Gonorrhoea

Introduction

Gonorrhoea is a sexually transmitted bacterial infections 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

• It presents as a 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 called gonococcal conjunctivitis
  • Haematogenous spread leading to meningitis, arthritis etc

Differential diagnoses

• Urethral discharge:
• Spermatorrhoea/prostatorrhoea (sexual arousal)
  • Trichomonas vaginalis and Candida albicanscan 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:
  • Candidiasis
  • Trichomoniasis
  • Bacterial vaginosis
  • Chlamydia
  • Cervical herpes genitalis
  • Cervical warts
  • Syphilitic chancre
  • Toxic shock syndrome (Staphylococcus aureus)
  • P-haemolytic streptococcal infection,
  • Mycoplasma infection
• 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
• It is 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
• About 30% of babies infected will also have oropharyngeal gonorrhoea
• If not treated promptly, the cornea may be eroded and perforated, leading to secondary glaucoma, conophthalmus and blindness

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 objectives

• 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 therapy

Recommended Regimen for Uncomplicated Gonococcal Infection of the Cervix, Urethra, Pharynx or Rectum Among Adults and Adolescents

Ceftriaxone 500 mg IM in a single dose for persons weighing <150 kg and 1 g in those weighing ≥150 kg

If chlamydial infection has not been excluded, treat for chlamydia with doxycycline 100 mg orally 2 times/day for 7 days.

Alternative Regimens if Ceftriaxone Is Not Available or Contraindicated

Gentamicin 240 mg IM in a single dose

PLUS

Azithromycin 2 g orally in a single dose

OR

Cefixime 800 mg orally in a single dose
If chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally 2 times/day for 7 days

Neonatal gonococcal conjunctivitis

Recommended regimen:

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

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 of Gonorrhoea

• 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)