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Pelvic inflammatory disease in the adolescent
JOURNAL OF ADOLESCENT HEALTH CARE 1!NO;11:304-309
olesce
Pelvic Inflammatory Disease in MICHAEL AND
R. SPENCE,
M.D.,
ROBERT McLELLAN,
M.P.H.,
JOAN ADLER,
F.A.A.P.,
M.D.
We studied 17l women, 106 young adults, and 65 ado-
lescents, with a clinical diagnosis of pelvic inflammatory disease (PID) to determine whether differences existed in the presentation in these two groups. The study pop-
ulation was an age-stratified, random sample obtained from 1162women with this condition. Demographic characteristics, sexuai history, physical findings, severity of illmess, and laboratory findings we* compared between the two groups. The most signitlcant tidings were that the adolescents sought health care later in the course of the illness (7.8 vs. 5.6 days; p C 0.02) and were more commonly infected with the gonococcus (42% vs. 28%; p < 0.05). No statistically significant differences were found in the other parameters evaluated. Implications of these findings regarding the health care for sexually transmitted diseases (STDs) and the education of adolescents are discussed.
REY WORDS:
Pelvic inflammatory disease Sexually transmitted disease Fertility Gonorrhea Severity index Salpingitis
Pelvic inflammatory disease (PID) is a major complication of sexually transmitted infections in women. There are approximately 250,000 women hospitalized annually with this diagnosis, and it is estimated that two to three times that number are
From the Department of Obstetrics and Gynecok~gy, Hahnemann University School of Medicine, Philadelphia, Pennsylvania and DepurttnentofObstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland RM.). Address reprint requests to: Michael R. Spence, M.D., M.P.H., Department of Obstetrics and Gynecology, Hahnemann University School of Medicine, Broad and Vine, Philadelphia, PA 19102. Manuscript accepted November 13. 1989. 304 0197-oo7o/90/$3.50
M.D.,
treated as outpatients (l-3). There are deleterious effects of PID on fertility. The approximate rates of lo%, 30%, and 75% infertility in women following a single, two, or three or more episodes of PID, respectively, is well-documented (4). Other MD sequelae include chronic pelvic pain, tuboovarian abscess, ectopic pregnancy, pelvic adhesions, and repeat episodes of PID (5-7). Gonorrhea is the most frequently reported communicable disease. It is implicated as the etiologic agent in 33-809’0of PID (8-11). The highest incidence of gonorrhea occurs in adolescents and young unmarried adults. Among adolescents, reported rates are higher for females than for males (12). Because approximately 15% of women with endocervical gonorrhea develop PID, it follows that the highest incidence of salpingitis also occurs in females between the ages of 15 and 20 years (13). The literature is replete with data concerning adolescents and sexuality, contraception, and venereal disease. One conclusion is clear: Sexually active adolescents are at high risk for venereal disease, including acute PID. The relationship between adolescence and acute PID is only rarely alluded to in the literature. The purpose of this study is to determine whether the clinical aspects of salpingitis in the adolescent distinguish it from the disease process in older patients.
Methods The study population consisted of an age-stratified, random sample of 171 women chosen from 1162 pa-
tients with a diagnosiS of acute PID who attended the Johns Hopkins Hospita.1 Pelvic Infections Clinic. Patients had been referred following initial treatment in the emergency room or presented to the Pelvic Infections Clinic independently. A problemoriented history and physical examination had been
0 So:iety for Adolescent Medicine, 1990 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY IO010
July 1990
conducted and recorded. Charts were reviewed for the following data: age, parity, contraceptive method, socioeconomic status (SES), number of different sexual partners, previous episodes of acute salpingitis or gonorrhea, duration of symptoms prior to seeking treatment, interval between the first day of the last normal menstrual period and the onset of symptoms, pulse, temperature, severity index, endocervical Gram stain for Neisseria gonovrheue, N. gonorrheue endocervical culture result, hematocrit, white blood cell (WBC) count, and treatment. Pelvic inflammatory disease is a syndrome and not a disease. The diagnosis of this condition was made if the patient presented with an abdominal pain and, at the time of examination, was noted to have abdominal tenderness, cervical motion tenderness, and adnexal tenderness (unilateral or bilateral). Diagnostic criteria also included an oral temperature z 38°C (100.4”F) and a leukocytosis in excess of 10,000 WBCs/mm3. All patients had negative urine pregnancy tests. The severity index is an arbitrarily defined measure intended to determine the extent of illness. Each of the following physical characteristics is assigned a value of O-4 points, based on the subjective assessment of its magnitude at the Yme of physical examination: upper abdominal tenderness, lower abdominal tenderness, rebound tenderness, vaginal discharge, cervical motion tenderness, uterine fendemess, and adnexal tenderness. The severity index is computed by adding the points from each of these parameters to obtain a total. The higher the score is, the more extensive the illness. Socioeconomic status was determined by manner of payment: cash, medical assistance, or insurance. Endocervical specimens were obtained for Gram stain at the time of speculum examination by cleqning the ectocervix with a dry, gauze sponge and inserting a sterile, cotton-tipped applicator into the endocervical canal, rotating it through 360” several times, and then rolling it on a clean microscope slide. Gram stain was carried. out in the routine manner. Endocervical cultures for N.. gonorrheue were obtained as described previously, using a swab separate from the one used to obtain the Gram stain (14). The presence or absence of Chlamydiu truchomutis in the endocervix was not determined. Hematocrit and WBC counts were determined by the Johns Hopkins Hospital Hematology laboratory. Subjects 19 years of age or younger were considered adolescents. Individuals older than 19 years of age, presenting in a similar manner, were considered the young adult comparison population.
I’ID IN THE ADOLESCENT
Table 1. Demographics and Clinical Charactetistics the Study Population Variable Age (yr) Pulse (beatslmin) Temperature (“F) Hematocrit (%) WBC count (thousands) Severity index Endocervical smear with gonocci Positive gonorrhea culture Contraception Nulliparity Days of symptoms until examined Day of menstrual cycle symptoms began Previous salpingitis Previous gonorrhea infection Number of sexual partners Single partner ah
305
of
Adult (n=106)
Adolescent (n=65)
29.4 91. 99.4 38.2 10.8 6.0 23(57.5%) 28(31.1%) 36(38%) 20(18.9%) 5.0
17.2 91.5 99.7 37.3 11.8 6.6 19(76%) 32(51.6%) 29(52%)-+ 37(56.9%)7.9***
9.0 34(38.2%) 27(31.4%) 2.5 30(28%)
1:&I;%) 10(17.2%) 2.6 17126%)
““p <0.017; **p <0.00&j;***,
The variables were tabulated and analyzed by comparing adolescents to young adults. Data were analyzed employing Chi-square analysis and Student’s t-test for unpaired variates to determine statistical significance of differences. The 0.05 level was employed to determine significance.
Results The results are summarized in Table 1. The mean age of the 65 patients in the adolescent group was 17.2 (16-19) years. The mean age of the 106 patients in the adult group was 29.4 (20-33) years. There were no statistically significant differences on physical examination between the two populations. The pulse, temperature, hematocrit, WBC, and severity index were similar in both groups. Many differmt therapeutic regimens had been used to treat both groups of patients. Intramuscular aqueous procaine penicillin G, spectinomycin, oral ampicillin, and tetracycline were the most common agents employed. There were no statistically significant differences in the use of any of these regimens. The majority of patients in both groups had more than one sexual partner. In the young adult group, 30 (28%) patients had only one sexual partner, as compared with 17 (25%) in the adolescent group. The average number of sexual partners in young adult and adolescent groups were 2.5 and 2.6, respectively. Thirty-four (38%) of the adult patients and 14
306
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 11, No. 4
SPENCE ET AL.
Table 2. Contraceptive Use in Adult and Adolescent
Patients with PID _ Contraceptive method wd None
Adult Adolesxnt
Oral
xi(37.9) ll(11.6) s51.8) ll(19.6)
KID
Barrier
Stedizdion
M(31.6) 16(28.6)
4(4.2) 0
14(14.7) II
(24%) adolescents reported a previous episode(s) of acute PID by history. Similarly, 17 (31%) adults and 10 (17%) adolescents had a history of gonorrhea. Neither of these variables was significantly associated with either population. There were no statistically significant differences in SES between the groups. Although an.endocervical smear positive for gonococci was not associated with either group, adolescents had a significantly higher incidence of positive cultures for the gonococcus. Thirty-two (52%) adolescents had positive cultures for gonorrhea compared to only 28 (31%) of the adults. Of the adults, 59 (62%) used some form of contraception, including 14 (15%) who had undergone a sterilization procedure. Only ‘27 (48%) of the adolescents used a contraceptive method. The methods of contraception used by both groups are displayed in Table 2. Nulllparity was significantly associated with adolescence. Thirty-seven (57%) adolescents were nulliparous, as opposed to 20 (19%) of the adults. A major fmding was that adolescents presented significantly later in the course of their disease than did the adult patients. The mean duration of symptoms prior to seeking treatment was 8 days in the adolescents, as opposed to 5 days in the adults. Additionally, the onset of symptoms in the adolescents appeared to occur earlier in the menstrual cycle. The mean day of onset was day 7 in the adolescents, as compared to day 9 in the adults.
Discussion Sexually transmitted infections occur most commonly in individuals between the ages of 16 and 24 years. It has been postulated that the initiation of coitus at a young age results in exposure to an increased number of partners and, thus, an increased risk of infection (15,X). The highest rate of PID occurs in women between the ages of 15 and 20 years (13). Our data support this observation (Fig. 1). Despite the theoretical predisposition of adoles-
24 25 262729293031
3233
PATIENT AGE (YEARS)
Figure1. A graphic representation of the age distribution of 1172 patients with PlD.
cents to acquire PID, there are few data specifically addressing this issue (7). This is particularly disconcerting in the light of the consequences of PID: infertility, chronic pelvic pain, recurrent episodes of acute MD, and ectopic pregnancy (4,6,7,17,18). Delay in seeking medical care and subsequent delay in treatment may put the adolescent at increased risk for all of these sequelae. Because the majority of teens are nulliparous, these findings have profound, potential implications for their future life and families. Some investigators have suggested that psychosocial factors influence the sexually transmitted disease (STD) process in the adolescent (19-21). These factors include (1) sexual activity as a response to peer pressure, (2) little knowledge about STDs and their symptoms, and (3) no regular use of contraception, particularly barrier methods, which could decrease the transmission of disease. The lack of knowledge of confidential health services also has an influence. The adolescent may not be obtaining routine health services, including examinations and testing, which could identify a genital tract infection before PID develops. Adolescents may also deny symptoms of disease and avoid seeking medical attention until complications have occurred. This last premise is supported by our data that demonstrated the delay in seeking health care in the adolescent when compared to the adult. Our age-stratified, randomized data were gathered retrospectively, thus permitting the age distribution of our study cohort to be representative of
July 1990
the patient population seen in our facility. Virtually all patients treated for PID in the Johns Hopkins medical institutions during the study period were referred to the Pelvic Infections Clinic (22). The patient population is comprised of predominantly black, inner city women of lower SES. The study variables in this report are part of a data base that is recorded on each patient attending the clinic and are representative of the patients served. Factors from the physical examination that correlate with disease severity were compared. On the basis of pulse, temperature, hematocrit, WBC count, And severity index, the extent of illness appeared to be equivalent in the two groups at the time of treatment. A trend toward increased severity in the adolescent group was observed. Findings on physical examination are subjective. The severity index, a method of grading the magnitude of certain clinical signs found in PID, is an attempt to quantitate findings more objectively on physical examination. Because multiple clinicians were providing care, this technique may provide a means by which the magnitude of the inflammatory process can be semiquantitated based on physical signs. It has been reported that women with previous PID are two to three times more likely to develop subsequent episodes (17). Additionally, patients with MD more frequently have a history of previous uncomplicated gonorrhea than do those with no evidence of PID (23). Our data suggest that there is no difference in the incidence of previous BID or uncomplicated gonorrhea between the adult and adolescent groups. This may Fe due to the inclusion of older teens in the adolescent group. Nulliparity is significantly associated with the younger age group, although 43% of the adolescent patients were parous. The combination of pregnancy and venereal disease in the adolescent is the subject of other reports (24,25). Two of the most important sexually transmitted conditions affecting the adolescent are PID and unwanted pregnancy. Differences in contraception were also significant between adults and teens (Table 2) in this study. A si@ficant nrlmber of adolescents used no contraception (52%); others used an oral contraceptive (20%) or the intrauterine device (IUD) (28%). The majority (56%) of adults practiced some form of contraception or were sterilized. As in the adolescent group, a remarkably high percentage (32%) of adults had an IUD. This was much higher than the prevalence of IUD use in our overall population. It is well-established that individuals who use an IUD are more likely to develop PID than those who do
PID IN THE ADOLESCENT
307
not (17,26,27). The relative risk of developing PID an IUD is highest among nulliparous patients with lower SES (19,23). Our data support this supposition. It has been postulated that barrier contraceptives may be protective against development of BID (23). None of our adolescent patients and only 4% of the adult patients reported ucing a barrier method. Tubal ligation is also believed to prevent the contiguous spread of microorganisms to the endosalpinx and, thus, may prevent PID. Our data do not support this hypothesis. Fifteen percent of our adult patients with MD had undergone tubal ligation. The majority of the patients in both groups reported having multiple sexual partners. It is wellaccepted that the greater the number of sexual contacts, the higher the probability is of acquiring a sexually transmitted disease. Women with multiple sexual partners are four to six times more likely to develop PID than those with only one partner (17). Patients reporting only one sexual partner were in the minority among adults and adolescents in this study. only 25% of adolescents with PID repoited a single sexual partner compared to 28% of adult patients. Among patients who had endocerrical smears for Gram stain, 58% and 76% were positive for gramnegative intracellular diplococci in the adult and adolescent groups, respectively. These differences were not statistically significant; however, these findings support the contention i:hat endocervical Gram stain is of major value in making the diagnosis of gonococcal ND. Eschenbach et al. reported that this technique identifies 62% of patients with concomitant BID and cervical gonorrhea (28). Positive cultures for N. gonorrheae were significantly more frequent in the adolescent group (52%) than in the adult group (31%). This is predictable if one accepts the view that adults are likely to have more previous episodes of PID than adolescents. Recovery of N. gonorrheae from the endocervh diminishes rapidly as the number of previous episodes of PID increases (29). We found that gonococci were never recovered from women with BID who reported three or more episodes of the disease. It should also be noted that although the gonococcus was isolated from 60 patients (28 young adults and 32 adolescents), the majority (111, 65%) of our patients were culture negative. We did not attempt to identify C. truchomatis or other microorganisms, such as Mycoplasma hominis or Ureaplasma uredyficum, and cannot determine what role, if any, they had in the PID syndromes in patients in this study. with
308
SPENCE ET AL.
()ur data suggest that adolescents with PID seek medical attention significantly later than adults. Adolescents sought medical attention approximately 2 days later than their adult counterparts. This SUPports the contention that psychosocial factors may play a role in this disease. We are of the opinion that adolescents may not only be likely to deny symptoms, but also distrust the confidentiality of medical service providers. We believe this may be particularly true when the health care provider represents a different generation, SES, gender, or ethnic background, A health care system designed for adolescents might encourage the identification of disease symptoms, seeking care early, better compliance with therapy, and more consistent followup, Patient education might play an important role in improving these important factors in medical management. However, we believe that patient education must not only come from the health care provider, but also from the school and particularly the home. Parent-child communication about sex appears to improve effective contraceptive use and often may lead to the postponement of sexual activity (30,31). Adolescent patients with PID had a high rate of parity; used less contraception, particularly a barrier method; had a higher incidence of positive culture for N. gonorrheae;and presented for medical attention later in the course of their disease than their adult counterparts. PID is a life-affecting condition in teens. In view of the complications of PID, such as infertility, recurrent PID, chronic pelvic pain, and ectopic pregnancy, a system designed to provide health care and education for the adolescent is needed, Instruction in contraceptive technique, particularly barrier methods, together with education on the etiology, prevention, treatment, and complications of STDs, is mandatory. Furthermore, we believe that encouragement of “sex education” in the home with a particular emphasis on pregnancy and STDs may also improve health care delivery to the adolescent and help prevent the consequences of this syndrome.
References 1. Eschenbach DA. Acute pelvic inflammatory disease: etiology, risk factors, and pathogenesis. Clm Obstet Gynecol 1976;19:147-53. 2. Sweet RL. Diagnosis and treatment of acute salpingitis. J Reprod Med 1977;19:21-4. 3. Washington EA, Cates W, Zaidi AA. Hospitalizations for PID epidemiology and trends in the U.S., 1975-1981. JAMA 1984;251:2529-33.
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 11, No. 4
4. Westrom L. Effect of acute pelvic inflammatory disease in infertility. Am J Obstet Gynecol1980;138$38-93. 5. Method MW, Umes P, Casas ER, Keith L. PID, laparoscopy, and the expenditure of health care dollars. Int J Fertil. 1987;32:17-37. Bernstein R, Kennedy WR, WaIdron J. Acute PID: a clinical 6. follow-up. Int J Fertil. 1987;32:229-32. 7. Shafer M-AB, Irwin CE, Sweet RL. Acute salpingitis in the adolescent female. J Pediah 1982;10&339-50. 8. Eschenbach DA, Buchanan TM, Pollock HM, et al. Polymicrobial etiology of acute pelvic inflammatory disease. N Engl J Med 1975;293:166-72. 9. Sweet RL, Mills J, Hadley KW, et al. Use of laparoscopy to determine the microbiologic etiology of acute salpingitis. Am J Obstet Gynecol. 1979;134:68-72. 10. Kinghom CR, Duerden BI, Hafig S. Clinical and microbiological investigation of women with acute salpin,gitis and their consorts. Br J Obstet Gynecol. 1986,93:869-80. 11. Golden N, Neuhoff S, Cohen H. PID in adolescents. J Pediatr 1989;114:138-43. 12. Darrow WW. Adolescents and venereal diseaues. Proceedings of the 1978 Annual Public Health Social Work Institute, 1978. 13. For&n L, Folk V, Danielsson D. Changes in the incidences of acute gonococcal and nongonococcal salpingitis. BrJ Vener LXS1978;54:247-53. 14. Spence MR, Blanco LJ, Brockman MM. A comparative evaluation of vaginitis, cervicitis, and peritoneal flora in normal health females. Sexually Transmitted Dis 1982;9:37-40. 15. Hofferth SL, Kahn JR, Baldwin W. Premarital sexual activity among U.S. teenage women over the past three decades. Fam Plann Perspect 1987;19:46-54. 16. Zeenick M, Kantner JF. Sexual activity, contracephve use and pregnancy among metropolitan-area teenagers: 1971-1979. Fam Plann Perspect 1980;12:230-8. 17. Flesh G, Weiner JM, Corlett RLL,et al. The intrauterine contracr-ptivedevice and acute salpingitis. Am J Obstet Gynecol 1979;13:402-9. 18. Loffer FD. The increasing problem of ectopic pregmncy and its impact on patients and physicians. J Reprod Med. 1986;31:74-7. 19. Eschenbach DA. Epidemiology and diagnosis of acute pelvic inflammatory disease. Obstet Gynecol. 198O;S5(5):142-5. 20. Smith MS, Eschenbach DA. Pelvic inflammatory disease: a review. Clin Pediatr 1980;19(12):791-6. 21. O’Reilly KR, Aral SO. Adolescence and sexual behavior. J Adolesc Health Care 1985;6:262-70. 22. Spence MR, Smith JL, Mason A, Vaeth CR. A problemoriented gynecology clinic for patients with sexually transmitted diseases. Am J Obstet Gyneco11980;138:1109-12. 23. Eschenbach DA, Ham&h JP, Holmes KK. Pathogenesis of acute pelvic inflammatory disease: role of contraception and other risk factors. Am J Obstet Gynecol. 1977;128:838-43. 24. Mumford DM, Smith PB, GoldfarbJL. Prevalence of venereal disease in indigent pregnant adolescents. J Reprod Med 1977;19(2):EI3-6. 25. Russell JK. Sexual activity and its consequences in the teenager. Clii Obstet Gynecol 1974;1(3):683-91. 26. Vassey M, Doll R, _.__ Peto R, et al._A _ long-term follow-up study _ ot women using ditterent methods of contraception: an interim report. J Biosoc Sci 1976;8:373-89. 27. Westrom L, Bengtsson LP, Mardh PA. The risk of pelvic inflammatory disease in women using intrauterine contra-
July 1990
ceptive devices as compared to non-users. Lancet 1976;ik 221-4. 28. Eschenbach DA, Buchanam TM, EoBock HM, et al. l’olymic&id etiology of acute pelvic inflammatory disease. N Engl J Med 1975;293+-72. 29. Sweet RL, Draper DL, Hadley WK. Etiology of acute salpin-
PID IN THE ADOLESCENT
gitis:
309
influence of episode number and duration of symptoms. Obstet Gynecol 1981;58(1):62-5. 30. Fox GL. The family’s influence on adolescent sexual behavior. Children Today 1979;8:21-36. 31. Newcomer SF and Udry JR. Parent/child communication and adolescent sexual behavior. Fam Plann Perspect 1985;17 169-74.
olesce
Pelvic Inflammatory Disease in MICHAEL AND
R. SPENCE,
M.D.,
ROBERT McLELLAN,
M.P.H.,
JOAN ADLER,
F.A.A.P.,
M.D.
We studied 17l women, 106 young adults, and 65 ado-
lescents, with a clinical diagnosis of pelvic inflammatory disease (PID) to determine whether differences existed in the presentation in these two groups. The study pop-
ulation was an age-stratified, random sample obtained from 1162women with this condition. Demographic characteristics, sexuai history, physical findings, severity of illmess, and laboratory findings we* compared between the two groups. The most signitlcant tidings were that the adolescents sought health care later in the course of the illness (7.8 vs. 5.6 days; p C 0.02) and were more commonly infected with the gonococcus (42% vs. 28%; p < 0.05). No statistically significant differences were found in the other parameters evaluated. Implications of these findings regarding the health care for sexually transmitted diseases (STDs) and the education of adolescents are discussed.
REY WORDS:
Pelvic inflammatory disease Sexually transmitted disease Fertility Gonorrhea Severity index Salpingitis
Pelvic inflammatory disease (PID) is a major complication of sexually transmitted infections in women. There are approximately 250,000 women hospitalized annually with this diagnosis, and it is estimated that two to three times that number are
From the Department of Obstetrics and Gynecok~gy, Hahnemann University School of Medicine, Philadelphia, Pennsylvania and DepurttnentofObstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland RM.). Address reprint requests to: Michael R. Spence, M.D., M.P.H., Department of Obstetrics and Gynecology, Hahnemann University School of Medicine, Broad and Vine, Philadelphia, PA 19102. Manuscript accepted November 13. 1989. 304 0197-oo7o/90/$3.50
M.D.,
treated as outpatients (l-3). There are deleterious effects of PID on fertility. The approximate rates of lo%, 30%, and 75% infertility in women following a single, two, or three or more episodes of PID, respectively, is well-documented (4). Other MD sequelae include chronic pelvic pain, tuboovarian abscess, ectopic pregnancy, pelvic adhesions, and repeat episodes of PID (5-7). Gonorrhea is the most frequently reported communicable disease. It is implicated as the etiologic agent in 33-809’0of PID (8-11). The highest incidence of gonorrhea occurs in adolescents and young unmarried adults. Among adolescents, reported rates are higher for females than for males (12). Because approximately 15% of women with endocervical gonorrhea develop PID, it follows that the highest incidence of salpingitis also occurs in females between the ages of 15 and 20 years (13). The literature is replete with data concerning adolescents and sexuality, contraception, and venereal disease. One conclusion is clear: Sexually active adolescents are at high risk for venereal disease, including acute PID. The relationship between adolescence and acute PID is only rarely alluded to in the literature. The purpose of this study is to determine whether the clinical aspects of salpingitis in the adolescent distinguish it from the disease process in older patients.
Methods The study population consisted of an age-stratified, random sample of 171 women chosen from 1162 pa-
tients with a diagnosiS of acute PID who attended the Johns Hopkins Hospita.1 Pelvic Infections Clinic. Patients had been referred following initial treatment in the emergency room or presented to the Pelvic Infections Clinic independently. A problemoriented history and physical examination had been
0 So:iety for Adolescent Medicine, 1990 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY IO010
July 1990
conducted and recorded. Charts were reviewed for the following data: age, parity, contraceptive method, socioeconomic status (SES), number of different sexual partners, previous episodes of acute salpingitis or gonorrhea, duration of symptoms prior to seeking treatment, interval between the first day of the last normal menstrual period and the onset of symptoms, pulse, temperature, severity index, endocervical Gram stain for Neisseria gonovrheue, N. gonorrheue endocervical culture result, hematocrit, white blood cell (WBC) count, and treatment. Pelvic inflammatory disease is a syndrome and not a disease. The diagnosis of this condition was made if the patient presented with an abdominal pain and, at the time of examination, was noted to have abdominal tenderness, cervical motion tenderness, and adnexal tenderness (unilateral or bilateral). Diagnostic criteria also included an oral temperature z 38°C (100.4”F) and a leukocytosis in excess of 10,000 WBCs/mm3. All patients had negative urine pregnancy tests. The severity index is an arbitrarily defined measure intended to determine the extent of illness. Each of the following physical characteristics is assigned a value of O-4 points, based on the subjective assessment of its magnitude at the Yme of physical examination: upper abdominal tenderness, lower abdominal tenderness, rebound tenderness, vaginal discharge, cervical motion tenderness, uterine fendemess, and adnexal tenderness. The severity index is computed by adding the points from each of these parameters to obtain a total. The higher the score is, the more extensive the illness. Socioeconomic status was determined by manner of payment: cash, medical assistance, or insurance. Endocervical specimens were obtained for Gram stain at the time of speculum examination by cleqning the ectocervix with a dry, gauze sponge and inserting a sterile, cotton-tipped applicator into the endocervical canal, rotating it through 360” several times, and then rolling it on a clean microscope slide. Gram stain was carried. out in the routine manner. Endocervical cultures for N.. gonorrheue were obtained as described previously, using a swab separate from the one used to obtain the Gram stain (14). The presence or absence of Chlamydiu truchomutis in the endocervix was not determined. Hematocrit and WBC counts were determined by the Johns Hopkins Hospital Hematology laboratory. Subjects 19 years of age or younger were considered adolescents. Individuals older than 19 years of age, presenting in a similar manner, were considered the young adult comparison population.
I’ID IN THE ADOLESCENT
Table 1. Demographics and Clinical Charactetistics the Study Population Variable Age (yr) Pulse (beatslmin) Temperature (“F) Hematocrit (%) WBC count (thousands) Severity index Endocervical smear with gonocci Positive gonorrhea culture Contraception Nulliparity Days of symptoms until examined Day of menstrual cycle symptoms began Previous salpingitis Previous gonorrhea infection Number of sexual partners Single partner ah
305
of
Adult (n=106)
Adolescent (n=65)
29.4 91. 99.4 38.2 10.8 6.0 23(57.5%) 28(31.1%) 36(38%) 20(18.9%) 5.0
17.2 91.5 99.7 37.3 11.8 6.6 19(76%) 32(51.6%) 29(52%)-+ 37(56.9%)7.9***
9.0 34(38.2%) 27(31.4%) 2.5 30(28%)
1:&I;%) 10(17.2%) 2.6 17126%)
““p <0.017; **p <0.00&j;***,
The variables were tabulated and analyzed by comparing adolescents to young adults. Data were analyzed employing Chi-square analysis and Student’s t-test for unpaired variates to determine statistical significance of differences. The 0.05 level was employed to determine significance.
Results The results are summarized in Table 1. The mean age of the 65 patients in the adolescent group was 17.2 (16-19) years. The mean age of the 106 patients in the adult group was 29.4 (20-33) years. There were no statistically significant differences on physical examination between the two populations. The pulse, temperature, hematocrit, WBC, and severity index were similar in both groups. Many differmt therapeutic regimens had been used to treat both groups of patients. Intramuscular aqueous procaine penicillin G, spectinomycin, oral ampicillin, and tetracycline were the most common agents employed. There were no statistically significant differences in the use of any of these regimens. The majority of patients in both groups had more than one sexual partner. In the young adult group, 30 (28%) patients had only one sexual partner, as compared with 17 (25%) in the adolescent group. The average number of sexual partners in young adult and adolescent groups were 2.5 and 2.6, respectively. Thirty-four (38%) of the adult patients and 14
306
JOURNAL OF ADOLESCENT HEALTH CARE Vol. 11, No. 4
SPENCE ET AL.
Table 2. Contraceptive Use in Adult and Adolescent
Patients with PID _ Contraceptive method wd None
Adult Adolesxnt
Oral
xi(37.9) ll(11.6) s51.8) ll(19.6)
KID
Barrier
Stedizdion
M(31.6) 16(28.6)
4(4.2) 0
14(14.7) II
(24%) adolescents reported a previous episode(s) of acute PID by history. Similarly, 17 (31%) adults and 10 (17%) adolescents had a history of gonorrhea. Neither of these variables was significantly associated with either population. There were no statistically significant differences in SES between the groups. Although an.endocervical smear positive for gonococci was not associated with either group, adolescents had a significantly higher incidence of positive cultures for the gonococcus. Thirty-two (52%) adolescents had positive cultures for gonorrhea compared to only 28 (31%) of the adults. Of the adults, 59 (62%) used some form of contraception, including 14 (15%) who had undergone a sterilization procedure. Only ‘27 (48%) of the adolescents used a contraceptive method. The methods of contraception used by both groups are displayed in Table 2. Nulllparity was significantly associated with adolescence. Thirty-seven (57%) adolescents were nulliparous, as opposed to 20 (19%) of the adults. A major fmding was that adolescents presented significantly later in the course of their disease than did the adult patients. The mean duration of symptoms prior to seeking treatment was 8 days in the adolescents, as opposed to 5 days in the adults. Additionally, the onset of symptoms in the adolescents appeared to occur earlier in the menstrual cycle. The mean day of onset was day 7 in the adolescents, as compared to day 9 in the adults.
Discussion Sexually transmitted infections occur most commonly in individuals between the ages of 16 and 24 years. It has been postulated that the initiation of coitus at a young age results in exposure to an increased number of partners and, thus, an increased risk of infection (15,X). The highest rate of PID occurs in women between the ages of 15 and 20 years (13). Our data support this observation (Fig. 1). Despite the theoretical predisposition of adoles-
24 25 262729293031
3233
PATIENT AGE (YEARS)
Figure1. A graphic representation of the age distribution of 1172 patients with PlD.
cents to acquire PID, there are few data specifically addressing this issue (7). This is particularly disconcerting in the light of the consequences of PID: infertility, chronic pelvic pain, recurrent episodes of acute MD, and ectopic pregnancy (4,6,7,17,18). Delay in seeking medical care and subsequent delay in treatment may put the adolescent at increased risk for all of these sequelae. Because the majority of teens are nulliparous, these findings have profound, potential implications for their future life and families. Some investigators have suggested that psychosocial factors influence the sexually transmitted disease (STD) process in the adolescent (19-21). These factors include (1) sexual activity as a response to peer pressure, (2) little knowledge about STDs and their symptoms, and (3) no regular use of contraception, particularly barrier methods, which could decrease the transmission of disease. The lack of knowledge of confidential health services also has an influence. The adolescent may not be obtaining routine health services, including examinations and testing, which could identify a genital tract infection before PID develops. Adolescents may also deny symptoms of disease and avoid seeking medical attention until complications have occurred. This last premise is supported by our data that demonstrated the delay in seeking health care in the adolescent when compared to the adult. Our age-stratified, randomized data were gathered retrospectively, thus permitting the age distribution of our study cohort to be representative of
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the patient population seen in our facility. Virtually all patients treated for PID in the Johns Hopkins medical institutions during the study period were referred to the Pelvic Infections Clinic (22). The patient population is comprised of predominantly black, inner city women of lower SES. The study variables in this report are part of a data base that is recorded on each patient attending the clinic and are representative of the patients served. Factors from the physical examination that correlate with disease severity were compared. On the basis of pulse, temperature, hematocrit, WBC count, And severity index, the extent of illness appeared to be equivalent in the two groups at the time of treatment. A trend toward increased severity in the adolescent group was observed. Findings on physical examination are subjective. The severity index, a method of grading the magnitude of certain clinical signs found in PID, is an attempt to quantitate findings more objectively on physical examination. Because multiple clinicians were providing care, this technique may provide a means by which the magnitude of the inflammatory process can be semiquantitated based on physical signs. It has been reported that women with previous PID are two to three times more likely to develop subsequent episodes (17). Additionally, patients with MD more frequently have a history of previous uncomplicated gonorrhea than do those with no evidence of PID (23). Our data suggest that there is no difference in the incidence of previous BID or uncomplicated gonorrhea between the adult and adolescent groups. This may Fe due to the inclusion of older teens in the adolescent group. Nulliparity is significantly associated with the younger age group, although 43% of the adolescent patients were parous. The combination of pregnancy and venereal disease in the adolescent is the subject of other reports (24,25). Two of the most important sexually transmitted conditions affecting the adolescent are PID and unwanted pregnancy. Differences in contraception were also significant between adults and teens (Table 2) in this study. A si@ficant nrlmber of adolescents used no contraception (52%); others used an oral contraceptive (20%) or the intrauterine device (IUD) (28%). The majority (56%) of adults practiced some form of contraception or were sterilized. As in the adolescent group, a remarkably high percentage (32%) of adults had an IUD. This was much higher than the prevalence of IUD use in our overall population. It is well-established that individuals who use an IUD are more likely to develop PID than those who do
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not (17,26,27). The relative risk of developing PID an IUD is highest among nulliparous patients with lower SES (19,23). Our data support this supposition. It has been postulated that barrier contraceptives may be protective against development of BID (23). None of our adolescent patients and only 4% of the adult patients reported ucing a barrier method. Tubal ligation is also believed to prevent the contiguous spread of microorganisms to the endosalpinx and, thus, may prevent PID. Our data do not support this hypothesis. Fifteen percent of our adult patients with MD had undergone tubal ligation. The majority of the patients in both groups reported having multiple sexual partners. It is wellaccepted that the greater the number of sexual contacts, the higher the probability is of acquiring a sexually transmitted disease. Women with multiple sexual partners are four to six times more likely to develop PID than those with only one partner (17). Patients reporting only one sexual partner were in the minority among adults and adolescents in this study. only 25% of adolescents with PID repoited a single sexual partner compared to 28% of adult patients. Among patients who had endocerrical smears for Gram stain, 58% and 76% were positive for gramnegative intracellular diplococci in the adult and adolescent groups, respectively. These differences were not statistically significant; however, these findings support the contention i:hat endocervical Gram stain is of major value in making the diagnosis of gonococcal ND. Eschenbach et al. reported that this technique identifies 62% of patients with concomitant BID and cervical gonorrhea (28). Positive cultures for N. gonorrheae were significantly more frequent in the adolescent group (52%) than in the adult group (31%). This is predictable if one accepts the view that adults are likely to have more previous episodes of PID than adolescents. Recovery of N. gonorrheae from the endocervh diminishes rapidly as the number of previous episodes of PID increases (29). We found that gonococci were never recovered from women with BID who reported three or more episodes of the disease. It should also be noted that although the gonococcus was isolated from 60 patients (28 young adults and 32 adolescents), the majority (111, 65%) of our patients were culture negative. We did not attempt to identify C. truchomatis or other microorganisms, such as Mycoplasma hominis or Ureaplasma uredyficum, and cannot determine what role, if any, they had in the PID syndromes in patients in this study. with
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()ur data suggest that adolescents with PID seek medical attention significantly later than adults. Adolescents sought medical attention approximately 2 days later than their adult counterparts. This SUPports the contention that psychosocial factors may play a role in this disease. We are of the opinion that adolescents may not only be likely to deny symptoms, but also distrust the confidentiality of medical service providers. We believe this may be particularly true when the health care provider represents a different generation, SES, gender, or ethnic background, A health care system designed for adolescents might encourage the identification of disease symptoms, seeking care early, better compliance with therapy, and more consistent followup, Patient education might play an important role in improving these important factors in medical management. However, we believe that patient education must not only come from the health care provider, but also from the school and particularly the home. Parent-child communication about sex appears to improve effective contraceptive use and often may lead to the postponement of sexual activity (30,31). Adolescent patients with PID had a high rate of parity; used less contraception, particularly a barrier method; had a higher incidence of positive culture for N. gonorrheae;and presented for medical attention later in the course of their disease than their adult counterparts. PID is a life-affecting condition in teens. In view of the complications of PID, such as infertility, recurrent PID, chronic pelvic pain, and ectopic pregnancy, a system designed to provide health care and education for the adolescent is needed, Instruction in contraceptive technique, particularly barrier methods, together with education on the etiology, prevention, treatment, and complications of STDs, is mandatory. Furthermore, we believe that encouragement of “sex education” in the home with a particular emphasis on pregnancy and STDs may also improve health care delivery to the adolescent and help prevent the consequences of this syndrome.
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