Gonorrhoea

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Introduction

  • Caused by Neisseria gonorrhoeae, a gram-negative aerobic diplococcus
  • It prefers the columnar epithelium of the urethra, the cervical canal, the rectum and the conjunctivae.
  • The keratinizing epithelium of the adult vagina is quite resistant to N. gonorrhoeae, but that of the pre-pubertal girls, pregnant women and the elderly is more easily colonized
  • Occasionally N. gonorrhoeae reaches the blood stream causing sepsis

Gonorrhoea in males

Clinical features

  • Presents as foul-smelling urethral discharge of pus with dysuria 2 - 6 days after exposure
  • Some patients have a scanty discharge that cannot be distinguished from non-gonococcal urethritis
  • Often asymptomatic during the day but there may be a drop of discharge in the morning
  • Urethral orifice is usually inflamed; there may be balanitis because of the irritation from the discharge and secondary infection
  • About half of infected males are asymptomatic
  • Ascending infection is common and may lead to inflammation of the epididymis (epididymitis)
  • Epididymitis usually manifests by acute onset of unilateral testicular pain and swelling, often with tenderness of the epididymis and vas deferens
    • Occasionally there is erythema and oedema of the overlying skin
    • The adjacent testis is often also inflamed (orchitis), giving rise to epididymo-orchitis

Complications

  • Local complications (now uncommon):
  • Littre abscess involving periurethral glands
  • Paraurethral abscesses
  • Proximal urethral involvement with frequency and terminal haematuria
  • Cowper's gland abscess involving the bulbourethral glands, producing a swelling behind the base of the scrotum that can produce a proximal or Cowper's stricture
  • Prostatitis
  • Proctitis
  • Urethral stricture leading to hydroureters and hydronephrosis
  • Chronic epididymo-orchitis leading to sterility
  • Contaminated fingers or other fomites can also lead to infection of the eyes- gonococcal conjunctivitis
  • Haematogenous spread leading to meningitis, arthritis etc

Differential diagnoses 

  • Urethral discharge: Spermatorrhoea/prostatorrhoea (sexual arousal)
    • Trichomonas vaginalis and Candida albicans can also give rise to urethral discharge and balanitis Ascending infections:
  • Escherichia coli, a common cause in the insertive male homosexuals
    • Other organisms may be transmitted non-sexually following genitourinary infections, surgery and instrumentation (including catheterization)
  • Scrotal swelling (epididymo-orchitis): In older men, where there may have been no risk of STIs, other general infections may be responsible, e.g. Escherichia coli, Klebsiella spp. or Pseudomonas aeruginosa
  • Tuberculous epididymo-orchitis, secondary to lesions elsewhere, especially in the lungs or bones
  • Brucellosis, caused by Brucella melitensis or Brucella abortups
  • Orchitis is usually clinically more evident than an epididymitis
  • In pre-pubertal children the usual aetiology is coliform, pseudomonas infection or mumps virus
  • Non-infectious causes of scrotal swelling: Trauma (haematocoele), testicular torsion, tumour, hydrocoele of the tunica vaginalis, cyst of epididymis, varicocoele, inguinoscrotal hernia

Investigations

  • Urethral swab for microscopy and culture and sensitivity

Gonorrhoea in women

Clinical features

  • Inflammation of the cervix and cervical canal (cervicitis) is the commonest presentation in women
  • Urethritis: the urethra becomes the most common site in women who have had hysterectomy
  • The most frequent complaint is discharge, often accompanied with burning on urination
  • Over 50% of infected women are asymptomatic
  • Oropharyngeal gonorrhoea from orogenital sex (fellatio) may present as sore throat

Complications

  • Local:
    • Infections of Skene's periurethral glands and Bartholin's labial glands; a Bartholin's gland abscess may cause pain on sitting or walking
  • Vulvitis
    • Ascending infection to the endometrium, fallopian tubes, ovaries and peritoneum (pelvic inflammatory disease)
  • Ectopic pregnancy
  • Infertility
  • Perihepatic abscess (Fitz-Hugh-Curtis syndrome)
  • Risk of disseminated gonococcal infection during pregnancy and menstruation
  • Risk to the newborn infant:
    • Premature rupture of membranes
    • Premature labour
    • Chorioamnionitis
    • Septic abortion
    • Ophthalmia neonatorum
    • Oropharyngeal gonorrhoea

Differential diagnoses

Other causes of vaginal discharge:

  • Accentuation of physiological discharge
  • Premenstrually
  • At the time of ovulation
  • In pregnancy
  • Use of contraceptive pills or an intrauterine device

Infective causes:

Non-infective causes:

  • Cervical ectropion
  • Cervical polyp(s)
  • Neoplasia e.g. cancer of the cervix
  • Retained products (tampon, post-abortion, post-natal)
  • Trauma
  • Semen (post-coital)
  • Contact irritants and sensitizers e.g. from douches or feminine hygiene sprays
  • Bullous diseases of the mucous membranes

Investigations

  • Endocervical swab (through a vaginal speculum) for microscopy, culture and sensitivity

Gonorrhoea in children

Clinical features

  • Sexual abuse is a common cause of gonorrhoea in young girls
  • Usually symptomatic in young girls
  • Pruritus and dysuria are common complaints
  • Discharge may cause irritant dermatitis of the upper thighs

Differential diagnoses

  • Other causes of vaginal discharge in young girls:
  • A vaginal foreign body such as a small toy, bead, or even a piece of food
  • Other infections caused by T. vaginalis, and C. albicans
  • Intestinal bacteria or pin worms due to inadequate cleaning after defeacation

Ophthalmia neonatorum

  • Gonococcal conjunctivitis in the neonate can be acquired perinatally
  • Purulent conjunctivitis; the lids swell; eyes are red and tender
  • If not treated promptly, the cornea may be eroded and perforated, leading to secondary glaucoma, conophthalmus and blindness
  • About 30% of babies infected will also have oropharyngeal gonorrhoea

Differential diagnoses

  • The silver nitrate prophylaxis can produce a chemical conjunctivitis, usually  appearing 6 -8 hours after treatment and resolving over 24 hours
  • The most common cause of neonatal conjunctivitis in most countries is C. trachomatis, E. coli, Staphylococci, Streptococci and Pseudomonas sp. can also cause conjunctivitis in the neonate.

Treatment goals

  • Eliminate the organism in the patient and sexual partner(s)
  • Prevent re-infection
  • Prevent complications
  • Counsel and screen for possible co-infection with HIV so that appropriate management can be instituted

Drug treatment

Recommended regimen:

Ciprofloxacin 500 mg orally, as a single dose

Or:

Ceftriaxone 500 mg by intramuscular injection, as a single dose

 

Neonatal gonococcal conjunctivitis

Recommended regimen:

Ceftriaxone 50 mg/kg by intramuscular injection, as a single dose, to a maximum of 125 mg/kg

Note

Single-dose ceftriaxone and kanamycin are of proven efficacy

The addition of tetracycline eye ointment to these regimens is of no documented benefit

Adjunctive therapy for gonococcal ophthalmia

  • Systemic therapy, as well as local irrigation with saline or other appropriate solution
  • Irrigation is particularly important when the recommended therapeutic regimens are not available
  • Careful hand washing by personnel caring for infected patients is essential

Follow-up

  • Review patients after 48 hours

Notable adverse drug reactions, contraindications, and caution

Ciprofloxacin

  • Avoid in pregnancy and breast feeding; children below 12 years
  • Reduce dose in renal impairment

Ceftriaxone

  • Caution in persons with known sensitivity to beta-lactam antibiotics
  • May cause diarrhoea (and rarely antibiotic-associated colitis); nausea, vomiting and abdominal discomfort

Prevention

  • Counselling, Compliance, Condom use and Contact treatment
  • Ocular prophylaxis provides poor protection against C. trachomatis conjunctivitis

Prevention of ophthalmia neonatorum

  • Clean the eyes carefully immediately after birth. The application of 1% silver nitrate solution or 1% tetracycline ointment to the eyes of all infants at the time of delivery is strongly recommended as a prophylactic measure
  • Infants born to mothers with gonococcal infection should receive additional antibiotic treatment (as those with clinical neonatal conjunctivitis)