How Common Are STIs?

Patient Presentation
An 18-year-old male came to clinic for his health supervision visit. His past medical history showed that he was generally healthy and had all of his immunizations. During the social history he denied using alcohol, drugs, tobacco or being sexually active. The pertinent physical exam showed a healthy male with normal vital signs and BMI of 22.2, He was Tanner stage V and the rest of his examination was negative.

The diagnosis of a healthy male was made. The pediatrician recommended for him to receive his second Group B Meningococcal vaccine along with an updated tetanus vaccine as he was going to be working in construction and gardening over the summer. He said, “We also are screening all adolescents for HIV at your age. I know that you said you have not been sexually active but it is still recommended. The most important part is two-fold. One, the best way wait to prevent sexual infections and pregnancy is not to have sexual relations. So I recommend that you continue your current lifestyle. Two, if you do decide to become sexually active, use condoms each and every time along with some type of spermicide. That is also another good option to help prevent pregnancy and infections.” The physician discussed and gave the teen a handout on how to properly use a condom and when to have sexually transmitted infection testing (STI). “I always think its best to have all the information. Besides you can also keep this information for later or give it to a friend who might need it,” he remarked.

Discussion
Of the 30 different microbes which can be transmitted by sexual contact, 8 have the greatest incidence of transmitting disease. Four are curable (Chlamydia, Gonorrhea, Syphilis and Trichomoniasis) and 4 are incurable at present (Hepatitis B, Herpes simplex virus (HSV), Human immunodeficiency virus (HIV) and Human papillomavirus (HPV)).
Sexually transmitted infections (STIs) are important as they can cause:

  • Increased rates of acquisition of other STIs (ie HSV and syphilis increase the rate of HIV infection acquisition)
  • Pelvic inflammatory disease and infertility
  • Stillbirth and neonatal death
  • Neonatal morbidity including low-birth weight, prematurity, conjunctivitis, pneumonia, sepsis, and congenital abnormalities
  • Genital cancer

In high-income countries diagnosis usually includes laboratory testing and then treatment. Short-course antibiotic treatment for curable infections is effective. In low- and middle-income countries laboratory testing is often cost prohibitive and the diagnosis is made by syndromic management using symptoms and guidelines to direct care. Syndromic management is good as patients can be treated the same day, but the majority of STIs are not detected because patients are asymptomatic. Preventative vaccines for Hepatitis B and HPV have and are showing high prevention rates. Other vaccines are also being developed. Other interventions show that male circumcision decreases the risk of heterosexually transmitted HIV infection and may provide some protection against other STIs. A vaginal microbicide called Tenofovir may have some efficacy against HIV and HSV prevention.

STI screening guidelines from the Centers for Disease Control (CDC) can be found here. 2016 STI treatment guidelines from the CDC can be found here.

Learning Point
The World Health Organization estimates that more than 1 million STIs are acquired daily with 357 million new infections of one of the 4 curable STIs occurring each year. An additional 500 million people are living with HSV and another 290 million women have HPV.

The United States saw an increase in STIs in 2015. It is estimated that 20 million new STIs occurred in 2015 with more than 50% of them in the adolescent/young adult population (age 15-24 years). The large increase in Chlamydia and Gonorrhea were in this age group. There is also an increase in Syphilis reported among men, particularly those who are bisexual or gay.

Total STIs by World Region from the World Health Organization Reported in 2016

Location Total STIs
Americas 64 Million
Africa 60 Million
Eastern Mediterranean 31 Million
Europe 18 Million
South-East Asia 39 Million
West Pacific 142 Million

STIs by Age Range in the United States Reported to the Centers for Disease Control in 2015

Location Total STIs Chlamydia Gonorrhea Syphilis
Age 0-14 years N.A. 11,308 2,538 Primary and secondary 12, Congenital syphilis 487, increase 6%
Age 15-24 years N.A. 981,359 increase 2.5-4.2% 196,593 increase 5.2-7.2% Primary and secondary 5,966 increase 10.2-14.9%
Total 20 Million 1,526,658 increase 6% 395,216 increase 13% Primary and secondary 23,872 increase 19%

Increased rates are from 2014 to 2015, ranges are given if more than 1 age group is included. N.A. is not available

Questions for Further Discussion
1. What are the 5P’s of screening in a sexual health history?
2. How is teenage confidentiality handled in your practice regarding sexual health?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sexually Transmitted Diseases.
To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

CDC Fact Sheet. Reported STDs in the United States. 2015 National Data for Chlamydia, Gonorrhea, and Syphilis.Available from the Internet at https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/std-trends-508.pdf (rev. October 2016, cited 5/2/17).
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016.

World Health Organization. Sexually Transmitted Infections (STIs) Fact Sheet. Available from the Internet at http://www.who.int/mediacentre/factsheets/fs110/en/ (rev. 8/2016 cited 5/2/17).
World Health Organization. Global Health Sector Strategy Sexually Transmitted Infections 2016-2021. Available from the Internet at http://apps.who.int/iris/bitstream/10665/246296/1/WHO-RHR-16.09-eng.pdf?ua=1 (rev. 6/2016, cited 5/2/17).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Do Children Grow Overnight?

Patient Presentation
A 14-year-old male came to clinic for his health maintenance examination. He was well and his mother was joking with the pediatrician saying, “He’s really growing. I measured him only 3 weeks ago and he’s already grown an inch since then. I can see it in his pants too because they were fitting a month ago and now you can see his ankles.” The past medical history was non-contributory.

The pertinent physical exam showed a well-appearing male, who was growing at the 50th percentile for height and 75% for weight. He had grown 8.5 centimeters in height over the past 12 months. He was Tanner stage 4 for pubic hair and genitalia. The diagnosis of a healthy male was made. The pediatrician said, “We hear the parents say this often that the kids grow overnight. They certain can have big growth spurts.” Later he was thinking about the conversation and decided to search the literature to see what medical literature might support this idea.

Discussion
Growth is an important vital sign for children. Normal growth patterns usually indicate healthy children and can be reassuring for both the parents and health care providers alike. Children are not usually measured very often by parents or health care providers and therefore the actual growth occurrence is not identified until after the event. Measuring small increments accurately also makes data collection difficult, along with the inconvenience of frequent serial measurements.

A review of various growth parameters in children can be found here.

Learning Point
There is evidence that children do grow over very short periods of time. Rogol writes, “…[T]here is compelling evidence to invoke a pattern characterized by short saltations flanked by longer periods of stasis, both in infant and during the pubertal growth spurt.” When these saltations or periods of rapid growth are averaged over longer periods of time, it can look like growth is a continuous process.

One adolescent male was measured almost daily for 389 consecutive days and was found to have linear growth on only 12 days. This is an average of ~1 day of growth out of 31, but the number of days between the growth days was heterogeneous ranging from 13-100 days. Another study of infants and toddlers, showed discontinuous growth spurts of 0.5-2.5 cm of linear growth separated by no measureable growth for 2-63 days. A third study of infants and toddlers, showed saltatory head circumference growth of 0.2 cm separated by no growth for 1-21 days. These head circumference growth saltations were also coupled to length growth saltations (median 2 days, range 1-8 days).

The mechanism for the saltatory growth for linear growth appears to be the chondrocytic life cycle itself and the changes that occur at the growth plates of long bones. Chondrocytes emerge from their stem cells, undergo proliferation, then a rest phase, then hypertrophy, and finally vascular invasion and mineralization. The timing of each state, especially the resting state and the hypertrophy state where linear growth occurs, is under numerous controlling factors including genetic, hormonal and nutritional. Lampl and Schoen state, “[i]n a sequence of “turn on” and “turn off” mechanisms across the chondrocytic life cycle, the final clonal chondrocyte hypertrophy operates as the cellular basis for saltatory growth, the biological process by which individuals accrue height in discrete spurts (saltations) separated by variable intervals of growth quiescence (stasis), empirically documented at the level of the whole body… and the growth plate itself….” They note that “…variation in saltatory amplitude and frequency characteristics underlie difference in growth rates, tempo, and time-based growth trajectories within and among individuals, including population-distinctive patterns.”

Questions for Further Discussion
1. What are the first signs of puberty?
2. The height spurt occurs during what Tanner stage(s) usually?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Development and Growth Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lampl M, Veldhuis JD, Johnson ML. Saltation and stasis: a model of human growth. Science. 1992 Oct 30;258(5083):801-3.

Lampl M, Johnson ML. A case study of daily growth during adolescence: a single spurt or changes in the dynamics of saltatory growth? Ann Hum Biol. 1993 Nov-Dec;20(6):595-603.

Robol AD. Growth, body composition and hormonal axes in children and adolescents. J Endocrinol. Invest. 2003; 26:855-860.

Lampl M, Johnson ML. Infant head circumference growth is saltatory and coupled to length growth. Early Hum Dev. 2011 May;87(5):361-8.

Fennoy I. Effect of obesity on linear growth. Curr Opin Endocrinol Diabetes Obes. 2013 Feb;20(1):44-9.

Lampl M, Schoen M. How long bones grow children: Mechanistic paths to variation in human height growth. Am J Hum Biol. 2017 Mar;29(2).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Summer Break

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What Causes Urinary Hesitancy?

Patient Presentation
A pediatrician asked his colleague for help with considering a differential diagnosis for a college age male who presented with true urinary hesitancy for ~2 weeks. “It’s just not that common a problem in pediatrics,” the pediatrician noted. “The patient has never had any urinary or bowel problems previously, denies dysuria or other pain, or fever. He says he has a normal stream, volume and urinates 6-8 times/day. He denies getting up at night to void. He also denies any bowel problems nor any neurological issues like issues with sensation or problems walking. He also denies any sexual activity for several months,” the pediatrician related to his colleague. “He just says that he wants to void and can’t seem to start his stream in a reasonable amount of time,” the pediatrician said. The second pediatrician agreed that it was not a common problem and asked some more questions about the potential for an occult malignancy or soft neurological signs for a neurological problem which the attending pediatrician said that the patient denied. “I guess I would do a urinalysis and screen him for sexually transmitted infections today and then consult urology. They obviously see this problem more than us and maybe the young man needs to have urodynamics testing or even have a cystoscopy performed,” the colleague stated. “In the meantime you can also have him keep a symptom diary so that you or the urologist can have a better idea of his bowel and bladder patterns,” the colleague also offered.

Discussion
Hesitancy” denotes difficulty in initiating voiding when the child is ready to void,” according to the International Children’s Continence Society. It is not seen that often in pediatrics in isolation, but is commonly associated with other symptoms such as dysuria, frequency, abdominal or anal pain which may indicate common problems such as a urinary tract infection, vaginal/perineal irritation, or constipation. Communication problems can also confound the accuracy of the history as patients and families can have a difficult time describing the urinary problem they are experiencing or may be embarrassed to fully communicate their concerns. Symptom diaries are often helpful to more accurately discern the frequency, and pattern of the problem, along with other concurrent symptoms. Some patients are more comfortable writing about the problem than expressing it verbally and diaries can sometimes assist. Testing for common problems usually begins the evaluation, but consultation with an urologist or another specialist may be necessary.

Learning Point
One of the classic causes of urinary hesitancy is benign prostatic hypertrophy but this is not a common cause in the pediatric and young adult age group. Another cause is medications, but as this age group generally takes fewer medications, drugs are also a less common cause but should be considered in the differential diagnosis.

The differential diagnosis of urinary hesitancy in children and teenagers includes:

  • Obstruction
    • Direct
      • Foreign body
      • Malignancy
      • Prostate
    • Indirect
      • Bowel bladder dysfunction
      • Constipation
      • Pregnancy
      • Abdominal/pelvic malignancy
  • Neurologic/Muscular
    • Bladder neck obstruction
    • Dysfunctional voiding
    • Detrusor urethral sphincter dyssynergy
    • Dysautonomia
    • CNS space occupying lesions – abscess, malignancy
  • Drugs – antidepressants and others which may cause urinary retention
  • Other
    • Sexually transmitted infections
    • Behavioral including abuse
    • Situational – public restrooms

Questions for Further Discussion
1. What are indications for referral to an urologist?
2. What is the difference between dysfunctional voiding and detrusor urethral sphincter dyssynergy?

Related Cases

    Symptom/Presentation: Urine

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Urine and Urination and Bladder Diseases.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Paner GP, Zehnder P, Amin AM, Husain AN, Desai MM. Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management. Adv Anat Pathol. 2011 Jan;18(1):79-89.

Glassberg KI, Combs AJ, Horowitz M. Nonneurogenic voiding disorders in children and adolescents: clinical and videourodynamic findings in 4 specific conditions. J Urol. 2010 Nov;184(5):2123-7.

Austin PF, Bauer SB, Bower W, et.al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodyn. 2016 Apr;35(4):471-81.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa