This study is based on a real-life case.1 Some details have been altered to fit the format of this study to preserve the identity of the patient. All photos are stock photos, used for illustrative purposes only. Posed by models.
Suzanne, a 24-year-old young professional living in a big city, presents to a nearby clinic with recent onset urinary frequency and urgency, and vaginal discharge and irritation.
In the exam room, the nurse collects medical and sexual history.2,3
Suzanne recounts her symptoms.
Suzanne shares that she is sexually active, but has an intrauterine device (IUD)4 and has regular menstrual periods. She does not believe she is pregnant. The nurse requests a urine sample to assess for a urinary tract infection (UTI)5 because some of Suzanne’s symptoms are consistent with a UTI, especially urinary frequency and urgency. The urine sample will also help to confirm a negative pregnancy status.5-7
Nurse: When did the urinary frequency and urgency start?
Suzanne: All my symptoms seem to have manifested around the same time - about 1 week ago.
Nurse: How would you describe the vaginal discharge and itching?
Suzanne: The discharge is more than usual and is white-ish. The itchiness is focused around the vaginal opening.
Nurse: Are you sexually active? If so, any new sexual partners?3
Suzanne: Yes, I’ve had a few relationships in the past 6-12 months, most of which turned sexual at some point. About 1 month ago, my boyfriend and I decided to be in a monogamous sexual relationship.
Nurse: You indicated that you have an IUD. Can you share what type of IUD it is?4
Suzanne: It is a copper IUD
Nurse: Do you and your partner(s) use any STI prevention methods? If so, with what frequency?3
Suzanne: Before I got the IUD, I always insisted on condoms, but now I worry less about using them. It’s rare that we use condoms now, maybe 10% of the time if I had to guess.8
Forms of long-acting reversible contraception (LAC), which include IUDs and contraceptive implants, are very effective in preventing pregnancy, but they do not provide protection against STIs.4,8,9
Therefore, the dual use method, which is the use of condoms in addition to an effective contraceptive (e.g. IUD), is recommended. However, dual use is not very common, especially among women using LARC.8,9
In the US, only 12% to 23% of sexually active young women (ages 18-24 years) report the use of dual methods. The use of dual methods is significantly lower among LARC users than those using other hormonal contraception (e.g. oral contraceptive pills).10
A systematic review and meta-analysis of 10 pooled studies (1990-2018) of adolescent and adult women showed that LARC users had approximately 60% lower odds of using condoms compared with those using oral contraceptive methods (odds ratio, 0.43 [95% CI, 0.30-0.63]).11
In fact, according to a US national sample of women (ages 15-44 years; 2006-2008) using LARC, only 7.3% reported dual use of methods.8
According to a recent CDC analysis, there was a total of 26 million new cases across 8 common STIs* in the US in 2018. Of those cases, what percentage were among people in the same age range as Suzanne (15-24 years)?
*The 8 common STIs inciuded in the CDC analysis were chlamydia, gonorrhea, hepatitis B virus, herpes simplex virus type 2, HIV human papillomavirus, syphilis, and trichomoniasis.12
The CDC analysis showed that 50% of the 26 million new cases of 8 common STIs* were experienced by adolescents and young adults, aged 15-24 years.12
Due in part to the high prevalence of STIs in this age range, routine laboratory screening or testing for some SIs is indicated for all sexually active adolescents and young adults.13
For example, the reported rates of chlamydia and gonorrhea are highest among 15- to 24-year-old females, which led to the CDC’s recommendation of annual screening for chlamydia and gonorrhea among sexually active females ‹25 years old.12,13
Suzanne provides a urine sample for in-house processing. She then waits in the exam room for the physician’s assistant (PA).2
Vaginal swab is collected for lab analysis.
In cases of suspected UTI, a dipstick urine test may be used to determine if the sample is positive for leukocyte esterase. Leukocyte esterase and pyuria are common findings in cases of UTI, but are these potential positive findings sufficient to exclude STIs as a cause of UTI?
Urinalysis findings of positive leukocyte esterase and pyria are common in cases of both UTs and STIs, meaning this urinalysis result alone is insufficient in eliminating STis as a possible underlying cause of Suzanne’s signs and symptoms.
The signs and symptoms of UTs and STIs in women are also overlapping, making it hard to discern the cause.17,19
In fact, a study of 264 adult females (median age: 27 years) presenting to the emergency room with UTI/STI-like symptoms showed that 92% had an abnormal urinalysis result. However, overdiagnosis of these symptoms as a UTI was observed in 52% of the women. Consequently, Sis (chlamydia, gonorrhea, and trichomoniasis) were underdiagnosed in these women; 64% of women with an ST were misdiagnosed as having a UTI?19
The PA reviews his case notes.
A definitive diagnosis from the lab test will likely not be available for several days, so the PA recommends empirical treatment or syndromic management targeting UTIs and VVC.2
*Oral fluconazole treatment is typically administered as a single dose of 150 mg for uncomplicated VVC; however, in cases of recurrent or severe VVC, a longer treatment course may be recommended13.
Urinary symptoms are associated with both UTIs and STIs, and both infections can occur concomitantly. It is estimated that about 20% of adult females with a culture-confirmed UTI also have a concomitant vaginal or cervical infection caused by an SI, including chlamydia, gonorrhea, and trichomoniasis.6
In a study of 296 sexually active females (aged 14-22 years), patients presenting with urinary symptoms in the absence of a formal UTI diagnosis, were more likely to have a trichomoniasis infection than a UTI. Additionally, 65% of patients presenting with sterile pyuria, actually had an STI, specifically trichomoniasis or gonorrhea. This makes it challenging for clinicians to determine if the origins of urinary symptoms are in fact due to a UTI or if they may be the result of an STI.6
The clinic receives ST lab results, which have been reviewed by the PA. The results confirm that Suzanne does not have VVC, but she does have chlamydia, gonorrhea, and trichomoniasis.
At this point, Suzanne has taken fluconazole and has had 4 days of therapy with nitrofurantoin - all without a definitive, data-driven diagnosis. Now, the clinic has to try to contact Suzanne by phone to instruct her to discontinue those treatments and return to the clinic to pick up prescriptions to treat for the 3 STIs:
According to the World Health Organization (WHO), simple, rapid, and accurate point-of-care tests (POCTs)31 can greatly improve STI management by allowing a clinician to definitively diagnose and appropriately treat potential STIs.32
What are the detrimental effects resulting from the undertreatment of STIs? Select all that apply.
The undertreatment or lack of treatment for STIs can result in many detrimental effects, including serious medical complications, ongoing community spread of STis, and increased transmission of other STIs, including HIV.
Undertreatment can result in:
Let’s revisit Suzanne’s story, but see how different it would play out if the clinic was equipped with a rapid, highly accurate POCT, such as the Visby Medical Sexual Health Click Test...
If this POCT had been used in the clinic, Suzanne would have promptly received the appropriate treatments for the three STIs and EPT, thereby reducing potential community spread and reducing the need for clinic follow-up.1,2
Detection of organisms that cause BV and VVC are not part of the Visby Medical Sexual Health Click Test; an alternate diagnostic test would be needed for those two infections.
Clinical counseling on STIs, including information about risk reduction, contraceptives, and safe sex practices, is an effective means to reduce high-risk STI behavior in both adolescents and adults.38
A systematic review of 13 meta-analyses (representing 248 studies) found that behavioral counseling aimed at promoting the use of condoms was effective in reducing STIs, improving safe sex practices, and providing education on STIs and their prevention.38,41
The American College of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians (AFP), and the Centers for Disease Control and Prevention (CDC) all recommend routine clinical counseling around STI prevention and safe sex practices.38 However, a recent Kaiser Family Foundation study showed that this type of counseling was not routine among women aged 15 to 44 years, with only 30% of women reporting a recent conversation with a clinician about STIs.38
The Visby Medical Sexual Health Click Test is a POCT that enables result-driven, effective treatment delivery during a single clinic visit.