For which STIs should sexually active girls be screened annually?
Chlamydia trachomatis and Neisseria gonorrhoeae
The U.S. Preventive Services Task Force recommends annual screening for both Chlamydia and gonorrhea in sexually active women 24 years of age and younger. The data is insufficient to make strong recommendations in males, but if a male presents with high-risk sexual contact history, it makes clinical sense to screen him as well.
A sexually active 17-year-old girl presents with:
- Right upper quadrant abdominal pain
- Vaginal discharge
- Fever
- She started her menses today.
What is the most likely diagnosis?
Perihepatitis (Fitz-Hugh-Curtis Syndrome)
Perihepatitis is due to Neisseria gonorrhoeae, Chlamydia trachomatis, and/or a mixed polymicrobial infection. It is a complication of pelvic inflammatory disease in ∼ 10% of cases. The inflammatory process is thought to ascend from the fallopian (uterine) tubes along the paracolic gutters to the right upper quadrant. There are minimal, if any, abnormalities of liver function tests. Diagnostic laparoscopic findings include purulent and fibrinous inflammation of the hepatic capsule.
A 16-year-old girl presents with:
- Homogenous, white vaginal discharge
- On wet mount microscopy, you see epithelial cells that appear granular and stippled with ragged borders.
- pH of vaginal fluid is > 4.5
- A fishy odor occurs when 10% potassium hydroxide (KOH) is placed on the vaginal discharge smear.
What is the most likely diagnosis?
Bacterial Vaginosis (BV)
The microscopic findings described are “clue cells”, which are the single most reliable predictor of BV. BV is a clinical syndrome due to the replacement of the normal vaginal flora (Lactobacillus) with anaerobes (Prevotellaand Mobiluncus), Gardnerella vaginalis, and Mycoplasma hominis. Although not a true vaginitis (in that it is not characterized by an inflammatory response of the vaginal mucosa), it is the most common cause of abnormal vaginal discharge.
What is the #1 cause of adolescent morbidity and mortality?
Motor Vehicle Accidents
Motor vehicle (automobile and motorcycle) accidents are #1. Homicides are #2.
A 15-year-old boy presents with:
- A left-sided mass that feels like a “bag of worms”
- The mass increases with Valsalva
- What is the most likely diagnosis?
Varicoceles
They are dilated scrotal veins and are usually idiopathic but can be secondary to intraabdominal masses, Hepatosplenomegaly, and other disorders. Surgery is necessary if the testicle has become hypotrophic on that side; so watch for loss of testicular volume (> 2 mL difference between the two testicles) or if the testicle fails to grow during puberty.
A 15-year-old boy presents with:
- A painless ulcer on his dorsal penis that is “punched out” with clean-appearing, sharp, firm, slightly elevated borders
- Bilateral regional lymphadenopathy
What is the most likely diagnosis?
Primary Syphilis
This is a classic description of a chancre, and it most likely is primary syphilis. Test him with a VDRL or RPR and then send specific antitreponemal tests to confirm. Treat primary syphilis (chancre) with benzathine penicillin G, 2.4 million units IM × 1 dose (if he weighs < 48 kg, dose with 50,000 units/kg IM).
A 17-year-old girl presents with:
- Bilateral painless parotid gland swelling
- Loss of tooth enamel
- Metabolic alkalosis
What is the most likely diagnosis?
Bulimia Nervosa (BN)
BN occurs in 1–4% of girls but <1% of boys. Patients with BN have recurrent episodes of binge eating during which they have feelings that they “lack control” of their eating behavior. They regularly resort to self-induced vomiting, use diuretics and/or laxatives, fast, and overexercise to prevent weight gain. They have a persistent concern with their body shape/weight.
What is the organism responsible for chancroid?
Haemophilus ducreyi
It is a painful genital ulcer disease with unilateral inguinal lymphadenopathy.
A 15-year-old girl presents with dysmenorrhea. What is the likely mechanism for her pain?
Prostaglandin Production
It causes vasoconstriction and muscular contractions. Cyclooxygenase inhibitors like ibuprofen or naproxen work well to inhibit the symptoms. If the pain does not respond to ibuprofen and naproxen, then the pain is likely due to the lipoxygenase pathway instead. Oral contraceptives are helpful as well in reducing or eliminating dysmenorrhea.
A 16-year-old girl presents with:
- Diffuse, frothy, malodorous yellow-green vaginal discharge
- Dysuria
- Pruritus
- Vulvular irritation
- A “strawberry” cervix is seen.
What is the most likely diagnosis?
Trichomoniasis
Trichomoniasis due to Trichomonas vaginalis is classically asymptomatic in men but more commonly symptomatic in women. The “strawberry cervix” with the malodorous vaginal discharge, dysuria, and pruritus is a classic presentation. Treatment is metronidazole 2 g × 1 dose, or tinidazole 2 g × 1 dose, or metronidazole 500 mg 2×/day for 7 days. Treat women at any stage of pregnancy with metronidazole 2 g × 1 dose. Treat sexual partners.
A 16-year-old girl presents with:
- Diffuse, frothy, malodorous yellow-green vaginal discharge
- Dysuria
- Pruritis
- Vulvular irritation
- A “strawberry” cervix is seen
What is the most likely diagnosis?
Trichomoniasis
Due to Trichomonas vaginalis is classically asymptomatic in men but more commonly symptomatic in women. Treatment is metronidazole 2 g x 1 dose, or tinidazole 2 g x 1 dose.
What is the most common reason for secondary amenorrhea?
Pregnancy
It can also be an etiology for primary amenorrhea.
An adolescent boy presents with:
- Dizziness
- Dilated pupils
- Says he “sees smells” and “hears colors”
- Delusions that he is someone else
What illicit drug did he likely take?
LSD (Lysergic Acid Diethylamide)
It is a potent hallucinogen. Classically somatic symptoms (dizziness, dilated pupils, flushing) are 1st, followed by perceptual changes (e.g., “seeing smells” or “hearing colors”). Finally, psychic effects (delusional ideation, body distortion, psychosis) occur.
A pregnant teen presents in active labor. You note that she has active genital warts. She and her baby have no other issues.
Which type of delivery should she have?
Vaginal Delivery
Do not get genital warts confused with genital herpes. Mothers with active genital herpes lesions at the time of delivery require C-section. Genital warts at the time of delivery do not require C-section, although you still worry about possible complications in the newborn (e.g., laryngeal papillomatosis).
A 15-year-old boy presents with:
- A nodule above and posterior to the right testes
- There is no change with Valsalva
- The nodule transilluminates
What is the most likely diagnosis?
Spermatocele
It is a retention cyst of the epididymis containing spermatozoa and is located in the efferent ductal system. It presents as a nodule above and posterior to the testes. Spermatoceles do not affect fertility and do not usually require therapy.
A 15-year-old boy presents with a nontender fluid-filled mass in his right tunica vaginalis. What is the most likely diagnosis?
Hydrocele
Hydroceles are nontender and fluid-filled masses that collect between the parietal and visceral layers of the tunica vaginalis. You can evaluate with an ultrasound (particularly if associated with a hernia or testicular mass). Transillumination is also useful. Generally no treatment is necessary.
An 18-year-old college freshman presents with:
- Painless swelling of his left testicle that he noticed while washing himself
- You feel an irregularly shaped firm mass that does not transilluminate.
What is the best diagnostic test to perform at this point?
Complete Orchiectomy
Complete Orchiectomy with a peritoneal lymph node dissection is the best method of staging and diagnosis for presumed testicular cancer. Do not do a transscrotal CT-guided biopsy - this will just seed the path that the needle travels back out.
What is the most common organism to cause mastitis in an adolescent girl?
Staphylococcus aureus
Treat with antibiotics, heat, and analgesia.
What is the first sign of sexual development for girls?
Onset of Breast Budding
In most females, the onset of breast budding (thelarche) is the first physical sign of puberty. In the U.S., puberty occurs in Caucasian girls at a mean age of 10.0–10.4 years (range of 7.8–11.6 years of age) and for African American girls at a mean age of 8.9–9.5 years (range of 6.1–10.1 years of age). Puberty for girls generally lasts an average of 4 years (range of 1.5–8 years).
A 17-year-old girl presents with:
- Amenorrhea
- Galactorrhea
- Pregnancy test is negative
What is the most likely diagnosis?
Prolactinoma
It is rare in adolescence, but, if it occurs, it will present with amenorrhea and galactorrhea. Most prolactinomas are microadenomas and will not have symptoms of headache, etc.
What Body Mass Index (BMI) is considered to be the definition of obesity?
_> 95th Percentile
Obesity is defined as having a BMI > 95th percentile or having a BMI between the 85th and 95th percentile and one of the following: family history of premature heart disease, obesity, HTN, or DM; HTN themselves; cholesterol > 200 mg/dL; increase of _> 2 points in BMI in 12 months; or the adolescent is concerned about his/her weight.
What is the first sign of sexual development in boys?
Testicular Enlargement
Male sexual development generally begins at an average age of 11.6 years (range of 9.5–13.5 years of age), with the first physical sign of puberty being testicular enlargement. Onset of puberty occurs, on average, 6 months earlier for African American boys than for Caucasian boys. For boys, puberty usually lasts an average of 3 years (range of 2–5 years).
A 15-year-old boy presents with:
- Gradual pain at the upper pole of the left testis
- On exam, you feel a tender, pea-sized swelling at the upper pole of the testis, and a bluish hue is visible through the scrotum.
What is the most likely diagnosis?
Torsion of the Testicular Appendage
It affects the appendix testis or appendix epididymis. Pain can be sudden or gradual. Treat with analgesics and antiinflammatories. The torsion will resolve spontaneously in 2-12 days without surgery.
A 14-year-old girl presents with:
- Anxiety about the way her body looks
- Absence of 3 consecutive menstrual cycles
- Intense fear of becoming obese
- BMI < 5%
Anorexia Nervosa
Girls outnumber boys by 10:1, and anorexia Nervosa occurs in 1/100 girls.
A 15-year-old boy presents with:
- Acute onset of severe pain and swelling of his left testicle and inguinal area
- Nausea/vomiting
- Exam shows a diffusely swollen and tender left testicle and an absent cremasteric reflex.
What is the likely diagnosis?
Torsion of the Spermatic Cord
It is a surgical emergency! Urologic evaluation should be immediate.
A sexually active 17-year-old girl presents with:
- Right upper quadrant abdominal pain
- Vaginal discharge
- Fever
- She started her menses today
What is the most likely diagnosis?
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
It is due to disseminated gonorrhea and is quite common, especially on Boards! Look out for disseminated gonococcal infection with tenosynovitis, dermatitis, and monoarticular arthritis (knee especially). Blood cultures can be positive but always do cervical and rectal cultures as well. Disseminated disease is treated with IV ceftriaxone.
Diethylstillbestrol (DES) was used in the 1960s and 70s and was associated with what type of cancer in the female offspring?
Clear Cell Adenocarcinoma
It can present with vaginal bleeding. Be on the lookout on Boards for this presentation in a girl born to a mom who took this drug during her pregnancy.
A teen with anorexia Nervosa is admitted and is placed on observed meals. Besides potassium and magnesium, what other electrolyte abnormality are you most concerned about with refeeding her?
Hypophosphatemia
This is classic for the refeeding syndrome. The body has been so poor in energy that refeeding overwhelms conversion of ADP to ATP and results in severe hypophosphatemia as phosphorus stores are depleted. Hypokalemia and hypomagnesemia also occur.
A 16-year-old girl presents with PID and will require inpatient therapy. She has anaphylaxis to cephalosporins. What 2 antibiotics should be used for her therapy?
Clindamycin and Gentamicin
Clindamycin 900 mg IV q 8 hours, plus gentamicin-loading dose of 2 mg/kg IV/IM, followed by a maintenance dose of 1.5 mg/kg q 8 hours.
A pregnant patient presents with signs and symptoms of secondary syphilis. She has anaphylaxis to penicillin. What is the best appropriate therapy?
Desensitize Her; Treat with Penicillin
Pregnant women with syphilis must be treated with IM penicillin. Other therapies are not as effective; also, doxycycline is contraindicated in pregnancy. If she is penicillin-allergy, the next step is to desensitize her and then proceed with penicillin therapy in appropriate doses depending on her stage of syphilis.
An adolescent with known history of substance abuse is arrested on a drunk driving charge and placed in jail. It has been about 6 hours since he has been held in the jail. He is now having noticeable yawning. What is one of the illicit drug categories that he likely uses?
Opiates (Heroin)
Opiate withdrawal occurs about 8 hours after the last exposure. One of the first signs is yawning. Then lacrimation, mydriasis, insomnia, “goose flesh,” diarrhea, and systolic hypertension occur. Diazepam is helpful for the withdrawal symptoms, but the patient should be managed in a professional setting.
A sexually active 16-year-old boy presents with:
- Urethral discharge
- Gram stain shows 10 WBCs/hpf with no organisms seen
What is the most likely diagnosis?
Chlamydia trachomatis Infection
Treatment is either azithromycin 1 g x 1 dose or doxycycline 100 mg bid x 7 days.
What is the most common breast mass in an adolescent girl?
Solitary Cyst
More than 50% of these will resolve in 2-3 months and do not require further work up - simply follow with serial exams.
A 15-year-old boy presents with a nontender fluid-filled mass in his right tunica vaginalis.
What is the most likely diagnosis?
Hydrocele
Hydroceles are nontender, soft, fluctuant masses formed by a collection of fluid between the parietal and visceral layers of the tunica vaginalis. Hydroceles can be associated with a hernia or testicular mass, so evaluate with an ultrasound. Transillumination is also useful. Generally, no treatment is necessary.
A 17-year-old boy presents with:
- Ataxia
- Euphoria
- Verbal abusive language uncharacteristic for him
- Thrashing out and difficult to control because he says people are trying to “get him”
What illicit drug did he likely get exposed to?
PCP (Phencyclidine)
PCP causes cramps, diarrhea, and hematemesis for GI effects, and euphoria, nystagmus, ataxia, and hallucination as neurologic effects. Higher doses result in frank psychosis and verbal abusive language. Even higher doses can result in cardiac arrhythmias and seizures.
A pregnant teen presents in active labor. You note that she has active genital warts. She and her baby have not other issues. What type of delivery should she have?
Vaginal Delivery
Do not get genital warts confused with genital herpes. Genital herpes at the time of delivery requires C-section. Genital warts at the time of delivery do not require C-section, although you still worry about possible complications in the newborn (e.g., laryngeal papillomatosis).
What is the most common cause of epididymitis in an adolescent?
Chlamydia trachomatis
Neisseria gonorrhea is 2nd. In men who have sex with men, unprotected anal intercourse may cause epididymitis due to E. coli and other bowel flora.
A 15-year-old boy presents with:
- Acute onset of severe pain and swelling of his left testicle and inguinal area
- Nausea/vomiting
- Exam shows a diffusely swollen and tender left testicle and an absent cremasteric reflex.
What is the likely diagnosis?
Testicular Torsion (a.k.a. Torsion of the Spermatic Cord)
Testicular torsion is a surgical emergency! Urologic evaluation should be immediate. Survival of the testicle is directly related to how many hours have passed since the onset of the torsion.
A pregnant teen presents in active labor. You note that she has active herpes infection of her genital area. What type of delivery should she have?
C-Section
For adolescents, what body mass index (BMI) is considered to be obese?
≥ 95th Percentile
The Centers for Disease Control and Prevention (CDC) defines obesity as having a BMI ≥ 95th percentile for children and adolescents of the same age and sex. Overweight is defined as having a BMI ≥ 85th and < 95thpercentile for children and adolescents of the same age and sex.
What is the #1 cause of adolescent mortality?
Unintentional Injuries
Unintentional injuries (motor vehicle accidents, discharge of a firearm, drowning, or poisoning) account for 39% of all deaths during adolescence. Consistently, males face more than twice the risk of females from death due to unintentional injury. Suicides are #2. Homicides are #3.
A 14-year-old boy presents with the following:
- Asymmetric left breast tenderness and swelling
- The swelling is about 3 cm.
- He is on no medications.
What is the appropriate management?
Observation
Most gynecomastia resolves spontaneously within 12 months. Normal pubertal gynecomastia is < 4 cm and does not require specific workup or therapy. It is often asymmetric.
What organism is responsible for chancroid?
Haemophilus ducreyi
Haemophilus ducreyi is the organism responsible for chancroid, a painful genital ulcer disease that often develops unilateral inguinal lymphadenitis.
A 16-year-old girl presents with:
- Low-grade fever
- Inguinal lymphadenopathy
- Vesicular lesions that are painful and itchy
- Cervical motion tenderness
- Thin, white vaginal discharge
What is the most likely diagnosis?
Herpes Simplex
Don’t be dissuaded by the presence of lymphadenopathy, cervical motion tenderness, and vaginal discharge…all 3 of these are common with herpes infection - especially the initial herpes infection. The key here is the vesicular lesions that are painful and itchy, which makes syphilis unlikely. Obviously, she can be co-infected with Chlamydia or other STDs, but the vesicles are specific for herpes simplex infection.
What is the most common solid breast mass in an adolescent girl?
Fibroadenoma
Fibroadenomas represent a benign mix of stromal elements, ducts, and acini. The masses are firm, painless, rubbery in character, and distinct from the rest of the breast. They are typically asymptomatic but can cause discomfort for a few days prior to onset of menses; however, they do not regress or change with hormonal fluctuations. They tend to be in the upper-outer quadrant of the breast and most range in size from 2–3 cm. Simply observe asymptomatic solid breast masses that are < 3 cm. Perform excisional biopsy on persistent, larger, or suspicious lesions.
A 15-year-old boy presents with:
- Gradual pain at the upper pole of the left testis
- On exam, you feel a tender, pea-sized swelling at the upper pole of the testis; a bluish hue is visible through the scrotum.
What is the most likely diagnosis?
Torsion of the Testicular Appendage
Torsion of the testicular appendage affects the appendix testis or appendix epididymis. It is a benign condition but must be differentiated from testicular torsion, which is a true emergency. Pain can be sudden or gradual. Treat with analgesics and antiinflammatories. The torsion will resolve spontaneously in 2–12 days without surgery.
A 16-year-old girl presents with pelvic inflammatory disease (PID) and requires inpatient therapy. She has anaphylaxis to cephalosporins.
What 2 antibiotics should be used for her therapy?
Clindamycin and Gentamicin
With hospitalized PID and allergy to cephalosporin, the best choice is clindamycin 900 mg IV every 8 hours, plus gentamicin-loading dose of 2 mg/kg IV/IM, followed by a maintenance dose of 1.5 mg/kg every 8 hours × 14 days.
A teen with anorexia nervosa is admitted and is placed on observed meals.
Besides potassium and magnesium, what other electrolyte abnormality are you most concerned with while refeeding her?
Hypophosphatemia
Hypophosphatemia is classic for refeeding syndrome. The body has been so poor in energy that refeeding overwhelms conversion of ADP to ATP and results in severe hypophosphatemia as phosphorus stores are depleted. Hypophosphatemia typically occurs within 1–2 weeks of refeeding and causes hemolytic anemia, arrhythmias, heart failure, mental status changes and coma, and sudden death. Hypokalemia and hypomagnesemia also occur. True refeeding syndrome is thankfully rare, but always monitor for it.
Diethylstilbestrol (DES) was used as an antiemetic in the 1960s and 1970s. It is associated with which type of cancer in the female offspring of women who took this drug during pregnancy?
Clear Cell Adenocarcinoma
DES-related clear cell adenocarcinoma is a rare cancer that can present with vaginal bleeding. On exams, be on the lookout for the presentation of a girl born to a mom who took this drug during pregnancy.
An infant is born to a mother with a positive RPR. The newborn has the following:
- Jaundice
- Hepatosplenomegaly
- Rhinitis (severe)
- Vesicular skin rash
- Chorioretinitis
What is the best treatment?
Aqueous Crystalline Penicillin G
Congenital syphilis should be treated with aqueous crystalline penicillin G 50,000 units/kg/dose IV q 12 hours x 7 days, then q 8 hours to complete 10 days.
A 16-year-old girl presents for well care. While her mother is out of the room, she discloses to you that she has had vaginal intercourse twice in the past year.
Along with counseling and testing for STIs, which birth control method do you tell her is recommended as 1stline by the AAP?
Long-Acting Reversible Contraception (LARC)
LARC, with either an IUD or subdermal progesterone implant, is the current standard of care for birth control in adolescent females. Worry about the risk of introducing or causing pelvic inflammatory disease (PID) with an IUD has been shown to be unfounded, with equal rates of PID in females with and without IUDs in place. Male condoms are the most effective method besides abstinence for preventing STIs; recommend them to adolescents even if they are using other forms of birth control.
A pregnant patient presents with signs, symptoms, and lab confirmation of secondary syphilis. She has anaphylaxis to penicillin.
What is the most appropriate therapy?
Desensitize Her; Treat with Penicillin
Pregnant women with syphilis must be treated with IM penicillin. Other therapies are not as effective; also, doxycycline is contraindicated in pregnancy. If she is allergic to penicillin, the next step is to desensitize her and then proceed with penicillin therapy in appropriate doses depending on her stage of syphilis.
An 18-year-old male presents with gynecomastia and decreased school performance. What illicit drug has he been likely taking on a chronic basis?
Marijuana
Marijuana in the short-term causes short-term memory loss, decreased judgment, and time perception distortion. Over extended use, it causes decreases in plasma testosterone levels with decreased spermatogenesis, decreased glucose tolerance, and gynecomastia.
What is the most common organism to cause mastitis in an adolescent girl?
Staphylococcus aureus
Acute mastitis is a localized breast infection more common in newborns and lactating females (puerperal mastitis) and is only occasionally seen in a nonpregnant adolescent. Patients present with an indurated, fluctuant, red, tender, and swollen lesion on the breast. The most common causative organism is Staphylococcus aureus. Treat with antistaphylococcal antibiotics, heat, and analgesia.
What is the organism responsible for granuloma inguinale?
Klebsiella granulomatis
(formerly known as Calymmatobacterium granulomatis)
This used to appear on the Boards much more often because of the “cool” name, Calymmatobacterium; now it is just a boring Klebsiella…
A 16-year-old boy presents with a 3-week history of:
- Decreased appetite
- Hypersomnia
- Fatigue
- Decreased ability to concentrate
- Weight loss
- Irritability
- Diminished interest in playing soccer (his favorite sport)
What should you be considering as a possible diagnosis?
Depression
An adolescent who presents with depressed mood or irritability in particular with diminished interest or lack of pleasure in previous enjoyable activities should make you think of depression. Plus, if they have 4 or more of the following: weight changes, appetite changes, sleep changes, fatigue and energy loss, feelings of worthlessness, excessive feelings of guilt, decreased ability to concentrate, or recurrent thought of death; then consider a major depressive disorder is occurring.
An 18-year-old college freshman presents with:
- Painless swelling of his left testicle that he noticed while washing himself
- You feel an irregularly shaped firm mass that does not transilluminate.
What is the best treatment?
Complete Orchiectomy
Complete orchiectomy, potentially coupled with peritoneal lymph node dissection, radiation, and chemotherapy, is the best diagnosis and treatment for testicular cancer. Prior to orchiectomy, workup includes measuring β-hCG (elevated in choriocarcinoma and mixed germ cell tumors), α-fetoprotein (elevated in yolk sac tumors and embryonal carcinoma), and LDH; performing testicular ultrasound or MRI, and CT scan of chest and abdomen. Note: Most seminomas do not produce any markers!
A 17-year-old girl presents with:
- Amenorrhea
- Galactorrhea
- Pregnancy test is negative.
What is the most likely diagnosis?
Pituitary Adenoma
A pituitary lactotroph adenoma (i.e., prolactin-secreting adenoma) may cause amenorrhea and is often associated with galactorrhea. By definition, a microadenoma measures < 10 mm; most do not increase in size. Bromocriptine, a dopamine agonist, often restores menses and decreases prolactin levels to normal in patients with a microadenoma.
What is the #1 reason for hospitalization for adolescents?
Pregnancy
A 15-year-old boy presents with:
- A painless ulcer on his dorsal penis that is “punched out” with clean-appearing, sharp, firm, slightly elevated borders
- Bilateral regional lymphadenopathy is present
What is the most likely diagnosis?
Primary Syphilis
This is a classic description of a chancre, and it most likely is primary syphilis. Test him with a VDRL or RPR and then send specific antitreponemal tests to confirm. Treat primary syphilis (chancre) with benzathine penicillin G 2.4 million units IM x 1 dose (if he weighs
A 9-year-old girl is evaluated after she was sexually abused by her cousin.
Is the HPV vaccine indicated in this patient, and if so, what is the recommended schedule for vaccine administration?
Yes; 2-Dose Series: 1st Dose at This Visit,
2nd Dose in 2–6 Months
While the vaccine series is routinely recommended at 11–12 years of age, it can be started as early as 9 years of age (even in the absence of high risk). For persons initiating vaccination at ≥ 15 years of age, the recommended immunization schedule is a 3-dose series: 0, 1–2, and 6 months. There are 3 types of HPV vaccines: 2vHPV, 4vHPV, and 9vHPV. Any of the 3 types can be used with females. Only the 4vHPV and 9vHPV are given to males because, in addition to containing HPV serotypes known to cause cervical cancer, they also include serotypes 6 and 11, which cause most genital warts.
A sexually active 16-year-old boy presents with:
- Urethral discharge
- Gram stain shows 10 WBC/HPF with no organisms seen on first-void urine.
What is the most likely diagnosis?
Urethritis
Urethritis with a Gram stain showing a high WBC count without an organism is generally due to Chlamydia trachomatis. Treatment is either azithromycin 1 g orally in a single dose or doxycycline 100 mg twice a day for 7 days.
A 14-year-old boy presents with the following:
- Asymmetric left breast tenderness and swelling
- The swelling is about 3 cm
- He is on no medications
What is the appropriate management?
Observation
Most gynecomastia resolves spontaneously within 3 years. Normal pubertal gynecomastia is < 4 cm and does not require specific workup or therapy.
What is the mean age for menses to begin?
12.5 years
Range of 10 - 16.5 years
A 16-year-old girl presents with:
- Homogenous, white vaginal discharge
- On microscopy, you see epithelial cells that appear granular and stippled with ragged borders.
- pH of vaginal fluid is > 4.5
- A fishy odor occurs when 10% KOH is placed on the vaginal discharge smear.
What is the most likely diagnosis?
Bacterial Vaginosis
The microscopic findings described are “clue cells” and are the single most reliable predictor of bacterial vaginosis. Bacterial vaginosis is a clinical syndrome due to the replacement of the normal vaginal flora (Lactobacillus) with anaerobes (Prevotella and Mobilincus), Gardenella vaginalis, and Mycoplasma hominis.
What is the first sign of sexual development for girls?
Breast Development (Thelarche)
It can occur anywhere from 6 to 11.5 years of age.
A 15-year-old boy presents with:
- A left-sided scrotal mass that feels like a “bag of worms”
- The mass increases with Valsalva.
What is the most likely diagnosis?
Varicoceles
Varicoceles are dilated scrotal veins. They are typically idiopathic but can be secondary to intraabdominal masses, hepatosplenomegaly, and other disorders. Surgery is necessary if the testicle has become hypotrophic on that side, so watch for loss of testicular volume (> 2 mL difference between the 2 testicles) or if the testicle fails to grow during puberty.
What is the most common cause of epididymitis in an adolescent?
Chlamydia trachomatis
Chlamydia trachomatis is the most common cause of epididymitis in an adolescent, followed by Neisseria gonorrhoeae. Infections of E. coli and other bowel flora, contracted via unprotected anal intercourse, can also cause epididymitis.
A 9-year-old boy includes genitals in a drawing of his family.
What should you consider as a possibility?
Sexual Abuse
It is unusual for older, grade school–aged children to draw genitals on figures; this requires further inquiry. Sexual abuse must be strongly considered and thoroughly investigated when an older child includes genitals in a drawing.
A 15-year-old girl presents with dysmenorrhea.
What is the likely cause of her pain?
Prostaglandin Production
Prostaglandin production causes vasoconstriction and muscular contractions. NSAIDs improve the symptoms. Combined oral contraceptives, which inhibit ovulation leading to an atrophic endometrium, decreased menstrual flow, and decreased prostaglandin release, are often effective in adolescents who do not improve with NSAIDs.
A 15-year-old boy presents with:
- A nontender nodule above and posterior to the right testis
- No change with Valsalva
- The nodule transilluminates
What is the most likely diagnosis?
Spermatocele
A spermatocele is a retention cyst of the epididymis containing spermatozoa and located in the efferent ductal system. It presents as a smooth, cystic, mobile nodule above and posterior to the testis. Spermatoceles typically do not affect fertility or require therapy.
What organism is responsible for granuloma inguinale?
Klebsiella granulomatis
Granuloma inguinale is caused by Klebsiella granulomatis. It is rare in the U.S. and typically presents as a painless, friable, progressive, beefy-red ulcerative lesion that is extremely vascular and bleeds easily on contact.
A 17-year-old girl presents with:
- Bilateral painless parotid gland swelling
- Loss of tooth enamel
- Metabolic alkalosis
What is the most likely diagnosis?
Bulimia
Bulimia nervosa occurs in 1-2% of girls. They have recurrent episodes of binge eating and have feelings that they “lack control” of their eating behavior. They regularly have self-induced vomiting and use diuretics and/or laxatives. They commonly overexercise to prevent weight gain and have a persistent concern with their body shape/weight.
What is the #1 reason for hospitalization of adolescents?
Pregnancy
Pregnancy and related conditions account for 3% of all adolescent hospitalizations. It is the leading cause of hospitalization in the adolescent age range.
A 14-year-old girl presents with:
- Anxiety about the way her body looks
- Intense fear of becoming obese
- BMI < 5th percentile
What is the most likely diagnosis?
Anorexia Nervosa (AN)
AN has specific DSM-5 criteria; this girl meets all of them. AN is the deadliest of all psychiatric conditions, with a mortality rate of ~ 20% if severe. Girls outnumber boys by 10:1. AN occurs in 1/200 girls.
What is the most common reason for secondary amenorrhea?
Pregnancy
Secondary amenorrhea is the absence of menses for > 3 months in adolescents who previously had regular menstrual cycles or the absence of menses for 6 months in those who had irregular cycles. Pregnancy is the most common reason for secondary amenorrhea. Pregnancy can also be the cause of primary amenorrhea (no menses to 15 years of age), but this is rare.
What is the mean age for menarche?
12.5 Years of Age
The mean age for menarche is 12.5 years (normal range is 9–16 years of age). Menarche commonly occurs at sexual maturity rating (SMR; a.k.a. Tanner) stages 3–4, or approximately 2 years after onset of breast budding. It usually occurs just after peak height velocity (PHV).
A 16-year-old girl presents with:
- Low-grade fever
- Inguinal lymphadenopathy
- Vesicular lesions that are painful and itchy
- Cervical motion tenderness
- Thin, white vaginal discharge
What is the most likely diagnosis?
Herpes Simplex
Do not be dissuaded by the presence of lymphadenopathy, cervical motion tenderness, and vaginal discharge—all 3 of these are common with herpes infection, especially the initial herpes infection. The key here is the vesicular lesions that are painful and itchy, which makes syphilis unlikely. Obviously, she can be coinfected with Chlamydia or other STIs, but the vesicles are specific for herpes simplex infection.
A pregnant teen presents in active labor. You note that she has active herpes infection of her genital area.
Which type of delivery should she have?
C-Section
The risk of passing herpes simplex virus (HSV) from a mother with primary genital infection at or near delivery to her baby is very high (40–45%), so women presenting with lesions at the time of delivery should have a C-section. Women without prodromal or clinical signs and symptoms of herpes at delivery can deliver vaginally.
What is the first sign of sexual development in boys?
Testicular Growth and Thinning of the Scrotum
For Caucasian boys it begins at about 10 years of age and African-American boys at about 9.5 years of age.