Gonorrhoea

Original article by Tom Leach | Last updated on 19/5/2014
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Introduction

Gonorrhoea (aka the clap)
Nisseria Gonorrhoae (aka Gonococcus, GC)is a Gram-negative intracellular diplococcus. It only infects humans, and likes moist areas, typically infecting the genitourinary tracts, retum, pharynx and conjunctiva. It is particularly intolerant to a dry environment.
It is usually spread by person to person contact, but there are occasional reports of its spread via inanimate objects (fomites). Most commonly spread by sexual transmission, but also spread via vertical transmission from mother to baby. This can result in a conjunctivitis (ophthalmia neonatum), which if untreated can result in blindness, and is an ophthalmological emergency. 
  • Oral sex can result in pharyngeal infection, which can cause a sore throat and fever.
 

Epidemiology

  • A relatively common STD, but less common than chlamydia and genital warts
  • Most commonly affects 16-24 year olds
    • This age group accounts for about 50% of new diagnoses
  • Incidence has declined in recent years
 

Aetiology

High number of sexual partners
Non-practice of safe sex
Sharing sex toys
Associated with other STI’s

 

Clinical features

50% of women and 10% of men are asymptomatic
It has an incubation period of 2-14 days. Most people get symptoms about 2-5 days after infection.  
Symptoms consistent withUrethritis:

  • Pain and frequency of micturition
  • Discharge –usually white and purulent

Gonorrhoea of the rectum – sometimes seen in gay men. Can vary from being symptom free, to causing a discharge of painful bloody pus from the rectum (proctitis)
Extra symptoms in women – inter-menstrual bleeding, pelvic pain (with an ascending infection)

  • The most common site of infection in women is the endocervical canal. This is the canal between the external os and the uterine cavity.
  • Sometimes it can spread to the anus from the vagina
 

Complications

Men – the infection can ascend the urinary tract, and cause epididymitis or prostatitis. These can be acute or chronic.

  • Proctitis in those that practice anal sex.

Women:

  • PIDcan be serious, and lead to infertility
  • Bartholin’s abscess – a tender, red, fluctuant mass, usually found in the fold between the labia majora and minora, at the 5 or 7 o’clock position. May cause severe unilateral vulvar pain.
  • Septic arthritis aka disseminated GCrare in men, but can occur in untreated women. Tend to be mono- or olioarthritis and asymmetrical. This is associated with a papular or pustular rash, and sometimes fever and malaise.
  • Fitz-hugh-Curtis Syndrome - Periphepatitisrare - can be caused by chlamydia or gonorrhoea, and is the result of infection of the Glisson’s capsule tissue , which surround the liver. This tissue becomes scarred, and will cause acute onset URQ pain and tenderness. Symptoms will be aggravated by coughing, laughing or heavy breathing. Sometimes pain is referred to the right shoulder tip. Laparoscopy may show violin string tip adhesions, which can be removed surgically.
 

Diagnosis

Smear testing – a swab from the urethra, cervix, throat or rectum can be used for diagnosis.

  • Culture - The sample is cultured with a sensitivity of 95%.
  • Microscopy:
    • Men – Urethral Sampling – is 90% sensitive
    • Women – Endocervical sampling – only 50% sensitive
  • Taking a swab sample in women – when testing for gonorrhoea, you should use the standard swab (looks like a big cotton wool bud), and, whilst using a speculum, swab where there is most discharge. This is usually on the posterior surface of the vagina.

Nucleic acid amplification testing – (NAAT’s) this uses a urine sample, and is highly sensitive, but results in a large number of false positives.
Blood culture, and joint aspiration – should be performed if disseminated GC is suspected
Tests for other common STD’s should be performed in light of a positive diagnosis of GC – e.g. syphilis, chlamydia and trichomonas.

 

Treatment

Should be given to anyone with a positive test for GC. It may also be given to anyone who has had close sexual contact with the patient, via contract tracing. It can usually be treated with a single dose of AB’s:

Agents – about 10% of GC is resistant to penicillin and ciprofloxacin, and about 40% is resistant to tetracyclines.
Anogenital infection – use cefixime (400mg) or (if sensitive) ciprofloxacin, however, as treated is usually started before diagnosis is confirmed, usually cefixime is used. In areas where resistance is low:

  • single dose amoxicillin (1g) + probenecid (1g) OR
  • Ciprofloxacin (500mg) OR
  • Ofloxacin (400mg)

Pharyngeal infection – ceftriaxone (IM)

Complicated and disseminated cases will require longer courses of treatment. The patient should be followed up 72 hours after treatment to check efficacy.
 

Screening

Although not an official ‘screening’ program, the NHS offers free chlamydia and gonorrhoea testing through the post via the R U Clear campaign.
  • Eligible to under 25’s
  • Text (SMS) details to the service, and they send out a pack in the post
  • Pee in the pot, and send it back
  • Results sent back via SMS text messaging