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Most patients with lower genitourinary tract symptoms are not tested for STIs, even those with conditions known to be caused by these infections.

“Adolescents and young adults have the highest rates of chlamydia and gonorrhea, based on CDC sexually transmitted infection (STI) surveillance data, with the highest rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) rates in women and men aged 20-24. These patients should be tested for STIs when presenting with lower genitourinary tract symptoms such as dysuria, urogenital discharge, and pelvic pain,” Rebecca Lillis, MD, explains. “In fact, these diagnoses should be considered in all sexually active persons presenting with lower genitourinary tract symptoms.”

However, she notes that “busy clinicians may not ask the right questions to determine STI risk, and patients may not be comfortable answering questions about their sexual behavior even when asked.”

For a study published in BMC Infectious Diseases, Dr. Lillis and colleagues examined testing patterns for gonorrhea and chlamydia in patients with lower genitourinary tract symptoms. The researchers analyzed data from visits with ICD codes indicating signs, symptoms, or the diagnosis of a urogenital condition that could be caused by an STI, as well as testing patterns and drug claims.

STI Testing Limited; Presumptive Treatment Common

The analysis identified 23.5 million episodes with lower genitourinary tract symptoms from 12.3 million patients, most of which (87.4%) were in women compared with men (12.6%). The median age of patients at index was 38 (interquartile range, 26–51); nearly half (46.2%) of the cohort was between 40 and 64.

Most (89%) patients with lower genitourinary tract symptoms who were treated within 2 weeks of the index visit received treatment within 3 days.

“In most cases, this would not be a sufficient amount of time for diagnostic tests to result,” Dr. Lillis says. “We considered these patients to be presumptively treated based upon their symptom at presentation. The high percentage of presumptive treatment may indicate that clinicians are not waiting for test results to initiate treatment for lower genitourinary tract symptoms and may not be testing at all.”

Study results showed that CT/NG testing was only done in 17.6% of all episodes, Dr. Lillis notes, and testing for other causes of lower genitourinary tract symptoms, such as urinary tract infections and vaginitis, occurred in two-thirds of visits.

“In the age groups most at risk for gonorrhea and chlamydia—young adults aged 20-24—gonorrhea and chlamydia testing was done in 31.3% of women and 44.3% of men, indicating that the vast majority of young adults are not being tested for STIs when they present with STI symptoms,” she says. “Further, testing rates in the group aged 20-24 were the highest of any of the groups; all other age groups were less likely to be tested for gonorrhea and chlamydia.”

The low CT/NG testing rate among patients with conditions known to be caused by these infections also concerns Dr. Lillis.

“Only 15% of women with PID, 24.2% of women with cervicitis, 10.3% of men with orchitis/epididymitis, and 57.7% of men with urethritis were even tested for gonorrhea and chlamydia,” she says.

The most common anti-infectives prescribed were those indicated for urinary tract infections, which may indicate missed STI diagnoses, Dr. Lillis notes. “This may also contribute to suboptimal antimicrobial stewardship.”

Advancing Diagnostics & Increasing STI Testing

The high rate of presumptive treatment seen in the study underscores the importance of test results in prescribing the correct treatment. Future research that examines STI diagnostics for use at the point-of-care would expedite diagnosis, treatment, and referral for STIs, Dr. Lillis says.

“I would also like to see more at-home testing options for patients to improve access to STI care, as well as more sex-positive, patient-empowering STI prevention modalities.”

She believes that all clinicians—regardless of practice setting—should consider STIs as a cause of urogenital symptoms.

“Part of this requires obtaining an accurate sexual history from patients, regardless of where they are presenting for care. These discussions need to be normalized.”

Key Takeaways

•  Testing for gonorrhea and chlamydia is low among patients with lower genitourinary tract symptoms
• Most patients with these symptoms are treated within 3 days of the index visit, indicating a high rate of presumptive treatment
• Research that examines STI diagnostics for point-of-care use would expedite STI diagnosis and treatment