindamycin cream 2%, 5 g intravaginally qhs for 7 days
Specific Bacteria (Group A hemolytic White-yellow discharge(CT) →ID bacteria using a vaginal swab & select antibiotic according
streptococcus, pneumococcus, enterococcus, shigella
flexneri, Gardnerella vaginalis, mycoplasma hominis, PATIENT EDUCATION (Leukorrhea):
Neisseria gonorrhoeae, chlamydia trachomatis (CT)) emphasize that it is a normal part of puberty
Viral (herpes simplex virus, human suggest wearing “panty liner” to absorb excess wetness and staining,
papillomavirus)
recommend AGAINST the use of douches & creams

Parasitic (pinworms, Trichomonas: Pale yellow- Pinworms: Mebendazole, pyrantel pamoate, albendazole as single
trichomonas vaginalis gray discharge, pH > 4.5 dose & repeat in 2 wks
(TV) (acidic) Trich: Metronidazole 15 mg/kg/day PO in 3 doses for 7 days
via wet mount with KOH (child <45 kg) (max 1g/day), 2 g PO as single dose or 1 g/day PO
in two divided doses for 7 days (child >45 kg),
 Fungal (candidiasis – White, thick, cheesy Fluconazole 150 mg single dose
especially after antibiotic discharge with hyphae on Topical agents (clotramazole, micanozole, butoconazole nitrate,
use) wet mount terconazole

DYSMENORRHEA: pain during menstrual cycle, usually on the 1st or 2nd day, cramping discomfort felt mid-to-lower abdomen as a
result of increased uterine prostaglandins, contractions, & ischemia (ovulation is a key component)
SIGNS/SYMPTOMS
Pain can start anywhere from 2 hrs before menses, at the onset of menses or several hours to days after menses begins
Crampy/spasmodic pain, primarily in lower abdomen (may radiate to inner thighs or lower back)
May be accompanied by nausea, vomiting, diarrhea, lightheadedness, dizziness, fatigue or general malaise
Pelvic exam only indicated if adolescent is sexually active (assess cervical motion tenderness as sign of PID)
PRIMARY DYSMENORRHEA (common in adolescents)
Not caused by any pelvic abnormality & develops 6-12 months after menarche & ovulation cycle
MANAGEMENT
Apply heat to abdomen
Exercise
Well balanced diet
Acknowledge that the pain is real
1st (mild): Ibuprofen (400 mg PO at onset of pain, q 6-8 hrs for 1-3 days, take with food,
milk, antacid to avoid GI distress)
2nd (moderate): Naproxen sodium (500 mg PO at onset of pain then 250 mg q 6-8 hrs)
3rd (moderate): Mefenamic acid (500 mg PO at onset of pain then 250 mg q 6-8 hrs)
4th (severe): Low dose combination oral contraceptives (OCPs) for at least 4 cycles
→Assess efficacy of medication after 3-4 cycles before switching to another medication
→ NSAIDs contraindicated in clotting disorders, renal/peptic ulcer disease, pre-op patients, NSAID or ASA allergy, ASA induced asthma
→ OCPs can be used in conjunction with NSAIDs
→ if nothing helps, refer to gynecologist
SECONDARY DYSMENORRHEA
Caused by congenital anomalies (septate uterus), cervical stenosis or strictures, cysts or tumors of the ovary or uterus, endometriosis,
pelvic inflammatory disease
MANAGEMENT
Begin PID treatment immediately if indicated
Refer to gynecologist if persistent after PID treatment or pelvic pathology exists

PREMENTRUAL SYNDROME (PMS): cluster of symptoms, physical, cognitive, & behavioral that occur in second half of menstrual
cycle (last week of luteal phase) and resolve with the onset of menses. Symptoms exist over several cycles and cause disruption of normal
activities (most women experience at least 1 symptom)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Fluid retention Onset within 1 week of menses: ↑ intake of complex carbohydrates, protein, fruits, vegetables, & food
Steroid hormone Muscle aches, hot flashes, chills rich in B6 (sunflower seeds, pasticcio nuts, tuna bananas, lean meats,
fluctuation Appetite Δ’s, weight gain, bloating died fruits, bananas, avocado, spinach)
Alteration in Mood swings, irritability, lethargy ↓ intake of sugar, salt, red meat,
serotoninergic Depression, Anxiety alcohol, coffee, tea, chocolate
neuronal mechanisms Breast tenderness Small frequent meals
Inappropriate ↓ concentration Regular aerobic exercise
prostaglandin activity Low back pain Stress & psychosocial management
Vitamin deficiencies Acne Track symptoms in a period diary
(evidence Headache Avoid alcohol
inconsistent) Constipation Sleep at last 9 hrs a day
Diuretics, NSAIDS, SSRIs
(fluoxetine, sertraline, paroxetine if women has PMDD)
Oral contraceptives with follow up (not helpful for all women)

GENIROURINARY TRAUMA: injury to the genitourinary tract due to ACCIDENTAL injury

ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
 Blunt insult Frank, urethral bleeding
from athletics, Hematuria,
MVA, falls bluish-red perineal mass
Hematomas (urethral,
scrotal, perineal)
Peri-urethral lacerations
Referral needed if extensive injury for radiographic imaging
Mild bruising, superficial lacerations to urethra/vulva → ice
pack, stiz baths, analgesics
Blunt/penetrating trauma to
urethra/vulva → surgical referral
Testicular trauma → surgical
referral
Suspected renal injury → referral
Penetrating injury → immediate
surgical exploration

GLOMERULONEPHRITIS: diffuse inflammatory, immune-mediated

kidney disease of theglomeruli
Primary acute→ post-streptococcal glomerulonephritis
Primary chronic→ usually with IgA nephropathy, others are membrano-
proliferative glomerulonephritis, mesangial proliferatove glomerulonephritis
Secondary→ associated with systemic lupus erythematous, anaphylactoid
purpura, vascular problems
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Not completely understood – a Severity depends on extent of renal All treatment is
combination of factors lead to involvement. symptom
kidney injury: Acute symptoms: Hematuria, ↓UO, management and
→Immune complex deposits in Edema (periorbital in the morning), Dark supportive care:
glomerular basement membrane urine (acute poststreptococcal HTN & edema relief
→Fibrin deposits from blood glomerulonephritis), HTN, Costovertebral → fluid restrict,
coagulation angle (CVA) tenderness diuretics, vasodilators
→Exogenous nephrotoxins Chronic disease: Fatigue, FTT Antibiotic if throat or
(penicillamine, trimethadione, Urinalysis: ✚RBC, ✚WBC(leukocytes), skin infection persists
captopril, probenecid, gold, ✚Casts, ✚ protein, low pH, ↑spec. grav.
mercury injection)

HYDRONEPHROSIS: unilateral or bilateral dilation of the kidney most commonly occurring at the site of
the ureteropelvic junction (UPJ) (slightly more common in males)
ETIOLOGY SIGNS/SYMPTOMS MANAGEMENT
Usually Nausea Renal scan shows effect of
caused by an Abdominal or flank pain obstruction on kidney
anatomic ↓UO Surgery needed to relieve obstruction
block of FTT (early exploration & repair indicated
urine flow to May be asymptomatic in to preserve renal parenchyma)
the kidney older children Long-term follow up for assessment
of kidney function required

ETIOLOGY SIGNS/SYMPTOMS RENAL TUBULAR ACIDOSIS (RTA): defect in normal urine

Cellular bases of Growth failure, Muscle weakness acidification resulting in persistent metabolic acidosis
defect unknown GI complaints Distal tube (type 1): defect in the distal tube secretion of hydrogen
(may be genetic) Serum electrolytes: NaHCO3<16mEq, ↑K+ ions → First morning urine pH > 5.8 (basic urine)
Proximal tube (type 2): defect in the reabsorption of bicarbonate →
First morning urine pH < 5.5 (acidic urine)
MANAGEMENT
GOAL: to achieve optimal growth and bone mineralization &
prevent nephrocalcinosis and progression to renal failure
Correct acidosis by restoring bicarbonate to normal level (IV for
infants, PO for most child) →Alkali administration as sodium
bicarbonate or sodium citrate (325mg – 650mg NaHCO3 tablets)
Normal growth resolves with corrected acidosis
Correct electrolyte imbalance: Potassium (K+) supplement if
 needed, diuretics to ↓ K+
Long term clinical monitoring warranted

SEXUALLY TRANSMITTED INFECTIONS

GONORRHEA: ETIOLOGY ↑RISK SIGNS/SYMPTOMS (common) TREATMENT
acute infectious Gram(-) Females < 25 yrs, Thick, purulent, greenish-yellow discharge from *Ceftriaxone
process primarily diplococcus previously infected, vagina or penis sodium 125mg, one
Antimicrobial
involving the Neisseria multiple sex Perineal discomfort IM dose
prophylaxis NOT
genital tract, gonorrhoeae partners, Frequent, painful urination (child <8yrs & <45 kg)
recommended for
anorectum, throat, inconsistent condom Rectal pain/itching Ceftriaxone sodium,
& ophthalmic abused PRE-
use, commercial sex Sore throat, fever, malaise, chills 125mg, one IM dose
epithelium work, drug use External genitalia redness & edema (child >8yrs & >45 kg)
OR Cefixime, 400
DIAGNOSTICS FEMALES MALES mg, PO, single dose
Nucleic acid 50-80% of females 10-40% of males (child >8yrs & >45 kg)
amplification asymptomatic asymptomatic Ceftriaxone
tests (NAATs) best Menstrual irregularity Enlarged, tender (same dose) is
sensitivity/specificity
Cervical erythema, prostate the
through vaginal exudative tenderness Unilateral scrotal antimicrobial
swab or first part & vaginal wall and groin pain prophylaxis
penile void discharge on pelvic Sore swelling for abused
exam over testis POST-
ETIOLOGY SYMPTOMS TREATMENT
Disseminated Bacteremic Infection after Polyarthralgias, Ceftriaxone, 50 mg/kg/day, IV/IM single dose for
gonococcal spread of N. recent menstruation, tenosynovitis (fever, 7 days (max 1g/day), (child <8yrs & <45 kg)
infection (DGI) gonorrhoeae pregnancy, or malaise, chills), Ceftriaxone, 1g, IV/IM, single dose, for 7 days OR
immediately dermatitis, triad, Cefixime, 1g, IV q8hr for 7days (child >8yrs & >45kg)
postpartum, SLE, purulent arthritis (no If improvement seen in 1-2 day, can switch to
compliment systemic symptoms) Ciprofloxacine 500 mg bid for 7 days
deficiencies Purulent arthritis requires joint drainage
CHLAMYDIA: ETIOLOGY ↑RISK SIGNS/SYMPTOMS (common)
most common Obligate intra- Females < 25 Conjunctivitis or pneumonia is transmitted to neonate from untreated
reported STI in cellular yrs, multiple maternal infection
the US primarily chlamydia sex partners, Yellow, watery discharge from vagina or penis
affecting the trachomatis (CT) MSM, & young Can be asymptomatic for months to years
genital tract, men in high- Abdominal/pelvic pain
cornea & prevalence Dysuria/burning
respiratory tract areas External genitalia redness & edema
Tenderness on pelvic exam
DIAGNOSTICS TREATMENT
Nucleic acid amplification tests Doxycycline, 100 mg bid for 7 days OR Azithromycin 1 g single dose
(NAATs) most sensitivity/specificity through (adolescents)
vaginal or urine of asymptomatic Azithromycin 1000mg PO x 1 OR Erythromycin base, 500mg qid for 7
days (if not well tolerated, give in ½ doses for 14 days), OR Amoxicillin
women, cervical if symptomatic, or
500mg PO tid for 7 days (pregnant women)
urine for males (rectal & pharyngeal
also by less specific) Erythromycin, 50mg/kg/day qid for 7 days OR Azithromycin 20mg/kg
single dose (child >6 mo & <12yrs), (max 1g/day)
Tissue culture containing epithelial
cells (for suspected abuse) Erythromycin, base or ethylsuccinate 50 mg/kg/day qid for 14 days, may
need 2nd coarse, monitor for infant hypertrophic pyloric stenosis (child < 6mo)
Retesting needed after treatment with Erythromycin or Amoxicillin
ACQUIRED SYPHILIS: a contagious systemic infectious disease characterized by three progressive clinical stages
CLINICAL STAGE TREATMENT
Primary stage → one or more painless lesions usually on Treatment for primary, secondary, & early
 genitals but are also seen on lips, tongue, or extremities at site latent syphilis without neurological symptoms:
of exposure that may go unnoticed. Penicillin G benzathine, 50,000 – 2.4 million
Chancres take 1-6 wks to resolve, very infectious. U/kg IM as single dose (children)
May also have painless regional lymphadenopathy Penicillin G benzathine, 2.4 million U/kg IM as
Secondary stage → occurs between 1 and 2 months after single dose (adults)
inoculation, characterized by fever, malaise, sore throat, Doxycycline, 100 mg PO bid for 14 days OR
generalized polymorphic maculopapular skin rash that includes Tetracycline, 500 mg, PO qid for 14 days (If
palms & soles, round to oval, reddish brown, “copper-colored” allergic to PNC & NOT pregnant)
lesions cutaneous lesions, hair loss, lymphadenopathy, Follow up in 6-12 months after treatment (more
arthralgia, headache, splenomegaly (25% relapse if untreated) frequently if co-infection with HIV)
Latent stage → No lesions, early latent period lasts less then 1 Frequent screening recommended for sexual
None year & late latent can last over 1 year but timeline usually active individuals and their partners
vague and difficulty to demarcate
Treatment for late latent & tertiary syphilis:
Tertiary stage → multisystem involvement that reoccurs years Penicillin G benzathine, 50,000 – 2.4 million
after primary infection if left untreated. Includes aortitis or U/kg IM as 3 single doses at 1 wk intervals
gummatous changes of skin, bone or viscera. Rarely in (children)
adolescents. Penicillin G benzathine, 2.4 million U/kg IM as 3
single doses at 1 wk intervals (7.2 million total)
(adults)
Doxycycline, 100 mg PO bid for 4 wks OR
Tetracycline, 500 mg, PO qid for 4 wks (If allergic
to PNC & NOT pregnant)
Follow up in 24 months after treatment (more
frequently if co-infection with HIV)
Neurosyphilis: May be asymptomatic Aqueous crystalline penicillin G 200,000-300,000 U/kg/day q 4-6 hrs for
and can occur at any stage of the 10-14 days (children, do not exceed adult dose)
infection. Neurological signs include Aqueous crystalline penicillin G, 18 – 24 million U/ U/day in doses of 3-
fever, headache, photophobia, 4 million units, IV q 4hrs for 10-14 days OR penicillin G procaine, 2.4
meningismus, cranial nerve palsies, & million units, IM once daily ✚ probencid, 500mg, 4X/day PO for 10-14
less frequently confusion, delirium, and days q 4-6 hrs for 10-14 days (adults)
seizures. Higher risk if co-infected with Doxycycline, 100 mg PO bid for 4 wks OR Tetracycline, 500 mg, PO qid
HIV. for 4 wks (If allergic to PNC & NOT pregnant)
Congenital syphilis: Trans-placental transmission Complication → Jarisch-Herxheimer reaction:
from infected mother to fetus that may result in sepsis like reaction to an antibiotic when
stillbirth or neurological impairment and bone endotoxins are released from the death of a
deformities in the infant harmful organism → warrants urgent medical
evaluation
TRANSMISSION ETIOLOGY ↑RISK DIAGNOSTICS
Sexual contact, Thin, motile MSM, Dark-field microscopy tests or direct fluorescent antibody
trans-placental, spirochete multiple or (DFA) test → presence of spirochete from scraping of lesions
direct contact with Treponema anonymous (inexpensive, definitive diagnosis)
infected tissue pallidum sex partners, Serology tests (presumptive diagnosis)
High rates Non-Treponemal→ rapid plasma reagin (RPR), venereal disease research
co-infection laboratory (VDRL), toluidine red inheated serum test (TRUST), unheated
w/ HIV serum regain (USR)
Treponemalgreater specificity→fluorescent treponemal antibody absorption
(FTA-ABS) and Treponema pallidum particle agglutination (TP-PA)
(expensive, detects specific antigens, inaccurate if co-occurring lyme disease, acute
infection, autoimmune disorders, narcotic addiction)

GENITAL HERPES SIMPLEX VIRUS (HSV): most common HSV infection among adolescents characterized by clusters of painful
lesions of genital tract, perineum, mouth, lips, or pharynx (rare in pre-pubertal children except in cases of child abuse)
TRANSMISSION ETIOLOGY ↑RISK SIGNS/SYMPTOMS COMPLICATIONS
Sexual contact, contact herpes simplex virus HSV Symptoms more severe & persistant if aseptic meningitis,
w/ open lesions, HSV- HSV-2 → primary infection infected person is immunosuppressed encephalitis, &
1 autoinoculation to source of genital herpes, increase Painful, ulcerated, vesicular, lesions on genital proctitis in MSM
genitals, transplacental usually effecting skin risk of tract, perineum, mouth, lips, pharynx
below the waist acquiring Genital, perianal erythema, edema
HSV-1 → primary HIV Cervial friability & discarge
source of oral herpes, Burning with urination
usually affecting skin Tender, swollen lymph nodes
above the waist & face Fever, malaise
DIAGNOSITCS TREATMENT EDUCATION
Tissue culture → only accurate if Primary genital infection (initiating treatment within 6 days of onset Sitz baths may also
done with vesicular lesions of primary may reduce duration and severity of symptoms): Acyclovir, 200 mg PO, provide some relief
infection 5 times/day for 7-10 days OR 400 mg tid for 7-10 days, Valacyclovir 1 Recurrences,
PCR-DNA probe test for CSF g PO bid for 7-10 days & Famiciclovir 250 mg PO tid for 7-10 days Viral shedding,
specimens → high sensitivity and (alternative with less frequent dosing) Abstinence with
specificity Recurrent episodes (initiate treatment as soon as lesions appear): lesions are present,
Direct fluorescent antibody/enzyme Acyclovir, 200 mg PO, 5 times/day for 5 days OR 800 mg PO bid for 5 use of condoms
immunoassay → faster results but less days OR 800 mg PO tid for 2 days, Famiciclovir 1000 mg PO bid for 1
sensitive day OR 500mg PO bid for 2 days OR Valacyclovir 500mg PO bid for 3
PCR → very sensitive, often used to days or 1000 mg PO qd for 5 days (acyclovir tends to be less effective
detect shedding during clinical trials for recurrent infections, topical treatment with acyclovir has so benefit)
Serologic testing → has limited Suppressive therapy (when occurring over 6 times/year): Acyclovir,
value, used to confirm diagnosis but 400 mg PO, bid, Famiciclovir 250mg bid, or Valacyclovir 500mg PO qd
often shows no rise in recurrences (1000mg qd of >10 occurrences per year)
GENTIAL WARTS (Condylomata acuminate): most common symptomatic viral reproductive tract infection in the united states
characterized by epithelial warts/tumors of mucous membranes and skin (rare in pre-pubertal children except in cases of child abuse)
TRANSMISSION ETIOLOGY ↑RISK SIGNS/SYMPTOMS
Sexual contact Human Sexually Firm, flesh colored, anogenital lesions resembling
(include anal Papillomavir active female cauliflower configuration (3-4 mm to 2-4 cm)
genital wards for us (HPV) adolescents Males→warts on penis shaft, meatus, scrotum & perineum
anal receptive (over 200 Females → warts on labia & perianal areas
intercourse) subtypes Occasional local symptoms such as burning,
exists) pain, itching, and bleeding
Often asymptomatic
DIAGNOSITCS TREATMENT EDUCATION
Usually based on None → treatment is focused on removal of lesions, symptoms relief & close First PAP smear at age 21
clinical inspection follow-up for reoccurrences - refer to gynecologist if warts on cervix Repeat every 3 years
alone (no culture Often resolve spontaneously with 3 months (25% of cases) If ✚ ASCUS or LSIL,
available) Podophyllum resin solution or gel 0.5% (contraindicated during pregnancy) repeat in 12 months
Colposcopy to detect → apply to lesions bid for 3 days, no need to washed off (can be repeated up to If High grade SIL
cervical lesions (not 4 times with a 4 day rest period between cycles, first application done in office suspected, refer directly to
definite) Podophyllum 10-25% in a compound tincture of benzoin (applied by GYN for colposcopy
Pelvic examination clinician, contraindicated during pregnancy) → repeated weekly for 6 wks. First HPV testing at age 30
(pap smear for Tincture washed off within 1-4 hrs. Best to prevent with HPV
cytological analysis Imiquimod 5% cream → apply tid for up to 16 weeks but may cause itching, vaccine, safe sex practices,
may be diagnostic) ulcers, pain, or burning (not recommended if pregnant, or HSV/HIV infected) and frequent STD
Biopsy of lesions for Trichloracetic acid (TCA 80-90%, applied by clinician) → topical application screening
histologic exam (may followed by careful drying and application of talc or baking soda, repeated
be diagnostic) weekly for up to 6 application but may cause so local discomfort
DNA probe (used to Liquid nitrogen or cryotherapy → preformed by a trained provider
detect asymptomatic Laser surgery, cryosurgery, excision, electrodessication → reserved for
HPV) extensive, severe, or resistant cases
TRICHOMONIASIS: common STI of the genital tract (rare in pre-pubertal children except in cases of child abuse)
TRANSMISSION ETIOLOGY ↑RISK SIGNS/SYMPTOMS
Sexual contact (GC/CT A flagellated If mother is FEMALES MALES
often co-occurs ) protozoan infected, Frothy, light yellow-gray green vaginal Dysuria
Trichomonas ↑risk of discharge with a musty odor & pH>4.5 Itching
vaginalis low-birth Vulvo-vaginal irritation & itching Often
weight and Dysuria, frequency, abdominal pain, asymptomatic
prematurity dyspareunia
Cervix is inflamed with punctate
hemorrhages know as “strawberry cervix”
25-50% asymptomatic
DIAGNOSTICS TREATMENT EDUCATION
Wet mount of vaginal secretions or spun Pre-pubertal children: Metronidazole 15 mg/kg/day PO Avoid alcohol & sexual
urine sediment shows presence of motile tid for 7 days (max 2g for 7 days) or 40mg/kg PO single activity during treatment & 24
trichomonads (may also be seen on PAP dose (max 2g) hrs after treatment (72 hrs if
smear & urinalysis) Adolescents & Pregnant women: 2g PO as single dose or treated with tinidazole)
Culture, NAATs, DNA hybrid probes, 375 mg bid for 7 days Inform partners, condom use,
✚ rapid antigen tests, PCR analysis Alt: Tinidazole 2.0g PO single dose evaluated for other STI’s
BACTERIAL VAGINOSIS (BV): clinical syndrome characterized by vaginal symptoms, mostly in sexually active adolescents/adults
TRANSMISSION ETIOLOGY SIGNS/SYMPTOMS
May or may not occur Not an actual infection (classified as STD) Profuse, thin, white-gray, vaginal
through sexual contact Occurs as a results of normal vaginal flora (lactobacillus) being discharge that adheres to vaginal
replaced with high concentrations of anaerobes (Gardnerella wall and has a “fishy” odor
vaginalis, mycoplasma hominis) May be asymptomatic
DIAGNOSTICS TREATMENT EDUCATION
Vaginal pH > 4.5 &10% KOH Metronidazole, 500 mg, PO, bid for 7 days or 2 g Avoid douching
mixed w/ vaginal discharge PO as single dose with 2nd dose in 48 hrs OR Commonly reoccurs
releases amine “fishy odor” Clindamycin cream 2%, one full applicator (5g) No need to treat male partner
(whiff test) intra-vaginally at bedtime for 7 days Increased risk for PID
Saline wet mount shows “clue cells” (epithelial Metronidazole gel 0.75%, one full applicator (5g) If pregnant mother is infected,
cells covered in bacteria) obliterating the nucleus intra-vaginally bid for 5 7 days ↑risk of chorioamnionitis &
Culture not helpful & expensive Clindamycin, 300 mg, PO, bid for 7 days prematurity

CONTRACEPTION:
MECHANISM DIFFERENT TYPES PROS CONS RISKS
Abstinence most effective (chosen by 50% of adolescents) Should be discussed as a viable option regardless of prior history
Male Condoms Mechanical barrier worn Over 100 brands Failure rate 18% due to nonuse/misuse
most effective
by the man that prevents 1-2% breakage rate
(male barrier) semen from entering the Latex→ Protects against Can only be used w/ water-based lubricant
vagina **If combined w/ recommended pregnancy & STD Latex breaks down w/ petroleum-based
spermicide, NOT more products, time, & heat exposure
effective at protecting Polyurethane (latex-free) → for those with a latex allergy
against STD’s & HIV Natural lambskin → NOT recommended Does NOT protect against STD’s & HIV
Female Mechanical barrier worn Available OTC Typical use failure rate 21%
Condom by woman that prevents Comes packaged with a lubricant
(Female barrier) semen flow into vagina Can be inserted up to 8 hrs before sex
Vaginal Topical creams, jellies, Used alone or with condom Typical use failure rate 6%
spermicide foams, suppositories, & *Should NOT be used with a Not effective in preventing cervical
films to stop pregnancy lubricant or microbicide for gonorrhea, chlamydia, or HIV
(Ingredient: nonoxynol-9 anal intercourse due to rectal Increased risk of UTI’s in women
or octoxynol-9) cell damage
Diaphragm Thin, latex dome w/ A cervical cap is a smaller, Side effect: Requires pelvic exam for proper fitting
(Female barrier) flexible ring & thimble size cup that is fitted vaginitis, UTI Must be kept in place for 6 hrs after sex
spermicide applied that to cover the cervix (difficult Spermicide agent must be used to
is inserted before sex. to place, high infection risk) subsequent intercourse
COMBINED ORAL CONTRACEPTIVES:(includes oral contraceptive, transdermal contraceptive patch, vaginal contraceptive ring)
MECHANISM HEALTH BENEFITS CONS & RISKS
Prevents ovulation ↓risk of endometrial & cervical cancer, Improved Typical use failure rate 0.5-9%
↑viscosity of cervical mucus, inhibiting androgen sensitivity, ↓risk of hospitalization from Side effects: thrombosis, vaginal
sperm penetration PID, ↓endometriosis, ↓iron deficiency anemia, spotting, nausea, bloating, irritability
Alters endometrium to resist implantation Improved dysmenorrhea Do not protect against STD’s & HIV
TYPE MECHANISM & USE CONS & RISKS
Oral contraceptive Estrogens: mestranol & ethinyl estradiol (1.2-1.4 ×’s stronger, Antibiotics, antifungals,
effective @ low doses, 20-35μg - start low) anticonvulsants, antacids
Progestin’s: morethindrone, norethindrone, acetate, etc.) Come in ↓ efficacy
monophasic, diphasic, or triphasic combinations which deliver Ascorbic acid, co-
constant or progressively increasing progestin during cycle trimaxazole ↑ efficacy
Transdermal Ethinylestradiol/norelgestromin → apply 1 patch & Apply to dry skin & rotate site each time
patch repeat w/ new patch weekly for 2 more weeks. Failure rate higher in women >198lbs
Vaginal ring Ethinylestradiol/etonorgestrel: Inserted ring must remain User must learn how to place and check for
in place for 3 weeks ring
ABSOLUTE CONTRAINDICATIONS RELATIVE CONTRAINDIATIONS
Impaired liver function Pregnancy Severe HTN Chronic diseases (DM, heart
Undiagnosed abnormal vaginal Estrogen-dependent carcinoma Migraines disease, sickle cell)
bleeding h/o clotting disorder Rheumatic disorders
LONG ACTING PROGESTINS: injectable and implantable to inhibit ovulation
TYPE MECHANISM & USE SIDE EFFECTS CONS & RISKS
DEPO (Depo- 150 mg/mL IM injection Quick start method can be used spotting, weight Typical use failure rate 0.35%
medroxyproge q 3 mo during 1st 5 days w/o waiting for menses but gain, bloating, May ↓ bone density (monitor Ca &
steron) of period to ensure non- requires (-) pregnancy test headaches, mood Vit D intake)
pregnant status & repeat 2 wks after dose changes Should not be used over 2 yrs
*EC can be give if intercourse occur in the prior 5 days ABSOLUTE CONTRAINDICATIONS
If over 13 weeks occurs between injections, preform a Pregnant, postpartum, or Undiagnosed abnormal vaginal bleeding
pregnancy test as a precaution lactating adolescent mothers Breast malignancy
Active thrombophlebitis Significant liver disease
Nexplanon Etonogestrel 68 mg, long acting & reversible Vaginal bleeding Typical use failure rate 0.35%
1 rod implanted in SubQ tissue of upper, inner arm & spotting are Does not protect against SDT’s &
Effective for 3 years not predictable HIV
Intrauterine Safe, long acting Copper T 380A → lasts 10 years, ↑ uterine & tubal fluids ↓risk of Does not protect
Device (IUD) reversible that impair sperm fxn, typical use failure rate 0.8% ectopic against SDT’s &
contraception Mirena (LNG-IUS) → lasts up to 5 years, releases, pregnancy HIV
placed by a levonorgestrel 20 mcg/day which thicken cervical mucus, Fertility
clinician inhibits sperm, & suppresses endometrium, reduces blood restored when
loss, typical use failure rate 0.2% discontinued

MECHANISM DIFFERENT TYPES CONS RISKS

Emergency Use of oral contraceptive within
contraception 72hrs of unprotected sex to
(EC) terminate pregnancy if
determine to be a
Strong possibility
Over 20 OTB brands on the market
Plan B→ progesterone only (i.e. leconorgestrel),
2 tabs or 1 tab, can be obtained OTC
Meclizine HCl 25-50mg may be given before
first dose of OTC method to ↓ nausea
Still preform pregnancy test if no
menses after 3 weeks
Typical use failure rate 1.6%
May not be covered by insurance
since it can be obtained OTC

ADOLECENT PREGNANCY
ETIOLOGY/RISKS INCIDENCE SIGNS/SYMPTOMS
Early onset of sexual activity U.S. has one of the 1st trimester: irregular menses, nausea, vomiting, urinary frequency, breast
Inadequate concept of fertility & highest rates of tenderness/fullness, nipple tingling/discharge, darkened areola, headache,
contraception adolescent vertigo, abdominal cramps, abdominal pelvis at symphasis pubis, ↑leukorrhea,
Low socioeconomic status pregnancy & births 2lb weight gain, fetal heart tones by Doppler (10-12 wks)
Poor academic achievement among developing 2nd trimester: darkened skin pigmentation, abdomen & breasts striae, fundus
Low self-image, few life options nations (although between symphasis pubis & umbilicus (14-15 wks) then at umbilicus @ 20-22
h/o physical/sex/substance abuse rates have decline wks fetal movement or “quickening” (16-20 wks), Braxton-hicks contractions
Barrier to contraception use in last 2 decades) (16-27 wks), fetal heart tones by fetoscope (20 wks), 11lb weight gain
(misinformed, lack of health Teen moms are 3rd trimester: increased contractions, colostrum from breasts (28-40 wks),
care, poor partner more likely to drop fundus between umbilicus & xiphoid (28 wks) then at xiphoid (38 wks), 11lb
communication out of school & weight gain, bloody show with impending labor, ruptured membranes
Exposure to irresponsible media have more teen Labor: STAGE 1 → effacement & dilatation of cervix, STAGE 2 → delivery
portrayal of sex pregnancies of fetus, STAGE 3 → separation & delivery of placenta
DIAGNOSTICS COUNSELING & EDUCATION
Urine test for human Impact of future plans, finances, family structure, anticipated paternal involvement
chorionic gonadotropic Options for pregnant adolescent include 1) Continue with pregnancy & maintain custody, 2) Continue with
(hCG) will be ✚ at 1- pregnancy & place child up for adoption, 3) Termination of pregnancy
10 days after Prenatal care (exam, 2500-2700 kcal/day diet, prenatal vitamins w/ folic acid, iron for anemia, calcium PRN)
conception Avoid all medication unless approved by a healthcare provider
Blood test for MATERNAL RISK FACTORS
quantified levels of Disease (DM, thyroid disorder, immune deficiency)
human chorionic Age (Younger then 16 and older then 35)
gonadotropic (hCG) Previous child with downs, anencephaly, meningo-myelocele
will be ✚ at 1-10 days Poor prenatal care and/or nutrition
after conception, more GENETIC SCREENING (often initiated after birth of affected child, both parents must be involved)
expensive & takes Family pedigree (graphic record, medical history)
longer to process Alpha-fetoprotein (screens for neural tube defects, trisomy 21 & 18, Serum levels less accurate but can be
Cervical cultures – to done early on in the pregnancy, amniotic fluid analysis more accurate)
screen for GC/CT Amniocentesis (collection of amniotic fluid @ 15-16 wks gestation, karyotype/chromosomal analysis, inborn
Serology – to screen errors of metabolism, confirmatory test with abnormal serum alpha-fetoprotein)
for syphilis, Hep B Chorionic villus sampling (tissue sample from fetal placenta @ 9-11wks gestation, chromosomal
surface antigen, blood abnormality, usually reserved for women > 35 years)
type/Rh facto, glucose, DNA analysis (metabolic disease, hemoglobinopathies)
CBC w indices, rubella
HIV
TERMINATION
Spontaneous termination (miscarriage) → Occurs in 20% of all pregnancies, my be complete or incomplete, occurs before fetal
viability, often associated with genetic abnormalities in the fetus)
Elective termination (induced abortion) → Procedural options depend of trimester of termination
1st trimester (rule out STI before procedure)
Manual syringe evacuation/early suction curettage (4-6 weeks) → cannula positions into uterus with aspiration or suction of
conceptus (menstrual extraction), low risk of genital injury or complications
Suction curettage/vacuum aspiration (up to 12-14 weeks) → cervical dilation 61 hrs before procedure using laminaria (hydrophilic
seaweed sticks), cannula positioned into uterus with suction followed by curettage, safest if done during first trimester
Medical abortion (49 days or less) → Administration of mifepristone 600 mg follow with 400 mcg of misoprostol (a prostaglandin) 2
days later which acts as a anti-progesterone, risks include pain & excessive bleeding
2nd trimester (rule out STI before procedure)
Dilation & evacuation curettage i.e. D&E (20-24 weeks of pregnancy) → cervical dilation with osmotic dilators, conceptus remove via
curettage aspiration or ring forceps under general anesthesia (risk of cervical trauma, antibiotics recommended post procedure)
Prostaglandin suppository technique (16-24 wks, rarely used) → Cervical dilation with osmotic dilators followed by vaginal
suppositories of prostaglandin E, use of 20mg prostaglandin suppositories every 3-4 hrs induces labor & subsequent abortion within 4-60
hrs, complications include flu-like symptoms & possible delivery of live fetus

At 6-8 Hegar sign: softening Chadwick sign: Goodell’s sign: cervical

wks of uterine isthmus bluish hue to cervix softening
& vaginal epithelium