Gonorrhea%20-%20uncomplicated%20anogenital%20infection Diagnosis

• Syndromic management approach may be used in health care facilities where equipment and trained personnel for determining sexually transmitted infection (STI) etiology are not available
• Syndromic management is based on consistent groups of symptoms and easily recognized signs
  
  • Treatment will cover the most common or serious organisms involved in causing the syndrome
  • Using syndromic management in cases of vaginal discharge is limited especially if lower genital tract infections are the cause (gonococcal or chlamydial)

• Inquire regarding patient’s sexual activities and identify possible risk factors 

• Perform general assessment and look for signs of STI 
• Examine mucocutaneous regions including the conjunctivae, pharynx and endocervix
• External genitalia should be inspected for anatomical irregularities, cutaneous lesions, inflammation, and urethral discharge
• Perianal inspection
  
  • Digital rectal exam and anoscopy should be considered if patient has practiced receptive anal intercourse or has rectal symptoms
  • Colonization can take place even without anal intercourse

• Inguinal lymph nodes should be palpated

Illuminated Speculum Exam

• Visualize cervix and vaginal walls
• Evaluate vaginal and endocervical vaginal discharges
• Observe for cervical mucopus, erosions and friability which may be associated with cervical infections 
• If resources are available, obtain specimens 
  • Cervical swab for Chlamydia test and gonorrhea culture 
  • Vaginal swab for Gram stain and Trichomonas slide

Bimanual Pelvic Exam

• Detect uterine or adnexal masses, tenderness or cervical motion tenderness
• A finding of lower abdominal tenderness or cervical motion tenderness should prompt the attending physician to evaluate the patient for PID
  • Treat patient accordingly (Please see Pelvic Inflammatory Disease disease management chart for further information)

• If resources permit, lab tests to screen women with vaginal discharge should be considered
• Screening for other possible STIs, especially C trachomatis, should be done in patients with or at risk of gonorrhea
  • Please see Chlamydia-Uncomplicated Anogenital Infection disease management chart for further information
• It is recommended that patients, who tested negative within 2 weeks of sexual contact with an infected partner, be tested again after this window period if they have not yet received epidemiological treatment

Lab Exams for N gonorrhoeae

• Identification of N gonorrhoeae at infected site establishes the diagnosis
  • Gram-negative intracellular diplococci present in an endocervical smear indicates probable gonorrhea
  • Gram-negative, oxidase-positive diplococci isolated by culture or N gonorrhoeae demonstrated through antigen or nucleic acid detection confirms gonorrhea

• Microscopic examination of Gram-stained smears of endocervical discharge can be used as an initial test to provide an immediate presumptive diagnosis of gonorrhea
  • Permits direct visualization of N gonorrhoeae as monomorphic Gram-negative diplococci within polymorphonuclear leukocytes
  • Microscopic exam of vaginal discharge may be attempted in settings where the Gram stain may be carried out in an efficient manner; however, the sensitivity of the procedure for vaginal discharge specimens is lower compared to urethral specimens in males
  • Urethral smear is less sensitive than endocervical smear

• Culture
  • Recommended for pharyngeal and rectal specimens
  • Readily allows antimicrobial susceptibility testing and monitoring, confirmatory identification, and treatment failure evaluation
    
    • Only method used to evaluate efficacy of antibiotic treatment eg “test of cure”
  • Specificity and sensitivity are 100% and 61.8-92.6%, respectively
  • May be negative if obtained <48 hours after exposure
  • Should be obtained in all cases diagnosed by nucleic acid amplification tests (NAATs) before an antibiotic is given
    
    • Allows testing of susceptibility and identifying resistant strains
  • Intracervical swab specimen is more reliable for culture during menstruation

• Nucleic acid amplification tests (NAAT)
  
  • Most sensitive (>95%) and specific (93.9-100%) test available for C trachomatis and N gonorrhoeae
  • Most useful when patients resist pelvic exam
  • May be done at the time of presentation or even <48 hours after exposure
  • Utilizes single sample to test both Chlamydia and gonorrhea
  • Specimens that may be used are endocervical swab, urethral discharge or self-obtained vaginal swab
    
    • Recommended specimen is the self- or physician-obtained vulvovaginal swab

• Routine use of the following lab tests is not recommended: Nucleic acid hybridization or probe test, nucleic acid genetic transformation test, direct fluorescent antibody test, enzyme immunoassay, and serological test
• For individuals who have undergone genital reconstructive surgery (GRS), the following specimens may be considered: 
  • Gram-stained smear for microscopy from a bowel segment neovagina 
  • First-pass urine and neovaginal swabs for transgender women
  • Vaginal swab if vagina is still present after GRS as directed by patient’s symptoms and sexual history

• In some settings, certain demographic and behavioral risk factors have been frequently associated with lower genital tract infection (the risk factors should be adjusted for local social, behavioral and epidemiological situations)
• Women with positive risk assessment (with ≥1 risk factor present) have a higher likelihood of lower genital tract infection than those who are risk-negative
• Women with vaginal discharge and positive risk assessment should be offered treatment for gonococcal and chlamydial cervicitis
• All sexually active women at high risk are advised to undergo annual screening for gonorrhea infection
• Screening of pregnant women is recommended during the 1st prenatal visit and during the 3rd trimester if the women continue to be at risk