Sexually transmitted diseases (STDs) do not always present to the pediatric urologist. However, pediatric urologists should be aware of the various types of presentations, differential diagnoses, diagnostic methods, and treatments for STDs. In addition, some STD diagnoses should prompt testing for more STDs and some are required to be reported to public health departments. For most STD diagnoses it is recommended that all sexual partners within the last 60 days be checked and that sexual activity be avoided while symptomatic and until 7 days after treatment is completed.

Herein, we will review the types of STDs based on common types of patient presentations. Treatment, diagnostic testing, and whether reporting to the public health department is necessary will be presented in tabular form based on the most recent Centers for Disease Control (CDC) recommendations. Reviewing the CDC guidelines at the time of any STD diagnoses is recommended.

Urethritis symptoms include dysuria and mucopurulent or purulent urethral discharge. STDs are typically classified as gonococcal urethritis (GU) caused by Neisseria gonorrhoeae and nongonococcal urethritis (NGU) which can be caused by various other organisms. Chlamydia trachomatis causes many cases of NGU along with other organisms such as Mycoplasma genitalium, Trichomonas vaginalis, herpes simplex virus, and adenoviruses. In addition, it is common that no pathogen is identified in NGU.

Urethritis diagnosis is currently made using nucleic acid amplification tests (NAATs) looking for N. gonorrhoeae and C. trachomatis in voided urine. A urine analysis should be obtained as well to evaluate for urethral inflammation. Culture of urethral swab can also be done but it has lower sensitivity and is not recommended if NAATs are available. Treatment of GU involves treatment for N. gonorrhoeae and possible C. trachomatis. Treatment of NGU involves treatment only for likely cause of NGU, typically C. trachomatis.

Epididymitis in men less than 35 years of age is caused by similar organisms to those that cause urethritis with N. gonorrhoeae and C. trachomatis being the most common. For men who practice insertive anal intercourse, treatment should cover enteric organisms also. Symptoms include pain, swelling, inflammation of epididymis and sometimes testis as well. Urethritis may be present and epididymal abscess can occur. A scrotal ultrasound is usually obtained to rule out testis torsion/abscess. Urinalysis (UA), urine
culture, and NAAT should be used for diagnosis. In men who are likely to have STDs (less than 35 and epididymitis), treatment for both N. gonorrhoeae and C. trachomatis is given. For men who practice insertive anal intercourse, treatment for enteric organisms is given as well (Table 31-1).

Cervicitis is characterized by purulent or mucopurulent discharge from the cervix and friable cervical mucosa. Cervicitis may be asymptomatic or present with vaginal discharge or bleeding after intercourse. Cervicitis can be caused by N. gonorrhoeae and C. trachomatis. NAAT testing should be obtained on vaginal, cervical, or urine samples. Trichomoniasis vaginalis can also cause cervicitis and should be tested for using one of several Food and Drug Administration- (FDA-) approved assays that are highly sensitive and specific, including NAAT. The older method of microscopic evaluation of a wet preparation of genital secretions has poor sensitivity. Therefore, it can still be used to diagnose T. vaginalis but cannot rule it out.

Genital ulcers from an STD are most commonly caused by genital herpes or syphilis. Other STDs to be aware of that cause genital ulcers include chancroid, granuloma inguinale, and lymphogranuloma venereum. More than one cause can be present in a genital ulcer. The diagnosis can often be made on history and physical examination alone. All patients with genital ulcers from presumed STD should be tested for herpes and syphilis. Other causes of genital ulcers should be tested for if a known outbreak is present in the area or clinical suspicion exists. See Table 31-2 for description of the clinical presentations of genital ulcer diseases.

Herpes is very common with approximately 50 million people in the United States having infection with most being undiagnosed and many asymptomatic. Genital herpes is usually caused by herpes simplex virus-2 (HSV2) but can also be caused by herpes simplex virus-1 (HSV1). Patients with herpes should be informed that recurrent episodes may occur and that HSV viral shedding can occur when asymptomatic. They should be advised about the importance of informing current and future sexual partners and the increased likelihood of HIV transmission during outbreak of ulcers. If herpes leads to recurrent outbreaks, suppressive therapy can be given such as acyclovir 400 mg by mouth twice a day or valacyclovir 1 g by mouth daily.