Sexually transmitted infections: Issues specific to adolescents

INTRODUCTION — This topic will focus on aspects of sexually transmitted infections (STIs) that are particularly relevant in adolescents. Details about clinical manifestations, diagnosis, and treatment of individual infections are discussed separately.

●Chlamydia trachomatis (see "Clinical manifestations and diagnosis of Chlamydia trachomatis infections" and "Treatment of Chlamydia trachomatis infection")

●Neisseria gonorrhoeae (see "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents" and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents" and "Disseminated gonococcal infection")

●Syphilis (see "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV" and "Syphilis: Screening and diagnostic testing" and "Syphilis in pregnancy" and "Syphilis: Treatment and monitoring")

●Human immunodeficiency virus (HIV) (see "Acute and early HIV infection: Clinical manifestations and diagnosis" and "Acute and early HIV infection: Treatment")

●Herpes simplex virus (see "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection" and "Treatment of genital herpes simplex virus infection" and "Genital herpes simplex virus infection and pregnancy")

●Chancroid (see "Chancroid")

●Pubic lice (see "Pediculosis pubis and pediculosis ciliaris")

●Trichomonas vaginalis (see "Trichomoniasis: Clinical manifestations and diagnosis")

●Condylomata acuminata (see "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis" and "Condylomata acuminata (anogenital warts): Treatment of vulvar and vaginal warts" and "Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in adult males")

●Mycoplasma genitalium (see "Mycoplasma genitalium infection")

●Lymphogranuloma venereum (see "Lymphogranuloma venereum")

ADOLESCENT SEXUAL DEVELOPMENT — Normal adolescent psychosocial development encompasses a desire for autonomy and an increase in risk-taking behaviors, making adolescents particularly vulnerable to STIs. (See "Sexual development and sexuality in children and adolescents", section on 'Adolescent development'.)

Early adolescence begins during the first years of the second decade and is marked by rapid physical growth and attainment of secondary sex characteristics.

Middle adolescence begins at approximately age 14 years, ends around age 17 to 18 years, and is marked by maturation of the reproductive systems and achievement of adult physical stature. Increased sexual interest and noncoital sexual behaviors are characteristic of middle adolescence. The average age of first coitus is approximately 16 years among American adolescents, but the age is lower in certain populations.

Late adolescence ends with the transition into young adulthood and is associated with high levels of sexual activity and acquisition of STIs.

EPIDEMIOLOGY — STIs are common in adolescents. Surveillance in the United States suggests that approximately two-thirds of incident chlamydia infections and one-half of incident gonococcal infections occur in adolescents and young adults (age 15 to 24 years) [1].

Between 2019 and 2020, rates of genital gonorrhea increased, rates of genital chlamydia decreased, and rates of primary and secondary syphilis decreased among male and increased among female adolescents (age 15 to 19 years) [2]:

●Genital gonorrhea – From 329 to 369 cases per 100,000 population in males and from 560 to 616 cases per 100,000 population in females

●Genital chlamydia – From 1012 to 846 per 100,000 population in males and from 3338 to 2858 cases per 100,000 in females

●Primary and secondary syphilis – From 11.2 to 10.9 per 100,000 population in males and from 4.9 to 5.9 cases per 100,000 population in females

Repeated acquisition of STIs is common: As many as 40 percent of the annual incidence of chlamydial or gonococcal disease occurs in adolescents previously infected with the causative organisms, and this proportion may be increasing [3]. Many adolescents are reinfected within a few months of an index infection [4,5]. (See 'Reinfection' below.)

Repeated acquisition of STIs is a risk factor for subsequent development of HIV infection. In a retrospective cohort of 75,273 high school students who participated in an STI screening program between 2003 and 2010, 248 students (0.3 percent) tested positive for HIV [6]. The risk of HIV infection was at least three times higher in students with multiple gonococcal infections than students with no history of gonorrhea (incidence rate ratio [IRR] 3.5, 95% CI 1.9-6.4 for females and IRR 5.1, 95% CI 3.6-7.1 for males). Among HIV-positive students, there was at least one year between the first STI and positive HIV test for 86 percent of females and 96 percent of males, suggesting a window of opportunity for preventive interventions.

Among adolescents, HIV infection is primarily transmitted sexually, although it may be transmitted by other routes (eg, injection drug use, blood products). Adolescent HIV is discussed separately. (See "The adolescent with HIV infection".)

RISK FACTORS

Behavioral — Behavioral factors have been linked to the increased risk of acquisition of STIs among adolescents, but biologic factors also may play a role.

Behavioral factors that have been associated with acquisition of STIs in adolescents include [5,7-11]:

●Time elapsed since first intercourse, particularly for human papillomavirus (HPV). In an observational study of urban females (14 to 17 years at enrollment), 25 percent were diagnosed with an STI within one year of first intercourse [5]. Repeated infections were common. These findings highlight the need for initiation of STI screening within one year of first intercourse and of retesting individuals who have been infected every three to four months. (See "Screening for sexually transmitted infections" and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Retesting' and "Treatment of Chlamydia trachomatis infection", section on 'Retesting for all patients'.)

●Sexual activity within early and middle adolescence, particularly for C. trachomatis infection [8].

●Multiple partners, new partners, or partners with multiple other partners [12].

●For male or transgender female adolescents: having sex with a person with a penis.

●Inconsistent use of condoms, especially with established partners.

●Alcohol and other drug consumption (although this factor may be associated with multiple partners, condomless sex, or sex with a high-risk partner) rather than serving as an independent marker of risky behavior) [13].

●Rectal douching or enemas in preparation for receptive anal sex (may break down the rectal mucosal barrier) [14].

●Receiving or sending sexually explicit messages ("sexting") is reported by approximately 20 percent of youth in the United States [15] and linked to sexual activities such as new partner acquisition and sex without a condom [16]; however, sexting has not been directly linked to increased STI risk.

Surveys of high school students in the United States indicate that the prevalence of sexual experience and most risk behaviors declined between 2001 and 2019, but fewer students reported using a condom during their last intercourse [17,18]. In the 2019 Youth Risk Behavior Survey, 38 percent of students reported that they ever had sexual intercourse (compared with 46 percent in 2001); 27 percent reported that they were currently sexually active (compared with 33 percent in 2001); 9 percent reported sexual intercourse with ≥4 persons during their life (compared with 12 percent in 2001); and 54 percent of those who were currently sexually active reported using a condom during their last intercourse (compared with 58 percent in 2001) [18].

Biologic — Several biologic factors have been hypothesized to influence the susceptibility of adolescents to acquisition of STIs. One such factor is cervical ectopy or cervical immaturity, which refers to the area of ectocervix that is covered by columnar epithelium after puberty. Young females with immature cervical epithelium have higher levels of several cervicovaginal and regulatory cytokines and chemokines than females with mature cervical epithelium [19]. Columnar epithelium is thought to be more susceptible than squamous epithelium (that replaces columnar epithelium upon maturation) to sexually transmitted organisms such as N. gonorrhoeae, C. trachomatis, and HPV [20], although one study could not demonstrate an independent association of cervical ectopy with STIs among adolescent females [21].

Adolescents' STI susceptibility may also be influenced by the composition of the cervical and vaginal microbiome. Vaginal microbiota play an important role in vaginal immune and inflammatory responses [22]. This microbiota – especially in terms of populations of various species of Lactobacillus – may be particularly variable after puberty and first sexual experiences [23,24].

Other risk factors — Other risk factors for acquisition of STIs in adolescents include [25]:

●Residing in a detention facility

●Mood disorders (which may increase the risk of substance use)

●Food insecurity (associated with increased risk behaviors and with STI positivity) [26]

●Adverse childhood experiences, including maltreatment, sexual abuse, and sexual trafficking [27]

SPECIFIC CONCERNS IN ADOLESCENTS — Although the evaluation and treatment of STIs in adolescents are similar to the diagnosis and treatment of STIs in adults, a number of specific concerns are particular to adolescents, including [28]:

●Consent and confidentiality

•Self-consent for diagnosis and treatment of STIs is recognized in all 50 states and the District of Columbia. However, state laws vary in terms of the specific infections defined as sexually transmitted. (See "Consent in adolescent health care", section on 'Sexually transmitted infections'.)

•Concerns about privacy and confidentiality are important barriers to seeking medical care among adolescents with possible STIs [29]. Specific discussion of the meaning and limits of confidentiality increases disclosure of sensitive information about symptoms, sexual activity, sexual partners, and preventive behaviors [30]. (See "Confidentiality in adolescent health care".)

•Patient portals in electronic health records and explanation of benefits are particular risks to adolescents' confidentiality for STI-related care. STI tests and results may be seen by parents unless systems are in place to limit access to adolescents only [31].

•Pharmacists or other medical personnel may inadvertently compromise confidentiality. A study from Indiana University shows that 30 percent of pharmacists would call parents about a prescription for antibiotics used to treat STIs [32]. (See "Confidentiality in adolescent health care", section on 'Potential threats to confidentiality'.)

●Pregnancy – Pregnancy or fear of pregnancy sometimes motivates care-seeking with a chief complaint of genital symptoms. (See "Pregnancy in adolescents", section on 'Diagnosis of pregnancy'.)

●Sexual minoritized youth – STIs in sexual minoritized (eg, lesbian, gay, bisexual, gender diverse) youth are discussed separately. (See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns", section on 'Sexually transmitted infections'.)

●Mandatory reporting in the United States

•Most states have "age of consent" laws that require notification of child protection authorities if sexual activity is identified, especially if there are large discrepancies in the partners' ages. Ages vary among the states. Large age discrepancies (>5 years) between partners are seen in approximately one-third of adolescents with first sexual intercourse very early in adolescence (ie, ages 11 or 12 years) and in approximately one-tenth of adolescents who have their first intercourse in middle or late adolescence [33]. (See "Confidentiality in adolescent health care", section on 'Consensual sexual activity'.)

•Reporting of some STIs is mandatory in all states, although the specific organisms vary. Syphilis, gonorrhea, and HIV/acquired immunodeficiency syndrome (AIDS) are reportable diseases in every state [34].

•Iowa requires parental notification for HIV infection [35]; the remaining states do not require parental notification, although notification is not expressly forbidden. (See "Confidentiality in adolescent health care", section on 'Sexually transmitted infections'.)

●Dating violence – In surveys, physical and sexual violence from dating partners are reported by as many as 20 percent of adolescent females [36,37]. However, such acts are infrequently reported to clinicians; questions regarding physical and sexual dating violence should be included in clinical assessments of sexual behavior and STI risk [38].

SEXUAL HISTORY — Routine assessment of sexual activity is an essential element of STI-related care and is endorsed by adolescents and parents/caregivers [39,40]. However, only approximately one-half of adolescents report being asked about sexual activity, and approximately one-fifth report being offered an STI test [41]. The sexual history (table 1) should be straightforward and nonjudgmental, with appropriate counseling regarding risk-taking behaviors as recommended by the United States Preventive Services Task Force [25,42]. An assurance of confidentiality is an important aspect of obtaining an accurate sexual history in adolescents; additional aspects are discussed separately. (See "Confidentiality in adolescent health care" and "Sexual development and sexuality in children and adolescents", section on 'Permission, privacy, and confidentiality'.)

SCREENING FOR STIs — Screening for STIs in asymptomatic adolescents and young adults is discussed separately. (See "Screening for sexually transmitted infections", section on 'Screening recommendations' and "Society guideline links: Sexually transmitted infections".)

EVALUATION FOR STIs — Adolescents with symptoms of STI should be evaluated for STI with examination and/or diagnostic tests. The components of the examination depend upon the suspected infection.

Examination — An external genital examination is indicated for evaluation of genital lesions that may be caused by genital herpes, primary syphilis, or human papillomavirus (HPV). Oral and anal/rectal examinations for signs of STI also are indicated based upon exposure risk.

Speculum and bimanual pelvic examinations may cause anxiety and/or discomfort and are not always necessary in the evaluation of suspected STI. Indications for speculum and bimanual pelvic examination in the evaluation of suspected STI include [43]:

●Abdominal and pelvic pain and tenderness

●Obtaining specimens for STI testing, although urine or other patient-collected (eg, vaginal swabs) specimens are effective and often are preferred by adolescents [44-51]

●Associated menstrual irregularities (eg, amenorrhea unrelated to pregnancy, prolonged or heavy vaginal bleeding)

●Evaluation of vaginal discharge if vaginal foreign body is suspected (eg, forgotten tampon, condom fragments, other objects)

●Cervical cancer screening (not routinely recommended for adolescents <21 years unless they are immune compromised) (see "Screening for cervical cancer in resource-rich settings", section on 'Age <21')

The pelvic examination is discussed in detail separately. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

STI clinical patterns — The pattern of presenting symptoms and signs guides the clinical approach to the patient with suspected STI. However, asymptomatic or minimally symptomatic presentations are common.

Discharge syndromes — Urethral or vaginal discharge and dysuria are the hallmarks of the following STIs:

●Gonorrhea – (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents" and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents" and "Disseminated gonococcal infection".)

●Chlamydia – (See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections" and "Treatment of Chlamydia trachomatis infection".)

●Trichomonas – (See "Trichomoniasis: Clinical manifestations and diagnosis".)

●Bacterial vaginosis – (See "Bacterial vaginosis: Clinical manifestations and diagnosis" and "Bacterial vaginosis: Initial treatment".)

●Candidiasis – (See "Candida vulvovaginitis: Clinical manifestations and diagnosis" and "Candida vulvovaginitis in adults: Treatment of acute infection".)

M. genitalium infections are increasingly recognized as causes of sexually transmitted discharge syndromes in adolescents and young adults [52]. (See "Mycoplasma genitalium infection".)

Genital herpes is sometimes associated with dysuria and a scant, mucoid urethral discharge, but nearly always in association with other genital lesions. (See "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection" and "Treatment of genital herpes simplex virus infection" and "Genital herpes simplex virus infection and pregnancy".)

Characteristics of the discharge, such as color (eg, clear, mucoid, yellow, green), are unreliable indicators of the etiology. (See "Vaginitis in adults: Initial evaluation".)

Genital ulcer syndrome — Clinical features do not reliably distinguish the various cause of genital ulcer syndrome (GUS). The features of the infections associated with GUS overlap, and mixed infections occur in as many as 10 percent of cases [53].

●Causes – In the United States, genital herpes (picture 1) is the most common cause of GUS among adolescents. Symptomatic genital herpes may be caused by herpes simplex virus (HSV) type 1 in addition to the more common HSV type 2. (See "Approach to the patient with genital ulcers" and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection".)

Primary syphilis is another diagnostic consideration in patients with genital ulcers (picture 2A-C), especially in young men who have sex with men and in the setting of commercial sex work or methamphetamine or cocaine use. (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Clinical manifestations'.)

Less common causes of GUS in the United States, and extremely rare in adolescents, include chancroid, lymphogranuloma venereum (LGV, which occurs primarily in young men who have sex with men), and granuloma inguinale (Klebsiella granulomatis). (See "Chancroid" and "Lymphogranuloma venereum" and "Approach to the patient with genital ulcers".)

Genital ulcers are not always due to sexually transmitted organisms. Nonsexually acquired vulvar ulcers (sometimes called Lipschütz ulcers or aphthous ulcers) may occur in association with viral illness, Crohn disease, vasculitis, and Behçet syndrome (picture 3). (See "Acute genital ulceration (Lipschütz ulcer)" and "Overview of vulvovaginal conditions in the prepubertal child", section on 'Vulvar ulcers'.)

●Evaluation – Most adolescents with GUS should be evaluated for syphilis and HSV; they should also be tested for HIV, gonorrhea, and chlamydia because patients with an ulcerative STI are at increased risk for coinfection with other STIs. Testing for chancroid, LGV, or granuloma inguinale may be indicated in patients with risk factors. (See "Approach to the patient with genital ulcers", section on 'Diagnostic testing'.)

Pelvic inflammatory disease — Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract structures (eg, uterus, fallopian tubes, ovaries). PID encompasses a wide spectrum of clinical presentations and may be challenging to diagnose. It should be suspected in sexually active adolescents who present with pelvic discomfort, though subclinical infection may also occur. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis" and "Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors".)

PID is a common sequela of genital gonorrhea and chlamydia infections. Douching may increase the risk, especially when performed frequently [54]. Regular douching is reported by 15 percent of adolescent females, with substantially higher proportions in some ethnic groups [55].

Dermatologic syndromes — The most common STI with a dermatologic presentation is genital warts (condylomata acuminata) caused by HPV. HPV types 6 and 11 are the most common causes of genital warts. Anogenital warts and the epidemiology of HPV are discussed separately. (See "Human papillomavirus infections: Epidemiology and disease associations" and "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis".)

Other STI and infections that can be transmitted by sexual activity that may present with skin rash include:

●Secondary syphilis (picture 4) (see "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Secondary syphilis')

●Disseminated gonococcal infection (picture 5) (see "Disseminated gonococcal infection")

●Pediculosis pubis (picture 6), caused by the crab louse (see "Pediculosis pubis and pediculosis ciliaris" and "Scabies: Epidemiology, clinical features, and diagnosis")

●Scabies (picture 7A-B) (see "Pediculosis pubis and pediculosis ciliaris" and "Scabies: Epidemiology, clinical features, and diagnosis")

Oral lesions — Sexually transmitted infections with oral manifestations include:

●Syphilis – Chancres are the initial manifestation of primary syphilis. They usually occur on the genitalia (picture 2A-C) but may occur on the lips, tongue, and tonsils. (See 'Genital ulcer syndrome' above and "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Primary syphilis (chancre)'.)

Mucous patches (condyloma lata), a manifestation of secondary syphilis, are characterized by large, raised gray to white lesions involving warm, moist areas such as the mucous membranes of the mouth (picture 8A-B) or perineum (picture 9). Secondary syphilis is uncommon in adolescents unless they belong to high-risk sexual networks (eg, commercial sex work, cocaine or methamphetamine users). Secondary syphilis in adolescents typically reflects delayed care-seeking for chancres. (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in patients without HIV", section on 'Dermatologic findings'.)

●N. gonorrhoeae – Gonococcal pharyngitis is usually acquired by oral sexual exposure. Although most patients with gonococcal pharyngitis are asymptomatic, clinical manifestations include sore throat, pharyngeal exudates, and/or cervical lymphadenitis. (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Pharyngitis'.)

●Human papillomavirus – (See "Human papillomavirus infections: Epidemiology and disease associations", section on 'Epidemiology of oropharyngeal infection'.)

●Herpes simplex virus – (See "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection", section on 'Oral infections'.)

Diagnostic testing for STI — Adolescents who are tested for STI should also receive testing and counseling for HIV infection [56]. This provides an opportunity for risk reduction education, as well as diagnosis of HIV infection. (See "Screening and diagnostic testing for HIV infection".)

Diagnostic testing for specific STIs is discussed separately [57].

●C. trachomatis (see "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Diagnosis of chlamydial infections')

●N. gonorrhoeae (see "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Diagnostic approach')

●Syphilis (see "Syphilis: Screening and diagnostic testing")

●HIV (see "Acute and early HIV infection: Clinical manifestations and diagnosis", section on 'Diagnosis')

●HSV (see "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection", section on 'Diagnosis')

●Chancroid (see "Chancroid", section on 'Diagnosis')

●Pubic lice (see "Pediculosis pubis and pediculosis ciliaris")

●T. vaginalis (see "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Diagnosis')

●Condylomata acuminata (see "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis", section on 'Diagnosis')

●Bacterial vaginosis (see "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation')

●Vaginal candidiasis (see "Candida vulvovaginitis: Clinical manifestations and diagnosis", section on 'Clinical evaluation')

Counseling — Adolescents who undergo diagnostic testing for STI should be counseled about STI prevention as an evidence-based clinical intervention [42]. They also should be instructed to practice abstinence while waiting for definitive test results (whether or not they receive empiric therapy). Those who are being treated for a STI (other than HIV) should be instructed to avoid sexual intercourse until they and their partner(s) have completed antimicrobial therapy [25]. (See "Prevention of sexually transmitted infections", section on 'Prevention counseling'.)

TREATMENT — Almost no clinical trials of STI-related medications include participants younger than 16 years of age, and relatively few include 16- to 17-year-olds. Most data regarding safety and efficacy are extrapolated from late adolescents and young adults. Guidelines for the treatment of specific STIs are regularly updated by the Centers for Disease Control and Prevention (CDC) [25].

Additional issues related to the treatment of STIs that are particularly relevant in adolescent patients (eg, confidentiality, parental notification) are discussed above. (See 'Specific concerns in adolescents' above.)

Challenges to treatment

Self-treatment — Self-treatment with topical medications, antibiotics, or vaginal or rectal douching may delay treatment [14,58]. Symptomatic adolescent females take approximately 10 days on average to seek care compared with only approximately 6 days for symptomatic males [58].

Incomplete adherence — Single-dose observed therapy is preferable when available, particularly for adolescents treated in the emergency department. In observational studies, approximately 30 to 40 percent of adolescents treated for STI in the emergency department failed to fill their prescriptions [59,60].

Partner notification — Many adolescents prefer to notify partners themselves [61]. However, this strategy means that a substantial number of partners are never notified. Because many adolescents have additional sexual contact with these partners, clinician counseling to reinforce the importance of notification and expedited partner therapy may be useful [62-64].

Expedited partner therapy — Expedited partner therapy (EPT) refers to the provision of appropriate antibiotics to patients with STIs for delivery to partners. EPT is endorsed by the Society for Adolescent Health and Medicine and the American Academy of Pediatrics as a strategy for ensuring partner treatment [65]. Additional information is available through the CDC. EPT is permissible or potentially allowable in the majority of states and the District of Columbia, prohibited in few states, and varies by the type(s) of STIs covered. The Guttmacher Institute maintains a current list of state laws and policies. Pharmacists may have little formal guidance in EPT provision from local regulatory agencies [66].

Reinfection — A high prevalence of C. trachomatis and N. gonorrhoeae (reinfection rather than treatment failure) is observed in patients who were treated for STIs in the preceding months [67-70]. To avoid reinfection, patients and sexual partners who are being treated for an STI other than HIV should abstain from sexual activity until they have been adequately treated [25]. (See "Prevention of sexually transmitted infections", section on 'Prevention counseling'.)

Individuals recently treated for chlamydia or gonorrhea should be retested approximately three months after treatment is completed and whenever they next seek medical care within the following 3 to 12 months (whether or not the patient thinks that the partner was treated) [25]. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Retesting' and "Treatment of Chlamydia trachomatis infection", section on 'Retesting for all patients'.)

PREVENTION — Prevention of STIs is discussed in detail separately. (See "Prevention of sexually transmitted infections".)

Routine and catch-up immunization against human papillomavirus (figure 1) and catch-up immunization (if necessary) against hepatitis B and hepatitis A (table 2) are important components of STI prevention in adolescents. (See "Standard immunizations for children and adolescents: Overview".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexually transmitted infections" and "Society guideline links: HIV infection in adolescents" and "Society guideline links: Adolescent sexual health and pregnancy".)

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Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

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SUMMARY

●Epidemiology – Sexually transmitted infections (STIs) are common in adolescents. At least 50 percent of all new STIs occur in adolescents and young adults (age 15 to 24 years). (See 'Epidemiology' above.)

●Specific concerns in adolescents – Although the evaluation and treatment of STIs in adolescents are similar to the diagnosis and treatment of STIs in adults, a number of specific concerns are particular to adolescents (eg, consent and confidentiality, mandatory reporting of sexual activity and/or STI, dating violence, and challenges to optimal treatment and prevention). (See 'Specific concerns in adolescents' above.)

●Sexual history – Routine assessment of sexual activity is an essential element of STI-related care for adolescents. The sexual history (table 1) should be straightforward and nonjudgmental. (See 'Sexual history' above.)

●STI clinical patterns – The pattern of presenting symptoms and signs of STIs can guide the need for additional information from the history, examination, and/or laboratory. (See 'STI clinical patterns' above.)

•STIs associated with urethral or vaginal discharge include gonorrhea, chlamydia, trichomonas, bacterial vaginosis, vulvovaginal candidiasis, Mycoplasma genitalium, and occasionally herpes simplex virus (HSV). (See 'Discharge syndromes' above.)

•STIs associated with genital ulcers in adolescents generally include HSV and primary syphilis (picture 2A). However, patients with ulcerative STI are at risk for coinfection, so most adolescents with genital ulcers should be tested for syphilis, HSV, HIV, gonorrhea, and chlamydia. (See 'Genital ulcer syndrome' above.)

•Pelvic inflammatory disease refers to acute infection of the upper genital tract structures (eg, uterus, fallopian tubes, ovaries). It should be suspected in sexually active adolescents who present with pelvic discomfort, although infection can be subclinical. (See 'Pelvic inflammatory disease' above.)

•STIs associated with skin lesions include genital warts caused by human papillomavirus (HPV), primary syphilis (picture 2A-C), secondary syphilis (picture 4), disseminated gonococcal infection (picture 5), pediculosis pubis, and scabies (picture 7A-B).

•STIs associated with oral lesions include syphilis (picture 8A-B), gonorrhea, HPV, and HSV. (See 'Oral lesions' above.)

●Treatment guidelines – Guidelines for the treatment of specific STIs are regularly updated by the Centers for Disease Control and Prevention. (See 'Treatment' above.)