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