Gonorrhea Curriculum

Gonorrhea

Neisseria gonorrhoeae

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 Gonorrhea Curriculum

Learning Objectives
Upon completion of this content, the learner will be able to:
1. Describe the epidemiology of gonorrhea in the U.S.
2. Describe the pathogenesis of Neisseria gonorrhoeae.
3. Discuss the clinical manifestations of gonorrhea.
4. Identify common methods used in the diagnosis of gonorrhea.
5. List CDC-recommended treatment regimens for gonorrhea.
6. Summarize appropriate prevention counseling messages for
patients with gonorrhea.
7. Describe public health measures for the prevention of
gonorrhea.

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Gonorrhea Curriculum Epidemiology

Incidence and Prevalence

• Number of reported cases underestimates
incidence
• Incidence remains high in some groups
defined by geography, age, race/ethnicity,
or sexual risk behavior
• Increasing proportion of gonococcal
infections caused by resistant organisms

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Gonorrhea Curriculum Epidemiology

Risk Factors
• Multiple or new sex partners or inconsistent
condom use
• Urban residence in areas with disease
prevalence
• Adolescents, females particularly
• Lower socio-economic status
• Use of drugs
• Exchange of sex for drugs or money

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Gonorrhea Curriculum Epidemiology

Transmission
• Efficiently transmitted by:
– Male to female via semen
– Female to male urethra
– Rectal intercourse
– Fellatio (pharyngeal infection)
– Perinatal transmission (mother to infant)
• Gonorrhea associated with increased
transmission of and susceptibility to HIV
infection
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Gonorrhea Curriculum

Lesson II: Pathogenesis

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Gonorrhea Curriculum Pathogenesis

Microbiology

• Etiologic agent: Neisseria gonorrhoeae

• Gram-negative intracellular diplococcus
• Infects mucus-secreting epithelial cells

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Gonorrhea Curriculum Pathogenesis

Gonorrhea: Gram Stain of

Urethral Discharge

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Gonorrhea Curriculum

Lesson III: Clinical

Manifestations

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Gonorrhea Curriculum Clinical Manifestations

Genital Infection in Men

• Urethritis – Inflammation of urethra

• Epididymitis – Inflammation of the

epididymis

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Gonorrhea Curriculum Clinical Manifestations

Male Urethritis
• Symptoms
– Typically purulent or mucopurulent urethral
discharge
– Often accompanied by dysuria
– Discharge may be clear or cloudy
• Asymptomatic in 10% of cases
• Incubation period: usually 1-14 days for
symptomatic disease, but may be longer
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Gonorrhea Curriculum Clinical Manifestations

Gonococcal Urethritis:
Purulent Discharge

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Gonorrhea Curriculum Clinical Manifestations

Epididymitis
• Symptoms: unilateral testicular pain and
swelling
• Infrequent, but most common local
complication in males
• Usually associated with overt or
subclinical urethritis

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Gonorrhea Curriculum Clinical Manifestations

Swollen or Tender Testicles

(Epididymitis)

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Gonorrhea Curriculum Clinical Manifestations

Genital Infection in Women

• Most infections are asymptomatic

• Cervicitis – inflammation of the cervix

• Urethritis – inflammation of the urethra

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Gonorrhea Curriculum Clinical Manifestations

Cervicitis
• Non-specific symptoms: abnormal vaginal
discharge, intermenstrual bleeding, dysuria,
lower abdominal pain, or dyspareunia
• Clinical findings: mucopurulent or purulent
cervical discharge, easily induced cervical
bleeding
• 50% of women with clinical cervicitis have
no symptoms
• Incubation period unclear, but symptoms
may occur within 10 days of infection
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Gonorrhea Curriculum Clinical Manifestations

Gonococcal Cervicitis

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Gonorrhea Curriculum Clinical Manifestations

Urethritis
• Symptoms: dysuria, however, most
women are asymptomatic
• 40%-60% of women with cervical
gonococcal infection may have urethral
infection

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Gonorrhea Curriculum Clinical Manifestations

Complications in Women
• Accessory gland infection
– Bartholin’s glands
– Skene’s glands
• Pelvic Inflammatory Disease (PID)
• Fitz-Hugh-Curtis Syndrome
– Perihepatitis

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Gonorrhea Curriculum Clinical Manifestations

Bartholin’s Abscess

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Gonorrhea Curriculum Clinical Manifestations

Syndromes in Men and Women

• Anorectal infection
• Pharyngeal infection
• Conjunctivitis
• Disseminated gonococcal infection (DGI)

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Gonorrhea Curriculum Clinical Manifestations

Gonococcal Ophthalmia

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Gonorrhea Curriculum Clinical Manifestations

Disseminated Gonorrhea—
Skin Lesion

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Gonorrhea Curriculum Clinical Manifestations

Gonorrhea Infection in
Children
• Perinatal: infections of the conjunctiva,
pharynx, respiratory tract

• Older children (>1 year): considered

possible evidence of sexual abuse

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Gonorrhea Curriculum

Lesson IV: Diagnosis

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Gonorrhea Curriculum Diagnosis

Diagnostic Methods
• Culture tests
• Non-culture tests
– Amplified tests (NAATs)
• Polymerase chain reaction (PCR) (Roche Amplicor)
• Transcription-mediated amplification (TMA) (Gen-Probe
Aptima)
• Strand displacement amplification (SDA) (Becton-Dickinson
BD ProbeTec ET)
– Non-amplified tests
• DNA probe (Gen-Probe PACE 2, Digene Hybrid Capture II)
– Gram stain

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Gonorrhea Curriculum Diagnosis

Clinical Considerations
• In cases of suspected sexual abuse
– Legal standard is culture with multiple
tests to confirm the identity of Neisseria
gonorrhoeae

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Gonorrhea Curriculum

Lesson V: Patient
Management

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Gonorrhea Curriculum Management

Treatment for Uncomplicated

Infections of the Cervix, Urethra,
and Rectum
Cefixime 400 mg Orally Once or

Ceftriaxone 125 mg IM Once or

Ciprofloxacin 500 mg Orally Once or

Ofloxacin 400 mg Orally Once or

Levofloxacin 250 mg Orally Once

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Gonorrhea Curriculum Management

Co-treatment for
Chlamydia trachomatis
If chlamydial infection is not ruled out:
Azithromycin 1g Orally Once or

Twice a day for

Doxycycline 100 mg Orally
7 days

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Gonorrhea Curriculum Management

Special Considerations:
Pregnancy
• Pregnant women should NOT be
treated with quinolones or tetracyclines
• Treat with alternate cephalosporin
• If cephalosporin is not tolerated, treat
with spectinomycin 2 g IM once

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Gonorrhea Curriculum Management

Alternative Regimens
• Spectinomycin 2 g in a single IM dose

• Single-dose cephalosporin regimens

– Ceftizoxime 500 mg IM
– Cefoxitin 2 g IM with Probenecid 1 g orally

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Gonorrhea Curriculum Management

Follow-Up
• A test of cure is not recommended if a
recommended regimen is administered.
• If symptoms persist, perform culture for
N. gonorrhoeae.
– Any gonococci isolated should be tested for
antimicrobial susceptibility.

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Gonorrhea Curriculum

Lesson VI: Prevention

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Gonorrhea Curriculum Prevention

Screening
• Pregnancy
– A test for N. gonorrhoeae should be
performed at the first prenatal visit for
women at risk or those living in an area in
which the prevalence of N. gonorrhoeae is
high.
– Repeat test during the 3rd trimester for those
at continued risk.
• Other populations can be screened
based on local disease prevalence and
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Gonorrhea Curriculum Prevention

Partner Management
• Evaluate and treat all sex partners for N.
gonorrhoeae and C. trachomatis infections if
contact was within 60 days of symptoms or
diagnosis.
• If a patient’s last sexual intercourse was >60
days before onset of symptoms or diagnosis, the
patient’s most recent sex partner should be
treated.
• Avoid sexual intercourse until therapy is
completed and both partners no longer have
symptoms.
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