gonorrhea%20-%20uncomplicated%20anogenital%20infection
GONORRHEA - UNCOMPLICATED ANOGENITAL INFECTION
Gonorrhea is a sexually or vertically transmitted infection secondary to Gram-negative diplococcus Neisseria gonorrhoeae.
It is one of the most common bacterial sexually transmitted infections that may cause pelvic inflammatory disease leading to infertility or ectopic pregnancy.
Most of the infected females are asymptomatic but may present with increased or altered vaginal discharge, dysuria, urethral discharge, abnormal vaginal bleeding, vulval itching or burning, dyspareunia, conjunctivitis and proctitis.

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)

History

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

Physical Examination

  • 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)

Laboratory Tests

  • 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

Screening

  • 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
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