Pediatric Primary Care (95 page)

H.  Follow up.

1.  Rescreen 3–4 months after treatment in high-risk population.

I.  Complications.

1.  PID.

2.  Ectopic pregnancy.

3.  Infertility.

4.  Chronic pelvic pain.

J.  Education.

1.  Abstain from sexual intercourse until 7 days after single-dose treatment or completion of 7-day regimen.

2.  Sex partner(s) need treatment.

3.  Inform about risks associated with untreated infection to motivate completion of treatment.

4.  Avoid multiple partners.

5.  Educate about safer sex: Use condoms during all intercourse, limit number of sexual partners, carefully screen any potential partner.

III. DYSMENORRHEA

A.  Primary: pain associated with menstrual cycle without organic source.

B.  Secondary: menstrual pain due to organic disease.

C.  Etiology.

1.  Primary: elevated prostaglandins, prostaglandin levels are higher in women with ovulatory cycles.

2.  Secondary: due to pelvic pathology such as infection, structural abnormalities, endometriosis.

D.  Occurrence.

1.  60% of teens report pain with menses; 10–14% of those miss school days due to pain.

E.  Clinical manifestations.

1.  Primary: may begin 6–36 months after menarche.

a.  Lower abdominal pain; may radiate to thighs or back.

b.  Nausea, vomiting, diarrhea, dizziness, nervousness, headache, fatigue may accompany.

c.  Commonly pain starts within 1–4 hours of onset of menses, lasts 1–2 days. Pain may begin before menses and last 2–4 days.

2.  Secondary: pain with menses and associated symptoms. History should include sexual history, gastrointestinal and genitourinary systems history.

F.  Physical findings.

1.  Primary: normal physical exam.

2.  Patients with STIs may have purulent cervical discharge, cervical motion tenderness, uterine tenderness, adnexal tenderness. Mass in adnexa could be cyst, ectopic pregnancy, tubo-ovarian abscess. Tender/nodular cul-de-sac may be found with endometriosis.

G.  Diagnostic tests.

1.  For sexually active teens: pelvic exam to rule out STIs, gonorrhea and chlamydia tests, pregnancy test (if menses are irregular/missed).

2.  Urinalysis if urinary symptoms.

H.  Differential diagnosis.

1.  Cervicitis or PID caused by agents such as gonorrhea, chlamydia.

2.  Cystitis, pyelonephritis.

3.  Inflammatory bowel disease.

4.  Constipation.

5.  Endometriosis: not common in adolescents but may be significant in adolescents with chronic pelvic pain. Pain may occur before and after menses, may include dyspareunia, pain on defecation, abnormal uterine bleeding.

6.  Uterine malformation.

7.  Ovarian cysts.

8.  Postsurgical adhesions.

I.  Treatment.

1.  Primary: nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives.

2.   Secondary: treat identified cause.

J.  Follow up.

1.  If standard treatments such as NSAIDs or oral contraceptives do not relieve pain or if etiology is complex, refer to gynecologist.

2.  When infections are the cause, treat and follow up per protocol.

a.  PID: inpatient or outpatient therapy, monitor for medication compliance.

b.  Gonorrhea or chlamydia: rescreen every 3–4 months.

K.  Complications

1.  Primary dysmenorrhea should improve with either NSAID or oral contraceptive therapy. If not, consider other causes.

2.  Secondary dysmenorrhea: may have complications based on diagnosis (e.g., teens with PID may suffer from infertility, adhesions, or ectopic pregnancy).

L.  Education.

1.  Take anti-inflammatory agents with food; start as soon as symptoms occur.

2.  Hormonal contraception is useful when contraception is needed. Teach sexually active teens about safer sex.

3.  When infection is cause, partners need to be treated.

IV. GENITAL HERPES

A.  Etiology.

1.  Recurrent lifelong infection, 2 types: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2).

2.  HSV-2 causes most genital HSV infection but increasing numbers of genital HSV are caused by HSV-1.

B.  Occurrence.

1.  50 million persons in United States have genital HSV infection.

C.  Clinical manifestations.

1.  Vesicular or ulcerative lesions of male or female genitalia.

2.  Infection can be more severe in immunocompromised individuals.

3.  Infections caused by direct contact.

4.  Incubation period: 2 days to 2 weeks. Virus persists for life in latent form.

5.  Recurrent infections shed virus for 3–4 days rather than 1–2 weeks in primary infection.

D.  Physical findings.

1.  Vesicular or ulcerative lesions of male or female genitalia.

E.  Diagnostic tests.

1.  HSV culture provides best sensitivity when lesions are cultured before they begin to heal.

2.  Type-specific and nonspecific antibodies to HSV develop in weeks after infection and persist indefinitely, but do not differentiate between genital and orolabial infections. Serologic type-specific glycoprotein G (gG)–based assays can be requested by providers to distinguish HSV-1 and HSV-2.

F.  Differential diagnosis.

1.  Folliculitis.

2.  Chancre of syphilis, warts, candidal inflammation, excoriation.

G.  Treatment.

1.  Primary infection: Oral acyclovir therapy begun within 6 days of onset of infection can decrease viral shedding by 3–5 days. Subsequent severity/ frequency of recurrences not affected by treatment. Topical antiviral drugs not recommended.

a.  Recommended regimens:

•  Acyclovir 400 mg PO tid for 7–10 days, OR

•  Acyclovir 200 mg PO 5 times per day for 7–10 days, OR

•  Famciclovir 250 mg PO tid for 7–10 days, OR

•  Valacyclovir 1 g PO bid for 7–10 days.

2.  Recurrent infections: Acyclovir therapy started within 2 days of onset of recurrence may shorten clinical course by 1 day. Provide prescription so immediate therapy can begin in case of recurrence.

a.  Recommended regimens:

•  Acyclovir 400 mg PO tid for 5 days, OR

•  Acyclovir 800 mg PO bid for 5 days, OR

•  Acyclovir 800 mg PO tid for 2 days, OR

•  Famciclovir 125 mg PO bid for 5 days, OR

•  Valacyclovir 500 mg PO bid for 3 days, OR

•  Valacyclovir 1 g PO once a day for 5 days.

3.  Suppressive therapy for recurrent infections (6 episodes per year): can benefit from daily therapy. Acyclovir: safety and effectiveness for 6 years; valacyclovir or famciclovir for 1 year. Because outbreaks diminish in frequency over time, periodic discontinuation of therapy (i.e., yearly) may be helpful in reassessing need for therapy.