Gonorrhoea

• Overview:

  • Sexually transmitted infection caused by the gram-negative bacteria Neisseria gonorrhoeae
  • Second most common bacterial STI in UK (after chlamydia)
  • Predominantly affects people under the age of 25 and men who has sex with men
• Pathophysiology:

  • Transmitted through unprotected vaginal/oral/anal sex
  • Can be vertically transmitted from mother to child
  • Gram-negative diplococcus that has a strong affinity for mucous membranes
  • Can infect the uterus, urethra, cervix, fallopian tubes, ovaries, testicles, rectum, throat and the eyes
  • Once adhered to the mucous membrane, it invades the host cell and causes acute inflammation
  • Has surface proteins that bind to the receptors of immune cells - prevents immune response
• Risk factors:

  • Aged <25 years
  • Men who have sex with men
  • Living in high density urban areas
  • Previous gonorrhoea infection
  • Multiple sexual partners
• Gonorrhoea is often asymptomatic (50% of females), but symptoms can occur 2-5 days following infection
• Female symptoms:

  • Altered/ increased vaginal discharge - thin, watery, green or yellow
  • Dysuria
  • Dyspareunia
  • Lower abdominal pain
  • Rarely intermenstrual and/or post-coital bleeding
• Female signs on exam:

  • Mucopurulent endocervical discharge
  • Easily induced cervical bleeding
  • Pelvic tenderness
  • Often examination can be normal
• Male symptoms:

  • Mucopurulent urethral discharge
  • Dysuria
• Male signs on exam:

  • Mucopurulent urethral discharge
  • Epididymal tenderness
• Rectal infection symptoms:

  • Usually asymptomatic
  • Anal discharge
  • Anal pain/discomfort
• Prostatitis symptoms:

  • Perineal pain
  • Dysuria
  • Prostate tenderness on exam
• Diagnosis is with a nucleic acid amplification testing (NAAT) and a charcoal endocervical swab
• NAAT:

  • Detects the RNA and DNA of gonorrhoea
  • Rectal and pharyngeal swabs are recommended in all men who have sex with men and in those with risk factors
  • Females - Endocervical/vaginal swab
  • Males - first pass urine
• Charcoal swab:

  • Sent for microscopy, culture and sensitivities (NAAT can't give this)
  • Amies transport medium
  • Females - endocervical/urethral swab
  • Males - urethral/meatal swab
• Management (uncomplicated)

  • Referral to GUM clinics for testing, treatment and contact tracing
  • Management depends on if antibiotic sensitivities are known
  • Sensitivities not known - single dose IM ceftriaxone 1g
  • Sensitivities known - single dose oral ciprofloxacin 500mg
• All patients should have a follow-up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:

  • 72 hours after treatment for culture
  • 7 days after treatment for RNA NAAT
  • 14 days after treatment for DNA NAAT
• Other factors to consider are:

  • Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
  • Test for and treat any other sexually transmitted infections
  • Provide advice about ways to prevent future infection
  • Consider safeguarding issues and sexual abuse in children and young people
• Complications

  • Pelvic inflammatory disease
  • Chronic pelvic pain
  • Infertility
  • Epididymo-orchitis (men)
  • Prostatitis (men)
  • Conjunctivitis
  • Urethral strictures
  • Disseminated gonococcal infection
  • Skin lesions
  • Fitz-Hugh-Curtis syndrome (inflammation of the liver capsule with adhesion formation)
  • Septic arthritis
  • Endocarditis
• Gonococcal conjunctivitis in neonates:

  • Vertical transmission from mother
  • Neonatal conjunctivitis is called ophthalmia neonatorum
  • Medical emergency - associated with sepsis, perforation of the eye and blindness
• Disseminated gonococcal infection:

  • Complication of untreated infection, where bacteria spreads to the skin and joints:
  • Various non-specific skin lesions
  • Polyarthralgia
  • Migratory polyarthritis
  • Tenosynovitis (inflammation of synovial membrane of tendons)
  • Systemic symptoms such as fever and fatigue
  • Can cause meningitis