Gonorrhea in Women: Clinical Guidelines

Sexually Transmitted Diseases and Infections

• Objectives include identifying prevalence, recalling therapy goals, matching clinical presentations to treatment regimens, selecting appropriate follow-up measures and matching drug information to treatment regimens.
• Key references include DiPiro: Pharmacotherapy (2021) and the Centers for Disease Control and Prevention 2021 Sexually Transmitted Infections Treatment Guidelines.
• Important considerations include public health risks, complications, prevalence, duration, psychosocial consequences, and healthcare costs.

General Epidemiology (2013-2022)

• Data shows trends in STD incidence (Chlamydia, Gonorrhea, and Syphilis).
• Graph presentation displays cases per 100,000 people in the US.
• Syphilis incidence is increasing, whereas Chlamydia and Gonorrhea have fluctuating trends.

2022 Texas STD Epidemiology

• Texas STD rates for Chlamydia, Gonorrhea, Primary/secondary Syphilis and congenital syphilis are provided.
• Texas's incidence is compared to the national average for each STD in 2022.

Clinical Prevention Strategy

• Accurate risk assessment, counseling, and changes in sexual behavior.
• Pre-exposure vaccination
• Identifying symptomatic and asymptomatic infected persons.
• Effective diagnosis, treatment, counseling, and follow-up of infected persons.
• Evaluation, treatment, and counseling of sex partners of infected persons.

CDC STD Prevention Measures for Patients

• Accurate sex education
• Abstinence
• Vaccination
• Decrease sex partners
• Mutual monogamy
• Condoms
• Get tested

Expedited Partner Therapy (EPT)

• Patient-delivered partner therapy (PDPT).
• Only one partner is assessed by the prescriber.
• Therapy is provided to the patient to deliver to their partner.
• Prescriber and patient partner relationship is not required for non-patient partners.
• EPT is permissible by law in Texas, encouraging treatment of gonorrhea and chlamydia.

STD Lesions

• A hierarchical chart showing different STD lesions and their associated conditions like Urethritis, Vulvovaginitis, Cervicitis, Chlamydia, Gonorrhea, Syphilis, Anogenital warts, Trichomoniasis, and Genital Herpes.

Urethritis

• Discharge may vary (clear, mucopurulent, or very purulent).
• Common causes include Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium, and herpes simplex virus.
• Symptoms include dysuria, hematuria, feeling of genital heaviness, epididymitis, or prostatitis if untreated.

Cervicitis

• Mucopurulent secretions from the endocervical canal.
• Causes include N. gonorrhoeae, C. trachomatis, and herpes simplex virus.
• Symptoms include dysuria, abnormal uterine bleeding, lower abdominal pain, dyspareunia, and postcoital bleeding.

Vulvovaginitis

• Inflammation of internal and external female genitals, caused by Trichomonas vaginalis or Candida albicans.
• Symptoms may include vulvular itching or irritation, dysuria, dyspareunia, purulent vaginal discharge, and a "musty" odor.

Skin and Mucous Membrane Lesions

• Types of lesions include chancres, condyloma latum, herpetic vesicles, and condyloma acuminata.

Chancres

• Primary syphilis symptom.
• Painless, highly infectious lesion at transmission site.
• Solitary, often occurring in the genitals.

Condyloma Latum

• Secondary syphilis skin lesion.
• Raised, nodular or plaque-like rash on genitals.

Palmar-plantar Rash

• Secondary syphilis manifestation.
• Pigmented, macular lesions on palms and soles of the feet.

Herpetic Vesicles

• Herpes simplex virus sores in clustered vesicles.
• Can be more painful in women.
• Occurs in clusters of small blisters.

Condyloma Acuminata

• Caused by human papillomavirus (HPV).
• Cauliflower-like masses, potentially oncogenic.
• Affect both internal and external genitals.

Overview

• Presentation flow for STDs includes etiology, epidemiology, clinical presentation, diagnosis, and treatment of the infection.

Chlamydia

• Etiology: Chlamydia trachomatis (intracellular bacterium), sexual or vertical transmission.
• Epidemiology: Commonly reported STD in US, affecting females < 25, MSM, and low socioeconomic populations.
• Clinical Presentation: Men often asymptomatic, sometimes with urethritis; cervicitis, conjunctivitis, and pharyngeal/rectal lesions are other presentation factors.
• Diagnosis: Urethral swab, endocervical/vaginal swab, or urine culture can identify the infection.
• Screening: Women < 25, pregnant women, and high-risk populations should be screened frequently.
• Treatment Strategies: Doxycycline 100 mg BID x7 days, Azithromycin 1 g POx1, or Levofloxacin 500 mg QD x 7 days is the regimen of choice. EPT is permissible.
• Follow-up: Adherence is key; retesting partners in 60 days (or 3 months for women after treatment) is crucial.

Gonorrhea

• Etiology: Neisseria gonorrhoeae (gram-negative diplococci). Transmission via sexual or vertical means; increased prevalence in Southern US.
• Epidemiology: More frequently reported in males < 25 and MSM.
• Clinical Presentation: Men often asymptomatic; symptoms may include urethritis, cervicitis, conjunctivitis, and pharyngeal/anal lesions. Women may have similar symptoms, though women frequently are asymptomatic.
• Diagnosis: Similar to Chlamydia, diagnosed via urethral swab, endocervical/vaginal swab, or urine culture.
• Screening: Screening for gonorrhea is very similar to screening for Chlamydia.
• Treatment: Ceftriaxone 500 mg IM x1 or 1 g IM x1 (weight >150 kg); concomitant treatment with doxycycline is frequently associated. EPT use is permissible.
• Follow-up: Testing partners within 60 days is crucial, and retesting women 3~6 months post-treatment is standard.

Syphilis

• Etiology: Treponema pallidum (spirochete bacterium). Transmitted through sexual, blood, or vertical means; increased male-to-male transmission.
• Epidemiology: Uncommon but increasing incidence. Texas is fourth nationally, and affects males and MSM.
• Clinical Presentation: Stages include primary (chancres), secondary (rash on palms and soles, condylomata lata), latent (asymptomatic), and tertiary (organ damage). Neurosyphilis, a potential complication, can lead to serious CNS damage.
• Diagnosis: Darkfield microscopy, non-treponemal tests (RPR, VDRL), and treponemal tests (FTA-ABS) are used to diagnose syphilis. Quantitiative testing is often used for this.
• Screening: Screening is based on risk factors: men and MSM under 25 should be screened frequently.
• Treatment: Benzathine penicillin G 2.4 million units IM x1 for primary, secondary, and early latent syphilis; penicillin G procaine 2.4 million units IM can be used in combination with probenecid. Alternative treatments are available for penicillin-allergic patients.
• Follow-up: Testing partners and retesting patients with various stages are necessary to avoid long term complications of syphilis.

Trichomoniasis

• Etiology: Trichomonas vaginalis (flagellated protozoa). Transmitted through sexual and vertical transmission.
• Epidemiology: Most common curable STD in US; high prevalence in women < 25, WSW and incarcerated persons.
• Clinical Presentation: Often asymptomatic, but symptomatic individuals may experience vulvovaginitis (in women) or urethritis (in men).
• Diagnosis: Vaginal/urethral culture, wet-mount slide, urine tests, or point-of-care (POC) rapid tests are frequently used to detect Trichomonas.
• Screening: High-risk populations should be screened frequently.
• Treatment: Metronidazole 500 mg PO BID x7 days for women; metronidazole 2 g PO x1 for men. Tinidazole 2 g PO x1 may be an alternative.
• Follow-up: Partner treatment, adherence is key; retesting is required 3 months later.

Genital Herpes

• Etiology: Herpes simplex virus type 2 (HSV-2). Sexually and vertically transmitted; recurs through reactivation and latency during normal disease expression.
• Epidemiology: ~50 million Americans affected, impacting women and MSM at higher rates.
• Clinical Presentation: Primary and recurrent infection stages exist; primary infection often asymptomatic; recurrent infection involves recurrent outbreaks of herpetic vesicles.
• Diagnosis: Tissue culture(most sensitive), serological testing (blood/serum testing), and virological testing (PCR for HSV DNA) exists to diagnose Genital Herpes.
• Screening: HSV serology is frequently recommended for individuals with multiple sexual partners or a history of STIs; routine screening for asymptomatic pregnant women is not recommended.
• Treatment: Initial therapy aims to reduce duration and severity of outbreaks; Suppressive therapy aims to reduce frequency of outbreaks; episodic therapy is often used to control individual outbreaks. Commonly used drugs include acyclovir, valacyclovir, and famciclovir for therapy.
• Follow-up: Adherence is essential. Follow-up recommendations are highly based on individual risk factors and prevalence of the STI.
• Important Note: No cure exists for genital herpes. Treatment focuses on reducing symptoms and preventing transmission.

Anogenital Warts

• Etiology: Human papillomavirus (HPV), a non-enveloped virus. Primarily transmitted through sexual contact.
• Epidemiology: HPV is the most common STI in the US; annual incidence of infections impacting ~14 million people. Prevalence rates among different demographics (eg. 15-19, 20-24, 25-29) vary.
• Clinical Presentation: Usually asymptomatic, but warts can develop on the genitals. Symptoms include itching, burning, discomfort and postcoital bleeding. Warts are commonly present in the genital/anal region.
• Diagnosis: Physical exam, biopsy, or testing for HPV using an Acetic Acid test.
• Treatment: Drugs like Imiquimod and Podofilox can be used; cryotherapy and surgical removal also present as options.
• Screening: Routine screening for all individuals based on their risk exposure.

Pelvic Inflammatory Disease (PID)

• Etiology: Untreated vaginal/cervical infections like gonorrhea and chlamydia (~50%), other bacterial infections.
• Risk Factors: Low socioeconomic status, recent IUD placement, previous PID, and sexual activity in those with multiple partners.
• Clinical Presentation: Can vary; may include lower abdominal pain, abnormal bleeding, dyspareunia, cervical/uterine tenderness, fever, and increased WBCs in vaginal fluid.
• Diagnosis: Clinical examination and lab tests (such as ESR and CRP) aid in diagnosis.
• Treatment: Empiric therapy covering potential polymicrobial infections; parenteral regimens are frequently used as initial treatment. Commonly used drugs include ceftriaxone, cefotetan, cefoxitin, and metronidazole.
• Follow-up: Treatment adherence and abstinence from vaginal intercourse and partner treatment for duration of treatment are crucial. Routine testing for cure is typically conducted after 3 months.