TORONTO — Despite guidelines to the contrary, 55% of adolescents presenting to the emergency department with urinary complaints were not investigated for a sexually transmitted infection in one study, Dr. Najah Musacchio said at the annual meeting of the Pediatric Academic Societies.
“It's not just an issue in our emergency departments [EDs], I think it's an issue in a lot of pediatric private practices as well,” Dr. Musacchio said in an interview. “We all need to be more comfortable dealing with issues of sexual health among our adolescent patients.”
In a retrospective chart review of 163 adolescents (82% girls, mean age 16 years) presenting to the ED, the patients had the following symptoms:
▸ Dysuria (87%),
▸ Urinary frequency (45%),
▸ Abdominal pain (45%),
▸ Hematuria (29%),
▸ Back pain (29%),
▸ Urgency (27%),
▸ Genital discharge (17%),
▸ Fever (17%), and
▸ Vomiting (10%).
Forty-nine (30%) of the patients were not asked if they were sexually active, reported Dr. Musacchio of Children's Memorial Hospital in Chicago.
“There are several guidelines saying any adolescents who present with urinary complaints should be asked if they're sexually active,” she said, adding that urinary tract infections (UTIs) are extremely uncommon in men “so we have to have a really high index of suspicion for an STI in males with those symptoms.”
Factors associated with sexual history taking included age more than 19 years (odds ratio 1.4), evening presentation at the ED (OR 2.3), being afebrile (OR 2.7), and having genital discharge (OR 4.6).
Among the 114 (70%) of patients who were asked about sexual history, 84 (74%) confirmed sexual activity. However, only 43 (51%) of those 84 patients were tested for sexually transmitted infection (STI). Among them, 13 had a UTI, and 12 had either gonorrhea or chlamydia. Of the 41 sexually active patients who were not tested for STI, 24 had a UTI.
The 55 % of patients who were not investigated for an STI represent “a missed opportunity for diagnosis and treatment of STI,” said Dr. Musacchio.
“First … we're not thinking about it, and then there are also a number of systems issues. In an extremely busy emergency department, spending the time to do a pelvic exam sometimes is really difficult—[as] in a busy pediatric practice. To fit in the time to do a full STI evaluation, there are billing issues and time issues.”
The implications of the findings are significant because gonorrhea and chlamydia are epidemic in adolescents—15- to 25-year-olds have the highest rates of these diseases in the United States—and the consequences can be devastating. In addition, adolescents who seek help in the ED may represent an even higher risk group because they are often of lower socioeconomic status and have poor access to primary care.
Dr. Musacchio stressed that one of the underrecognized barriers to STI diagnosis and treatment is the presence of an adolescent's parents during a visit. It's always important when teenagers present with any complaint that you spend some time speaking to them alone, she advised.