Internal Medicine 14: 18-year-old woman for pre-college physical

User: Ariana Amini

Email: [email protected]

Date: November 11, 2019 2:19AM

Learning Objectives

The student should be able to:

Obtain a history that differentiates among etiologies of dysuria.

Differentiate /distinguish signs and symptoms of lower versus upper urinary tract infection.

Recognize /recommend when to order diagnostic and laboratory tests in evaluation of dysuria, including urinalysis, wet prep, and KOH stain.

Describe current recommendations for cervical cancer screening.

Discuss safe sexual practices and efficacy of common methods of contraception.


Adolescent Interview – Safety


The leading causes of death in older adolescents are violent: suicide, injuries, and homicide. Bullying, family violence, sexual abuse, date rape and

school violence are all common. In many urban communities, up to one in four students report carrying a weapon to school. Family violence and

dating violence cross all economic and social boundaries.


For some teens, school violence and guns are the major risks, and in others, sports injuries and injuries from wheeled vehicles are more likely. It is

important to address use of a seat belt and bike helmets with every adolescent.

Even though you address the safety issues most prevalent in the patient’s community first, do not skip any part of the history based on assumptions

about the patient’s ethnic background or economic status.

Recommended Vaccinations for Adolescents and Teenagers


MMR is recommended in adults who have not been previously vaccinated as children. An exception to this recommendation is the

case of pregnant women. Pregnant women should not be vaccinated with MMR because of a risk of fetal transmission since it is a

live virus vaccine.

Hepatitis B
Hepatitis B vaccination is effective in preventing hepatitis B virus infection and its sequelae of cirrhosis and hepatic carcinoma. The

series of three injections is recommended for adolescents if they did not receive them when younger.


The meningococcal vaccine is given to prevent meningococcal meningitis. It is commonly given once at age 11-12 years during the

routine preadolescent immunization visit with a booster dose at age 16 and is recommended for all previously unvaccinated

adolescents aged 11-18 years.



There are two different human papillomavirus vaccines available. They vary by the number of strains of HPV they protects against,

ranging from four to nine, and can prevent most cases of cervical cancer and genital warts. It is recommended for girls and women

9-26 years old.

The Advisory Committee on Immunization Practices (ACIP) recommends the use of the HPV vaccine in males 11 or 12 years of age.

ACIP also recommends vaccination in males ages 13 through 21 who have not been vaccinated previously or who have not

completed the three-dose series. ACIP states that males aged 22 through 26 years may be vaccinated, but does not recommend

routine vaccination in this age group.





The tetanus, diphtheria, acellular pertussis (Tdap) vaccine protects against tetanus, diphtheria and pertussis. It contains acellular

pertussis vaccine (ap), which is less reactogenic than the older whole-cell pertussis vaccine that caused high fever and neurologic

symptoms when given to older children and adults. Tdap, which was licensed in 2005, is the first vaccine for adolescents and adults

that protects against all three diseases.

Adolescents should receive a single dose of Tdap as a booster between the ages of 11 and 18, with the preferred timing between 11

and 12 years. If a patient has received a Td booster, then waiting at least five years between Td and Tdap is encouraged because

the incidence of side effects is lower.

The exception to this rule is the case of type III hypersensitivity reactions. Type III hypersensitivity reactions (Arthus reactions), which

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are characterized by immune complex deposition in blood vessels, can rarely be seen following receipt of tetanus toxoid or

diphtheria toxoid-containing vaccines. These reactions are characterized by severe pain, swelling, and sometimes necrosis at the

injection site and occur between 4 and 12 hours following vaccination. It is recommended that patients who have had such a type III

hypersensitivity reaction avoid receiving a tetanus toxoid-containing vaccine more frequently than every 10 years.


The varicella vaccine series, which is a live virus vaccine, should be given to adolescents who have never had chickenpox or have

not received the vaccine.

Varicella was added to the list of standard childhood vaccines in 1995. Two doses are required, with the first administered at 12-15

months of age and the second at 4-6 years of age. There is also a combination measles, mumps, rubella, and varicella vaccine

(MMRV) available.


The influenza vaccine is recommended for everyone who is at least age six months. It is usually administered in September through

December when the influenza season is imminent.

The H1N1 strain, or “swine” influenza, the predominant strain circulating in the U.S. over the past several years, has high rates of

morbidity and mortality among children and adolescents.

Pneumococcal The pneumococcal vaccine is indicated for adolescents with certain chronic health conditions.


influenzae type


Haemophilus influenzae type b vaccine protects against meningitis, pneumonia, epiglottitis, and bacteremia in infants and young

children, but it is not recommended after the age of five years.

When a Pelvic Examination Is Indicated

Cervical cancer screening should start at age 21 regardless of sexual activity and should continue through the age of 65. There is recent

evidence that screening for cervical cancer in women less than 21 years of age leads to procedures and more harm than benefit. The frequency of

cervical cancer screening with the Papanicolaou (Pap) test for immunocompetent individuals with previously normal tests is once every three years

or, for women ages 30 to 65 years, screening with a combination of cytology and human papillomavirus (HPV) testing every five years.

STI Screening Recommendations

Current recommendations are for all patients age 15 to 65 years to be screened for HIV infection.

Test results for some STIs such as gonorrhea must be reported to the public health department.

Most Common Causes of Cystitis

E. coli causes a majority of all cases of uncomplicated urinary tract infections.

Other common organisms include Staphylococcus saprophyticus, Klebsiella pneumonia, and Proteus mirabilis.

Differentiating Cystitis from Pyelonephritis

It is important to make the distinction between cystitis and pyelonephritis because the treatment differs.

Cystitis Pyelonephritis



dysuria, frequency, urgency,

suprapubic pain, and/or


may or may not have symptoms of cystitis together with fever (> 38ºC) and other systemic

symptoms such as, chills, flank pain, costovertebral angle tenderness, and nausea/vomiting

Urinalysis pyuria pyuria, white blood cell casts (pathognomonic)


short-course antibiotic therapy

(three days);

hospitalization usually not


at least seven days of treatment;

hospitalization may be required

Dysuria in Males

Disease Presentation Diagnosis

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UTI and


Isolated acute cystitis is rare in males because their longer urethra hinders

bacteria from reaching the bladder, and prostatic fluid has antibacterial


Most males with acute cystitis have functional or anatomic abnormalities, and

need further evaluation.

Symptoms of lower and upper tract infections are the same in males and


Midstream culture and sensitivity of the urine


Usually sexually transmitted gonococcal and/or chlamydia infection.

Gonococcal urethritis is more likely in males with acute symptoms and

purulent urethral discharge.

Chlamydia is likely when dysuria is present alone or with minimal discharge.

Males with chlamydia infection may be asymptomatic.

Recommended that patients be treated presumptively for both gonorrhea and

chlamydia, pending results.

Herpes simplex virus is a rare cause of urethritis, but may be suggested by

the history of penile lesions.

Diagnosis can be made on a gram stain of

a urethral swab.

Leukocytes and gram-negative

intracellular diplococci confirm the

diagnosis of gonorrhea.

White cells without organisms suggest

non-gonococcal urethritis (NGU) which is

usually chlamydia but can also be

Trichomonas vaginalis.

Because many outpatient offices are not

equipped to do gram stains, NAAT testing

of the urethra or urine is becoming the

preferred diagnostic test for gonorrhea

and chlamydia.


Acute prostatitis

Presents with UTI symptoms of fever, chills, dysuria, dribbling, and hesitancy,

and is caused by gram-negative rods (Enterobacteriaceae, Pseudomonas,

Proteus), gram-positive organisms (Enterococcus, S. aureus), and sexually

transmitted agents such as Neisseria gonorrhoeae and Chlamydia


Prostate is edematous and very tender on digital rectal examination.

Chronic prostatitis

Characterized by lower urinary tract symptoms, perineal discomfort, pain with

ejaculation, and occasionally deep pelvic pain that radiates to the back. The

symptoms are often subtle and sometimes may be absent, and the physical

exam may be normal.

This diagnosis should be considered in men with recurrent UTIs without risk


Diagnosis can be difficult to make and may

require submitting urine specimens gathered

following prostatic massage for microscopic

urinalysis and culture.


Patients with epididymitis present with dysuria, frequency, urgency, and

unilateral testicular pain.

Fever and rigors may be present and there may be redness and tenderness

of the entire affected testicle.

Testicular torsion should be considered in all cases, especially when the

patient is an adolescent and the onset is sudden.

Epididymitis in men < 35 years is usually caused by Chlamydia trachomatis or Neisseria gonorrhoeae; in those > 35, enteric gram-negative rods

(Escherichia coli) are the most common causes.

If the diagnosis is questionable, color duplex

doppler scanning should be obtained


Factors that Contribute to Complicated Urinary Tract Infections

Hospital-acquired urinary tract infections are considered complicated because patients are more susceptible to developing

infections with antibiotic-resistant organisms that are found in the hospital environment.

Pregnant Urinary tract infections in pregnant females can progress to and can induce preterm labor so are thus considered complicated.

Urinary catheter or



Urinary tract infections in patients with urinary catheters or recent instrumentation are considered complicated because they

introduce external pathogens into the urinary tract and, in the case of indwelling catheters, provide a nidus for bacterial


Immunosuppressed Patients who are immunosuppressed or who recently have been treated with antibiotics are considered to have complicated

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or recently treated

with antibiotics


Anatomic or


abnormalities of the

urinary tract

Anatomic or functional abnormalities of the urinary tract lead to stasis and impede the free flow of urine, promoting bacterial

growth and causing complicated infections.


Urinary tract infections in men are complicated because they are commonly associated with bladder outlet obstruction,

instrumentation, or other urologic abnormalities. However, a small number of adult men can develop uncomplicated UTIs. Risk

factors associated with these infections are homosexuality, intercourse with a urinary tract-infected female partner, and lack of


Birth Control Options

Percentage of women experiencing an unintended pregnancy within the first year of use: United States

Method Typical use Perfect use

No method 85 85

Spermicides 29 18

Withdrawal 27 4

Fertility awareness-based methods 25

Standard days method 5

Two day method 4

Ovulation method 3


Parous women 32 20

Nulliparous women 16 9

Diaphragm 16 6


Female (Reality) 21 5

Male 15 2

Combined pill and progestogen-only pill 8 0.3

Evra patch 8 0.3

NuvaRing 8 0.3

Depo-Provera 3 0.3

Combined injectable (Lunelle) 3 0.05


ParaGard (copper T) 0.8 0.6

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Mirena (LNG-IUS) 0.2 0.2

Implanon 0.05 0.05

Female sterilization 0.5 0.5

Male sterilization 0.15 0.10

Adapted from WHO Medical eligibility criteria for contraceptive use (2009)

Male latex condoms: when correctly used with each episode of intercourse, are the best protection against sexually transmitted infections.

IUDs: can be considered for women at low risk of acquiring sexually transmitted infections, since sexually transmitted infections may require

removal of the IUD. Women with a history of PID can safely use the IUD with appropriate counseling. IUDs can be used as long as the woman

is not planning a pregnancy for at least one year, since attempting a pregnancy would require IUD removal. Women who have never been

pregnant can safely use the IUD.

Post-coital contraceptives: (emergency contraception) initiated within 72 hours of unprotected intercourse reduce the risk of pregnancy by at

least 75%.


First-Line Empiric Therapy for Cystitis

In large part, empiric choice of antimicrobial agents for uncomplicated cystitis depends on regional susceptibility patterns.

In most regions of the U.S., rates of resistance of E. coli to ampicillin and amoxicillin exceed 20%, which makes amoxicillin a poor choice for

empiric therapy.

In most areas, resistance rates for nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole are less than 10%. Therefore, these

have become recommended first-line empiric therapy in the U.S. However, the rates of resistance to these antibiotics vary by geographic

region and can exceed 20% in some areas.

Fluoroquinolones (ciprofloxacin, ofloxacin, and levofloxacin), in many areas, have favorable resistance profiles, but in some areas resistance rates

exceed 20%. Even if the resistance rates are < 10%, fluoroquinolone use can select for multidrug-resistant resistant organisms (sometimes referred to as "collateral damage"). Therefore, fluoroquinolones should be considered alternative therapy and reserved for patients who do not tolerate or are not eligible to receive recommended first-line agents. Selected beta-lactam agents may be reasonable choices as well when other agents cannot be used. However, there are less data with these agents. The beta-lactams that could be considered for treatment in select circumstances based on local susceptibility data include amoxicillin-clavulanate, 2nd-generation cephalosporins (cefaclor), 3rd-generation cephalosporins (cefdinir and cefpodoxime), and, in some instances 1st-generation cephalosporins (cephalexin and cefadroxil). In the end, the final choice of antibiotic should depend on a variety of factors, including local susceptibility patterns, patient allergies, potential drug- drug interactions, recent antibiotic use, and renal function, among others. Recommended Dosing and Duration for Cystitis Therapy Nitrofurantoin monohydrate or macrocrystals should be dosed at 100 mg twice daily for five days. The efficacy of this regimen has similar efficacy to

that of a three-day regimen of trimethoprim-sulfamethoxazole in a randomized-control trial. However, other recommended first-line agents have

different recommended durations. See the table below for recommended durations of first-line agents.

First-line antimicrobial regimens for use in acute uncomplicated cystitis in the United States.

Drug Dose and interval Duration

Trimethoprim-sulfamethoxazole 160/800 mg q 12 hours 3 days

Nitrofurantoin monohydrate macrocrystals 100 mg q 12 hours 5 days

Fosfomycin trometamol 3 gm in a single dose 1 dose

Recommended Therapy for Pyelonephritis

In patients with pyelonephritis, a urine culture with sensitivities should be sent in addition to a urine dipstick and microscopic urinalysis. Definitive

antibiotic choice should be based on the results of the urine culture.

For empiric therapy before the results of the urine culture are obtained, an oral fluoroquinolone is the first-line treatment if the local resistance rates

are < 10%, as in this case. Fluoroquinolones provide high drug concentrations in the renal medulla. A longer course of at least seven days should be given for pyelonephritis. © 2019 Aquifer 5/9 This study source was downloaded by 100000801385017 from on 07-03-2021 19:55:07 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m Trimethoprim-sulfamethoxazole should be used in pyelonephritis only if the culture and sensitivity results are available and if the infecting organism is known to be susceptible. Two-week regimens are generally advised when using trimethoprim-sulfamethoxazole. If trimethoprim-sulfamethoxazole is to be used prior to obtaining results of a urine culture, a single intravenous dose of a long-acting cephalosporin, such as ceftriaxone, should be given before starting the course of trimethoprim-sulfamethoxazole. Nitrofurantoin should not be used to treat pyelonephritis because adequate tissue levels in the kidney are not attained. Who Should Be Hospitalized For Pyelonephritis Patients who cannot maintain oral hydration or cannot take oral medicines should be hospitalized, as should those who have social circumstances or other factors that hinder adherence to therapy. Patients who appear septic, who are hemodynamically unstable and who have any complicating factors should also be hospitalized. In many cases, people with diabetes should be hospitalized for parenteral therapy because they have worse outcomes, and diabetics have an increased risk of complications such as emphysematous pyelonephritis or abscess. Pregnant women should be hospitalized because pyelonephritis is associated with an increased incidence of fetal complications and premature delivery. Preventing Recurrent UTIs 1. The first step in evaluating recurrent dysuria is to prove the patient is actually having urinary tract infections by urinalysis and urine culture. Dysuria could be due to atrophic vaginitis, genital herpes, interstitial cystitis, mechanical or chemical irritation, or urethritis. 2. The next step after proving recurrent cystitis is to ask the patient about risk factors and predisposing factors to complicating infections. These predisposing factors should be treated if present. 3. In patients without predisposing factors, some physicians attempt behavioral and lifestyle modification. Because sexual activity is associated with recurrent infections, doctors often recommend that women void before and after sexual intercourse. This, and advice to wipe "front to back," increase fluid intake (including cranberry juice), and avoid full bladders, have not been proven to reduce the recurrence of infection, but they are benign maneuvers, and still make sense to many clinicians. 4. For post-menopausal women, topical estrogen normalizes the vaginal flora and reduces the risk of recurrent infection. 5. Especially if these conservative measures fail and the patient has at least three proven urinary tract infections per year or at least two in six months, antibiotic prophylaxis may be considered. Potential strategies include continuous prophylaxis, post-coital prophylaxis, and self-treatment. Rates of urinary tract infections do not differ significantly between continuous and post-coital prophylaxis. Post-coital prophylaxis will result in less antibiotic use than continuous prophylaxis with similar efficacy, especially if the infections are temporally related to sexual intercourse. Likewise, patient-initiated treatment upon developing symptoms can represent a cost-effective management strategy if infections are not severe and not frequent. The ultimate choice of agent for prophylaxis or treatment should depend on local susceptibility patterns and susceptibility patterns of the patient's prior urine cultures. Generally, the recommended duration of continuous prophylaxis is six months followed by observation for reinfection. Recommended Chlamydia Therapy First-line chlamydia therapy is a one-time oral dose of azithromycin 1 gram or a seven-day course of oral doxycycline 100 mg twice daily . The one-time regimen of azithromycin is preferred because of better adherence. Levofloxacin and ofloxacin are considered alternative treatment agents and require seven days of therapy. Studies Cervical Cancer Screening Guidelines Age Recommendation Under 21 Women under the age of 21 should not be tested, regardless of sexual activity. 21-29 Women between the ages of 21 and 29 should have a Pap test every three years with the liquid-based cytology technique. HPV testing should not be used in this age range unless it is prompted by an abnormal Pap result. 30-65 There are three options for screening women between the ages of 30 to 65: 1. "Co-testing" with the Pap test and a high-risk HPV test every five years, 2. Pap test alone every three years, or 3. High-risk HPV testing alone every five years. Over 65 Women older than 65 who have had negative Pap tests are unlikely to have abnormal Pap tests with repeat testing so should no longer be screened. Screening should occur for 20 years after a pre-cancerous lesion is detected, even if testing continues after the age of 65. Women in the following groups should be screened yearly: those with HIV infection those who are immunosuppressed (i.e., patients with transplanted organs, on chemotherapy, or on chronic steroids) © 2019 Aquifer 6/9 This study source was downloaded by 100000801385017 from on 07-03-2021 19:55:07 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m those with diethylstilbestrol (DES) exposure before birth HPV vaccines target only certain genotypes of HPV. The 9-valent Gardasil-9 includes 7 genotypes that cause cervical cancer (types 16, 18, 31, 33, 45, 52 and 58) and 2 genotypes that most commonly cause genital warts (types 6 and 11), the quadrivalent Gardasil includes the most common genotypes to cause cervical cancer (types 16 and 18) and the 2 genotypes that most commonly cause genital warts (types 6 and 11). But recipients of either vaccine are still at risk of developing cervical cancer. Therefore, they should receive age-appropriate screening as discussed above. However, they are at a decreased risk because types 16 and 18 are the cause of cervical cancer in a majority of cases. Liquid-based cytology is a method where cervical cells are suspended in a vial of liquid preservative instead of spread from a brush and spatula onto a glass slide. There are fewer unsatisfactory specimens with liquid Paps, and testing for HPV can be done on fluid from the vial, if warranted. However, there are more false-positive results with liquid Pap, which can result in needless referrals for colposcopy. Recommended Pelvic Exam Tests in the Setting of Suspected STIs Nucleic acid amplification testing (NAAT) for N. gonorrhea and C. trachomatis The best way to test for chlamydia and gonorrhea during a pelvic exam is nucleic acid amplification testing (NAAT) for N. gonorrhea and C. trachomatis. NAAT is a sensitive and specific assay and has replaced culture methods. It can be used on urine specimens as well. Microscopic examination of slide with drop of vaginal discharge and potassium hydroxide The potassium hydroxide slide is used to visualize budding yeast and hyphae that are seen with candida vaginal infections. Microscopic examination of slide with drop of vaginal discharge and normal saline The saline-prepped or "wet mount" slide allows for diagnosis of Trichomonas and bacterial vaginosis. Smelling a slide with a drop of vaginal discharge and potassium hydroxide Placing a drop of potassium hydroxide on vaginal discharge is known as the whiff-amine test. The production of a fishy odor indicates a positive test. A positive whiff-amine test is seen in bacterial vaginosis. Tests not indicated: Gram stain in cervicitis is not sensitive enough to detect infection, although it is highly sensitive and specific for the detection of Neisseria gonorrhoeae in male urethral specimens. Culture of cervical specimens has largely been replaced by nucleic acid testing. Smelling a slide with normal saline is not useful. What to Look for on Wet Mount Slides In the case of trichomoniasis, wet mount slides reveal trichomonads, which are flagellated protozoans. The treatment is a single dose of 2 grams of metronidazole. Clue cells can also be seen on a saline slide and are characteristic of bacterial vaginosis (BV). BV, the most common cause of a vaginal discharge in women of childbearing age, is a condition characterized by reduced numbers of normal vaginal lactobacilli and overgrowth of other vaginal bacteria. Clue cells are epithelial cells entirely covered with these bacteria giving the perimeter a "furlike" appearance. The treatment of BV is a course of metronidazole 500 mg twice daily for seven days. It is also useful to measure the pH of vaginal discharge. A pH greater than 4.5 is seen in trichomoniasis, bacterial vaginosis, and atrophic vaginitis. Diagnostic Tests for Cystitis Microscopic urinalysis Pyuria, defined as at least two to five leukocytes per high-powered field in a spun urine specimen , is present in almost all women with cystitis, and evaluation of midstream urine for white blood cells is the most valuable lab test for urinary tract infection. If white cells are not present in the urine, an alternative diagnosis should be considered. Urine dip stick In ambulatory settings, urine dipstick testing has largely replaced microscopy to confirm the diagnosis of urinary tract infection (UTI), because it is cheaper, faster and more convenient. Dipsticks detect the presence of leukocyte esterase and nitrite and have comparable accuracy to microscopic urinalysis in the diagnosis of cystitis. However, they may be negative in low-colony count infections (less than 10 4 colonies/mL). Therefore, patients should also have a microscopic urinalysis performed. Tests not indicated for diagnosis of cystitis Microscopic evaluation of the urine for bacteriuria is generally not recommended for acute cystitis because bacteria in low quantities (less than 10 4 colonies/mL) are difficult to find, even with gram stain. Urine culture is not cost-effective and not necessary in women with cystitis, because the causative organisms and antibiotic sensitivities are predictable, and the results of the culture are not immediately available. There are certain situations when obtaining a urine culture is useful, such as in patients with refractory symptoms or those with history of urinary tract infections with antibiotic-resistant organisms. © 2019 Aquifer 7/9 This study source was downloaded by 100000801385017 from on 07-03-2021 19:55:07 GMT -05:00 Th is stu dy re so ur ce w as sh ar ed v ia C ou rs eH er o. co m Indications for Imaging or Urologic Evaluation in a Patient with a UTI Imaging studies and urologic referral are not indicated in the routine evaluation of young women with cystitis or pyelonephritis because they rarely uncover abnormalities that require treatment. However, in certain groups, further evaluation is recommended to exclude anatomic abnormalities and complications of pyelonephritis. Isolation of Proteus can be associated with urologic (struvite) stones so may require imaging, especially in patients with recurrent or refractory infections despite adequate antibiotic treatment. Recurrent …

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