The World Health Organization estimated that 106.1 million new cases of gonorrhoea would arise globally in 2008. In most of Europe, the diagnosis rates of gonorrhoea are rising. Infections with bacteria spread sexually are second most common in the UK. There were 21% more new gonorrhoea diagnoses in England in 2012 overall and 37% more in MSM.
Antibiotic regimens are losing effectiveness against diarrhoea. An international concern is multidrug-resistant gonorrhoea.
Neisseria gonorrheae is a Gram-negative intracellular diplococci cause infection.
Young people, those living in cities, MSM, and members of black ethnic minority are more likely to get diarrhoea.
Mucous membranes are directly the site of infection transmission. A single UPSI incident raises the chance of transmission from men to females by 60–80% and from females to males by 20%.
Primary infection sites include the mucosae of the pharynx, conjunctiva, urethra, rectum, and endocervix.
Together with coexisting with other sexually transmitted illnesses like chlamydia, gonorrhoea can spread HIV.
Symptoms and signs
Females
For half of female endocervical infections, there will be no symptoms.
Up to 50% of patients experience vaginal discharge; dysuria, lower abdomen or pelvic pain; and in rare cases, IMB or menorrhagia.
Cervicitis symptoms include lower belly or pelvic pain, contact bleeding, and mucopurulent discharge.
Males
Ten percent of urethral infections in men never cause any symptoms.
Symptoms within 2–5 days of exposure include dysuria (>50%) and/or urethral discharge (>80%). Though balanitis, epididymal pain, or edoema are rare, symptoms may include purulent or mucopurulent urethral discharge.
Rectal infection
Women usually get a rectal infection by transmucosal spread of tainted vaginal secretions, not by anal sexual intercourse.
Usually asymptomatic, both men and women, however 12% may have anal discharge or perianal/anal pain or discomfort.
Rectal gonorrhoea is a major sign of unprotected anal sex.
Pharyngeal infection
Ninety percent of the time asymptomatic.
Conjunctival infection (adult)
Swelling and purulent discharge from one or both eyes are unusual signs.
Influenza of the throat.
Diagnosis
Finding N. gonorrhoeae at an affected site results in a diagnosis. 100% specificity and sensitivity are not offered by any gonorrhoea test. Depending on clinical situations and regional factors like test availability and infection prevalence, there are three diagnostic methods accessible.
NAATs
The best approach to assess asymptomatic patients for urethral or endocervical infections and, in MSM, rectal and pharyngeal infections is to use NAATs. Comparatively speaking, women are more sensitive (almost 96%) than men are. Because urine has a lower sensitivity than endocervical or vulvovaginal specimens, urethral or first void urine (FVU) samples in women are not the best specimens. A reactive test from the throat or rectum should be verified by additional testing using a different nucleic acid target from the original test because urine assays are not licenced for extra-genital locations. It is usually possible to test for both gonorrhoea and chlamydia.
Microscopy
In PMNL, Gram-negative (light red) diplococci are identified by microscopy (1000x magnification.
Owing to low sensitivity, not advised for asymptomatic people.
While only offering a provisional diagnosis, this near-patient test is helpful in specialist settings for males with urethral discharge (sensitivity about 95%) and women with endocervical discharge (sensitivity <50%).
Not appropriate for pharyngeal specimens and not very sensitive for rectal specimens.
Culture
Antibiotic resistance and sensitivity monitoring depends critically on antibiotic susceptibility testing. If at all possible, a culture should be taken before giving antibiotics to any cases of gonorrhoea found by NAATs.
Take a culture from anyone who are exhibiting symptoms (e.g., urethra, rectum, endocervix, throat), who have had gonorrhoea through sexual activity, who have suspected PID, and who have had any genital or rectal discharge.
Samples can be gathered in transport medium for laboratory analysis or immediately put onto a culture medium (available in specialist settings).
Samples should be moved 48 hours after collection and kept at 4°C in a refrigerator. Because of its exacting growing needs, N. gonorrhoeae might become extinct from incorrect storage or delays in transportation.
Culture is cheap and has a decent sensitivity (85–95%).
Sites and timing of samples
While asymptomatic women get a self-taken vaginal swab for NAAT testing, asymptomatic men get an FVU.
Obtain samples for NAAT and culture from both men and women who are exhibiting symptoms.
Although symptoms could start to show up a few days after exposure, the ideal testing time is yet unknown. To test for gonorrhoea, do as you would for chlamydia: test at first presentation and, if exposure happened within the last two weeks, retest two weeks later.
Complications
PID, endometritis, epididymoorchitis, and prostatitis.
Although rare, DGI can cause tenosynovitis, arthralgia, arthritis, and skin lesions. Meningitis and endocarditis are rarely brought on by DGI.
An exposure in the birth canal can lead to a neonatal gonococcal infection.
Management
Treatment
Azithromycin 1 g orally once or doxycycline 100 mg twice per day for 7 days.
Resistance
Antibiotic resistance in gonorrhoea has surged recently worldwide. Because of the high resistance rates, most countries—including the UK—no longer recommend tetracycline, penicillin, or quinolone antibiotics.
General
As long as a negative TOC is not reached, advise complete abstinence (no sexual contact even with a condom).
Give written information on the infection. Check those with gonorrhoea for additional STDs, such as chlamydia, as coinfection affects 41% of women and 35% of heterosexual men. Regular testing is advised.
Talk about applying barrier techniques precisely and consistently.
Partner notification
For men having urethral issues, the “look-back” period is two weeks from the last partner, if that is longer, or from the start of symptoms.
‘Look-back’ periods for asymptomatic illnesses or infections at other locations are three months.
HIV testing and treatment should be provided to sexual partners.
Follow-up and TOC
Adherence and sex-free living depend on follow-up after treatment.
Check the antibiotic sensitivity, if it is available.
Everybody should read TOC.
If not exhibiting any symptoms, use an NAAT to test. If the antibiotics work, a culture will be taken two weeks later.
One should take a culture at least 72 hours after treatment ends if symptoms or signs persist.
A positive TOC test could point to medication resistance or reinfection.
Non-gonococcal urethritis (NGU)
Urethritis is a urethral inflammation. This is the most often diagnosed and treated male disease in UK GUM clinics. Neisseria gonorrhoeae-negative (NGU) or gonococcal (gonorrhoea positive) urethritis are the two types.
Aetiology
Although not usually, sexual activity is the usual manner that NGU is obtained. About half of men have no known infection. C. trachomatis and M. genitalium are the most often occurring isolates.
Signs and symptoms: Dysuria, urethritis, urethral discharge, and penile pain
Variations: SARA, or epidermo-orchitis, rare
Examination and Diagnosis The diagnosis is made by microscopy. Every field of a Gram-stained urethral smear viewed under high power microscopy (1000) should contain at least five PMNLs
Alternatively, a centrifuged sample of first-passed urine (>10 PMNL) can be used. Men without symptoms no longer have urethral smears done. Urinary culture should come after an NAAT to test for gonorrhoea and chlamydia. Suspect a UTI? Send an MSSU. HIV testing should be part of the whole STI screening provided.
Management
Until treatment is finished, avoid having sex—even with a condom.
Results should not be waited upon to begin treatment.
PN: Offer epidemiological treatment and continuous partner screening. ‘Look back’ time is four weeks.
Continued or recurring urethritis.
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