Gonorrhoea

Question 1

What is gonorrhoea caused by

Answer 1

Neisseria gonorrhoea (gram-negative diplococcus)

Question 2

What are the risk factors for gonorrhoea

Answer 2

Young age (15-24)
New sexual contact in the last year, or more than one partner in the last year
Inconsistent condom use
Certain sexual activities e.g. MSM
PMHx of STIs
Hx of sexual or physical abuse

Question 3

What tissues does gonorrhoea infection affect

Answer 3

Mucous membranes of the urethra, endocervix, rectum, pharynx, and conjunctiva

Question 4

What are the symptoms of gonorrhoea in women

Answer 4

50% asymptomatic

Dysuria without frequency (Urethral infection)
Altered vaginal discharge
Lower abdominal pain
Intermenstrual bleeding or menorrhagia
Dyspareunia
Rectal infection → anal discharge ± perianal/anal pain
Pharyngeal infection (sore throat)

Question 5

What are the symptoms of gonorrhoea in men

Answer 5

90% asymptomatic
Urethral infection → purulent urethral discharge
Dysuria 2-8 days after exposure
Testicular and epididymal pain
Rectal infection → asymptomatic or anal discharge, acute proctitis, perianal/anal pain or discomfort, tenesmus, rectal bleeding
Pharyngeal infection (sore throat)

Question 6

What are the differentials for gonorrhoea

Answer 6

Chlamydia (difficult to distinguish clinically)
Candidiasis
BV
Trichomonas vaginalis
PID
Genital herpes simplex

Men: ureaplasma urealyticum, acute prostatitis

Question 7

What are the signs of gonorrhoa on examination for women

Answer 7

Pelvic exam
- May be tender
- PID: Cervical motion tenderness, Uterine tenderness, Adnexal tenderness

Speculum
- Normal, May show mucopurulent discharge

Assess for extra-genital infection:
- Rectal gonorrhoea → mucopurulent discharge from the anus
- Pharyngeal gonorrhoea → erythema and exudate, anterior cervical lymphadenopathy
- Gonococcal conjunctivitis → thick white/yellow discharge

Question 8

What are the signs of gonorrhoea on examination in men

Answer 8

Testicular exam
- Check for epididymitis - swollen and tender epididymis on palpation
- Mucopurulent or purulent urethral discharge

PR
- Prostatitis

Assess for extra-genital infection:
- Rectal gonorrhoea → mucopurulent discharge from the anus
- Pharyngeal gonorrhoea → erythema and exudate, anterior cervical lymphadenopathy
- Gonococcal conjunctivitis → thick white/yellow discharge

Question 9

What investigations should be done for gonorrhoea

Answer 9

Refer to GUM clinic

Bedside:
- Vulvovaginal swab(F)/First catch urine (M) for NAAT
- Urine dip and culture; positive leukocyte esterase
- Rectal swab: positive (chocolate agar culture)
- Pharyngeal swab (chocolate agar culture)
- Direct microscopy: neutrophils, gram -ve diplococci

Bloods: HIV serology, syphillis serology
Other: TV USS (if PID suspected)

Question 10

What is the management for gonorrhoea

Answer 10

1. Refer to GUM clinic (if unwilling → primary care)
2. Antibiotics
   - ceftriaxone IM / Ciprofloxacin oral single dose
3. Screen for other STIs
4. Partner notification
5. Abstain from sex for 7 days after treatment completion

+ follow up in 1 week for test of cure

Question 11

What would indicate the need for hospital admission with gonorrhoea

Answer 11

Disseminated gonorrhoea (systemic symptom e.g. fever, malaise, joint pain, swelling, rash)
Women with severe or complicated PID

Question 12

What is the alternative antibiotics treatment for gonorrhoea in the following people: allergy, pregnant, Hx sexual abuse

Answer 12

Allergy: gentamicin IM single dose + azithromycin
Pregnant/breastfeeding: azithromycin single dose
Hx sexual abuse: ADD metronidazole

Question 13

Which partners should be notified for gonorrhoea infection and what is the management for them

Answer 13

Men with symptoms: All sexual partners within the preceding 2 weeks OR most recent if >2 weeks

All others: partners within the preceding 3 months

Management: empirical treatment not required, only given following positive test

Question 14

What are the complications of gonorrhoea in women

Answer 14

Pelvic inflammatory disease → chronic pelvic pain, tubal infertility, ectopic pregnancy
Peritoneal spread → perihepatic abscesses (Fitz-High-Curtis)
Pregnancy complications e.g. spontaneous abortion, premature labour, early rupture of foetal membranes, perinatal mortality, gonococcal conjunctivitis

Question 15

What are the complications of gonorrhoea in men

Answer 15

Epididymitis or orchitis
Prostatitis
Infertility
Urethral stricture
Infection of Mullerian or Cowper glands

Question 16

Describe disseminated gonorrhoea

Answer 16

Occurs in untreated gonorrhoea

Septic arthritis
Polyarthralgia
tenosynovitis
Petechial/pustular skin lesions
Endocarditis
Meningitis

Question 17

What is the prognosis for gonorrhoea

Answer 17

In most women, gonorrhoea infections usually resolve spontaneously
Untreated infections may result in complications.
Appropriate treatment with recommended antibiotics should resolve gonorrhoea infections.