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Gonorrhoea - Dr Deac Pimp

Definition

  • A sexually transmitted infection caused by the gram negative intracellular diplococcus bacteria Neisseria gonorrhoea

 

Risk factors

  • Unprotected sex
  • Previous STI
  • Comorbid STI, especially chlamydia
  • Risky sexual behaviour
    • Chemsex
    • Group sex
    • Anal sex
    • Unknown sexual partners
    • Many sexual partners
  • MSM
  • HIV postitive
  • Mother with gonorrhoea during birth (vertical transmission risk)

 

Differential diagnoses

  • Chlamydia
  • Mycoplasma
  • Bacterial vaginitis
  • Trichomonas vaginalis
  • Candida
  • Syphilis

 

Epidemiology

  • Incidence/diagnosis rate of 64.9 per 100,000 in England in 2016
    • Up to 600 per 100,000 in some parts of London
  • Down from 73 per 100,000 in 2015
  • General rise in incidence over the past 15 years, mainly in MSM populations
    • In 2013, 63% of diagnoses were in MSM
  • In 2013, accounted for 7% of new diagnoses in STI clinics, similar to genital warts and herpes

 

Aetiology

  • Intracellular gram negative diplococci
  • Transmitted through vaginal, anal and oral sex
  • Some evidence that it can be transmitted mouth/pharynx to mouth/pharynx during deep kissing
  • Can be spread vertically in perinatal period
  • Affects mucous membranes of pharynx, endocervix, urethra, rectum and conjunctiva
  • Incubation period is generally 2-5 days, can be up to 10 days, so should delay testing for 2 weeks post exposure
  • Coinfection with chlamydia may increase bacterial load, and increase risk of transmission
  • Resistant strains are appearing, dubbed ‘super gonorrhoea’, which can spread resistance via plasmids

 

Clinical features

  • Infection is symptomatic in 90-95% of men
    • Urethral infection
      • Mucopurulent or purulent discharge in over 80%
      • Dysuria in over 50%
      • Asymptomatic in less than 10%
    • Rectal infection
      • Often asymptomatic
      • Anal discharge in 15%
      • Perianal pain, itching or bleeding in 7%
    • Pharyngeal infection is usually asymptomatic
      • Can cause mild pharyngitis
    • Can cause epididymo-orchitis (rare)
  • Infection is symptomatic in about 50% of women
    • Cervical infection
      • Mucopurulent or purulent discharge in 50%
      • Abdominal pain in 25%
    • Urethral infection
      • Dysuria without frequency in 10-15%
    • Rectal and pharyngeal
      • Usually asymptomatic
      • Mild pharyngitis
  • Vertical transmission to infants
    • Usually within 2-5 days of birth
    • Acute bilateral purulent conjunctivitis
    • Lid oedema
    • Chemosis (swelling of conjunctiva)
    • Can result in blindness
    • Can also cause:
      • Rectal infection
      • Pneumonia
      • Pharyngitis
      • Meningitis (rare)
      • Arthritis
  • Gonorrhoea can become disseminated – in <1%
    • Bacteria break through the basement membrane
    • Fever
    • Pustular rash
    • Septic arthritis
    • Tendonitis

 

Pathophysiology

  • Intracellular infection of mucous membranes with Neisseria gonorrhoea bacteria

 

Investigations

  • Must wait 2 weeks post exposure to test
  • Swabs must be taken from all possible infection locations:
    • Cervix
    • Urethra
    • Rectum
    • Pharynx
  • Light microscopy can be used if available for point-of-care testing
    • Look for gram negative (pink) diplococci
    • 70-95% sensitivity
  • Nucleic Acid Amplification Test (NAAT) swabs are more sensitive than culture
    • Can be taken from a variety of locations
    • First pass urine can be used in males
  • Culture misses up to 1/3 of cases
  • The patient must be tested for other STIs including HIV, as 50% have a coexisting infection
  • If the patient has had sexual intercourse with a partner with gonorrhoea, or of unknown status, since the exposure 2 weeks previously, they must be tested again

 

Management

  • Local guidelines should be followed, best treatment changes frequently
  • Local sensitivities should be checked, as resistance varies locally
  • Currently local guidelines suggest:
    • 3rd generation cephalosporin eg Ceftriaxone 500mg IM
    • AND Azithromycin 1g stat
    • Treatment is the same in pregnancy and for pharyngeal infection
  • For PID:
    • Ceftriaxone 500mg IM
    • AND Erythromycin 100mg BD for 14 days
    • AND Metronidazole 400mg BD for 14 days
  • For epididymo-orchitis
    • Ceftriaxone 500mg IM
    • AND doxycycline 100mg BD for 10-14 days
  • For gonococcal conjunctivitis:
    • Wash with saline water
    • Ceftriaxone 500mg IM for 3 days
  • Treat any other infections
  • Test of cure at 2 weeks
  • Contact tracing
  • Education and behaviour change counselling if appropriate

 

Prognosis

  • Gonorrhoea in pregnancy
    • Preterm delivery
    • Miscarriage
    • Infection of baby (see above)
  • Men:
    • Scarring as a result of urethritis
      • Bladder outflow obstruction
    • Local spread to epididymis, prostate, seminal vesicles, lymph nodes
    • Disseminated infection
      • Reiter’s syndrome
        • Arthralgia, tendonitis, arthritis of hands, feet and ankles
      • Skin lesions
      • Meningitis
      • Endocarditis
      • Myocarditis
  • Women:
    • PID occurs in 10-20%
      • Infertility
      • Ectopic pregnancy
      • Chronic pelvic pain
    • Bartholin abscess
    • Peri-hepatitis: Fitz-Hugh Curtis Syndrome
Gonorrhoea.docx
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