17.3 STI Screening, Prevention & Sexual Health Counseling

This section is STI screening, prevention, and sexual-health counseling — still category #10. CDC STI guidelines and AAP adolescent statements are the authority. Domain II is a nonjudgmental sexual history and the right NAAT. Domain III is treat PID without delay, expedited partner therapy as a legal concept, HPV vaccine as prevention, and PrEP as referral-aware care. Child sexual abuse is Chapter 20; the SRH trigger you must not miss is already enough to report: any STI in a prepubertal child is maltreatment until proven otherwise.

Clinic opening. A 19-year-old woman is in for acne. She has had two partners this year. If you skip chlamydia testing because "this is a dermatology complaint," or you Pap her instead of ordering NAAT, you missed CDC.

Quick Answer: Annual chlamydia and gonorrhea NAAT for sexually active females younger than 25. Males: MSM (at least annually, extra-genital sites as indicated) or other risk. HIV at least once, more often if risk. Syphilis and trichomonas are risk-based. EPT where legal. HPV vaccine does not wait for coitarche. PID: lower abdominal pain plus cervical motion, uterine, or adnexal tenderness — treat empirically, do not delay. HSV and anogenital warts are counseling-plus-treatment problems. PrEP for high-risk adolescents is real — refer if you do not prescribe it. History without judgment. Prepubertal STI = maltreatment until proven otherwise.

Sexual history without judgment

Use a frame boards recognize: the Five P's — Partners, Practices, Protection from STIs, Past history of STIs, Pregnancy prevention — asked privately, after confidentiality limits. Add consent and identity and attraction without assuming heterosexual cisgender partners. "Are you sexually involved with anyone?" then partners who are male, female, both, or another identity, then which body parts contact which. That last question is how you order rectal and pharyngeal NAAT, not prurience.

Do not open with "you should not be doing this." Risk reduction is stepwise: fewer partners, condoms, vaccination, testing, PrEP when indicated, contraception. Abstinence is a valid choice; abstinence-only as the entire counseling plan is not AAP's evidence-based default (the promotion chapter already said that). Here you still test and treat the adolescent who is having sex. HEADSS and SSHADESS live in the history chapter. This section's add-on is specific enough to choose a test. A "socially well teen" checkbox is not a sexual history.

Ask about last contact, condom use last time (not "in general"), substance use that impairs consent, and whether any contact was unwanted. Unwanted contact in a minor is a reporting and safety problem, not a quieter STI panel.

CDC screening you must not under-order

Do not require a speculum to screen. Do not skip annual CT/GC in a 17-year-old because last year's Pap (which should not have been done) was NILM. Do not add "routine STI screening" to a prepubertal well visit without a maltreatment evaluation context — that is a forensic and reporting pathway, not a Bright Futures checkbox.

Treat confirmed chlamydia with current CDC therapy (doxycycline twice daily for 7 days is the usual nonpregnant adolescent regimen; azithromycin remains relevant in pregnancy and selected situations — use the current table, do not freeze a 2015 single-dose-only memory if the guideline has moved). Gonorrhea is ceftriaxone IM at the current dose plus chlamydia coverage if chlamydia has not been excluded. Test of reinfection at about 3 months (not a test of cure for uncomplicated urogenital chlamydia treated with recommended therapy in most nonpregnant patients). Partners need treatment. Abstain until therapy is completed and partners are treated.

Expedited partner therapy, HPV vaccine, and PrEP as concepts

Expedited partner therapy (EPT) means providing medication or a prescription for a partner who is unlikely to present, without examining that partner, when state law allows. Evidence is strongest for chlamydia (and EPT is used for gonorrhea in many jurisdictions with resistance caveats). Know it as a concept. Do not invent that EPT is federally mandatory or federally banned. MSM partners more often need their own evaluation (HIV, syphilis, extra-genital infection) rather than a bag of pills as the only strategy. Document what you dispensed, counsel about partner notification, and still treat this patient today.

HPV vaccine prevents oncogenic HPV and most anogenital warts from vaccine types. Principle: routine at 11–12 years, may start at 9, catch-up through the current ACIP young-adult ceiling (commonly through age 26). Do not wait for sexual debut. Do not tell a parent the vaccine is permission to have sex. Two-dose versus three-dose schedules by age at start live in the immunization chapter; here the SRH point is prevention of cancer and warts before exposure, and vaccinating males and females. Existing warts or a later Pap abnormality are not reasons to skip catch-up vaccination. The vaccine does not move average-risk cytology earlier than 21.

Pre-exposure prophylaxis (PrEP) for HIV is indicated for adolescents at substantial risk (teaching examples: MSM with a partner of unknown or positive unsuppressed HIV status, condomless anal sex, a recent bacterial STI, or injection-drug risk). AAP and CDC support PrEP for eligible youth. If you do not prescribe it, you still recognize the candidate and refer to a clinician who does — same week, not after college. Documented HIV-negative status is mandatory before starting. This is referral-aware primary care, not a requirement that every CPNP-PC independently run a PrEP clinic on the exam. Condoms remain part of the plan; PrEP is not a gonorrhea vaccine.

PID: treat, do not delay

Pelvic inflammatory disease is an ascending polymicrobial infection of the uterus, tubes, and adnexa, usually in sexually experienced adolescents, classically tied to gonorrhea and chlamydia but often mixed. CDC minimum clinical criteria: lower abdominal or pelvic pain plus one or more of cervical motion tenderness, uterine tenderness, or adnexal tenderness, in a sexually active patient, when another diagnosis is not more likely.

You treat empirically. Waiting for NAAT or ESR to come back is how tubes scar. Additional supportive findings (fever, mucopurulent discharge, abundant white cells on wet mount, elevated CRP or ESR, documented CT/GC) increase specificity; they are not required to start therapy.

Outpatient CDC skeleton (verify current doses at the time you practice): parenteral ceftriaxone once plus doxycycline for 14 days plus metronidazole for 14 days is the recent standard combination teaching. Hospitalize if pregnant, tubo-ovarian abscess is suspected, illness is severe or she is vomiting, or outpatient therapy failed. An IUD in situ is not automatic removal on day one of uncomplicated PID; treat and reassess. Counsel that future ectopic pregnancy and infertility risk is why you do not shrug off "a little cervical motion tenderness." Follow up in 48–72 hours to confirm improvement.

Do not diagnose PID in a prepubertal child as a casual STI; that is a maltreatment evaluation. Differential in adolescents includes ectopic pregnancy, appendicitis, ovarian torsion, and pyelonephritis — pregnancy-test everyone with pelvic pain.

HSV, warts, and counseling that lasts after the visit

Genital HSV is painful vesicles or ulcers, dysuria, inguinal nodes, and sometimes a severe primary episode with systemic symptoms. PCR from the lesion is the diagnostic test. Oral acyclovir, valacyclovir, or famciclovir for the episode; discuss episodic versus daily suppressive therapy if recurrences are frequent or if reducing transmission risk matters. Counsel: lifelong latent virus, condom benefit is incomplete, disclosure to partners, and neonatal risk in a future pregnancy (third-trimester primary infection is the obstetric nightmare). Type-specific serology in asymptomatic teens is a counseling swamp; do not order it as a well-teen panel.

Anogenital warts (HPV, often types 6 and 11): cauliflower lesions. Many clear spontaneously over months. Patient-applied therapy (imiquimod, sinecatechins, podofilox — several are not for pregnancy) versus clinician-applied cryotherapy or trichloroacetic acid. Recurrence is common; that is not your treatment failure alone. Warts are not a Pap indication under 21. Vaccine still helps against future types.

Partner services, school, and sports: treatable STIs are not a reason for public humiliation. Follow public-health reporting for named conditions in your state (typically gonorrhea, chlamydia, syphilis, HIV). Reporting to health departments is not the same as calling a parent. Offer HIV testing whenever you diagnose another STI.

Sexual abuse: the prepubertal STI rule

Any laboratory-confirmed gonorrhea, syphilis, or chlamydia, or acquired HIV or trichomonas, in a prepubertal child is sexual maltreatment until proven otherwise. Perinatal transmission windows exist for some pathogens in very young infants; they narrow quickly and still require expert sexual-abuse evaluation rather than a shrug. Anogenital warts in a toddler can be controversial (vertical, autoinoculation, versus abuse) — do not decide "it's nothing" in isolation; involve child-abuse pediatrics. HSV-1 can be nonsexual; HSV-2 is more specific for sexual contact. You report first when the finding meets maltreatment concern. You do not "treat the gonorrhea and see if it comes back." Forensic exam, evidence collection, and CPS or law-enforcement notification are Chapter 20 skills; this chapter's job is not to miss the trigger.

Consensual peer sexual activity in a post-pubertal adolescent is not automatically abuse, but age-discordant, forced, or caregiver-involved contact is. Know your jurisdiction's age-of-consent and mandated-reporting definitions without inventing them on the exam. When in doubt, consult, protect, and report rather than protect the alleged adult.

Exam traps. Skipping annual CT/GC NAAT in sexually active females under 25. Pap instead of NAAT. Urine-only testing in MSM who need rectal or pharyngeal sites. Delaying PID antibiotics for a culture. Universal HSV serology. Waiting for coitarche to give HPV vaccine. Ignoring PrEP in a high-risk 17-year-old. Treating prepubertal gonorrhea as a hygiene problem.

Clinic close. Ask specifically. Screen females younger than 25 for chlamydia and gonorrhea every year they are sexually active. HIV at least once, more if risk. Treat PID today. EPT where legal. Vaccinate for HPV as prevention. Name PrEP and refer. Prepubertal STI: maltreatment until proven otherwise.