Gonorrhoea

Introduction

• Oral sex can result in pharyngeal infection, which can cause a sore throat and fever.

• Resistance to first line treatments is starting to become a problem

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

• 20% of affected men also have chlamydia
• 40% of affected women also have chlamydia

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 with Urethritis:

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

Gonorrhoea of the rectum – sometimes seen in MSM. 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
• Dyspareunia is common

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:

• PID – can 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 GC –rare 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 – Periphepatitis – rare – 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

Testing can either be performed by swab for culture, or swab for NAAT (nucleic acid amplification testing – I.e. PCR)

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

• NAAT is not validated for non-genital sites, although is often used for this purpose
• False positives are possible
• Culture has the added benefit of testing sensitivities
• If culture not collected at time of diagnosis, collect at time of treatment to determine anti tic susceptibility

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.

• First pass urine for NAAT is recommended in most cases for men
  • If there is penile or ano-rectal discharge, collect a swab for culture
  • In MSM it is routine practice to collect NAAT for first pass urine, as well as swabs for culture from the anus and throat – even if they are symptomatic at these sites
• Ano-rectal swab for either culture or NAAT in symptomatic (ano-rectal symptoms) patients

Women

• Endocervical swab for NAAT and / or culture if symptomatic discharge
• Self-collected low vaginal swab is sufficient if asymptomatic and for screening purposes
• First pass urine is much less reliable in women and only recommended if swab cannot be taken
• Pharyngeal swab if history of oral sex (can be NAAT or culture)
• Ano-rectal swab if history of anal sex (can be NAAT or culture)

Treatment

Agents – about 10% of GC is resistant to penicillin and ciprofloxacin, and about 40% is resistant to tetracyclines.

As a result of increasing resistance, dual therapy is now usually recommended, with azithromycin and ceftriaxone. Anogenital infection and conjunctivitis

• Ceftriaxone 500mg IM STAT
  • Usually given 2mls in 1% lignocaine
• PLUS
• Azithromycin 1g PO stat

Pharyngeal infection

As above, but the dose of azithromycin is doubled:

• Ceftriaxone 500mg IM STAT
  • Usually given 2mls in 1% lignocaine
• PLUS
• Azithromycin 2g PO stat

In areas where resistance is low you could consider the following (in Australia, this only applies to some remote locations or in cases of severe allergic reactions):

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

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
• Australian STI guidelines – Gonorrohea

Read more about our sources

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