Gonorrhoea Overview and Clinical Manifestations

Gonorrhoea

• Caused by Neisseria gonorrhoeae
• Gram-negative diplococci (pairs)
• Intracellular, kidney-shaped
• Three-layered envelope enclosing cytoplasm
• Pili on the surface of virulent types 1&2

Transmission

• Primarily sexual, high prevalence in homosexuals
• Vertical transmission from infected mother to neonate
• Rarely, accidental non-venereal transmission (towels, lavatory seats)

Pathogenesis

• Incubation period: 2-7 days
• N. gonorrhoeae infects mucosal epithelium, primarily columnar cells
• Transitional and stratified squamous epithelium are more resistant to infection, thus bladder, upper urinary tract, vulva and uterus are less affected

Clinical Manifestations (Males)

• Affects anterior urethra, prostate, rectum, seminal vesicles
• Presents with dysuria and mucopurulent (yellowish-green) discharge
• Profuse and frequent micturition (anterior urethritis)
• Mild general symptoms may develop (fever, malaise)

Clinical Manifestations (Females)

• Commonly asymptomatic (50%)
• Vaginal discharge, dysuria, menstrual irregularity, and lower abdominal pain
• Gonococcal vulvovaginitis in children may indicate sexual abuse

Neonates (Ophthalmia neonatorum)

• Important cause of blindness in developing countries
• Infection through the birth canal
• Symptoms develop within the first week of birth (2-5 days)
• Inflamed eyes, profuse purulent discharge, edematous lids, and intense conjunctivitis
• Untreated cases can develop keratitis and corneal ulcers

Extragenital Gonorrhoea

• Anorectal Gonorrhoea: rectal sex, direct spread
• Oropharengeal Gonorrhoea: oral sex, tonsillitis, pharyngitis
• Gonococcal Conjunctivitis: contamination with genital discharge
• Disseminated Gonorrhoea: Septicemia (rare, more common in females), 2-3 weeks after initial infection, bacteremia associated with systemic symptoms, septic arthritis, and dermatitis

Complications (Males)

• Tysonitis, Littritis
• Periurethral abscess
• Urethral stricture
• Prostatitis
• Epididimitis
• Seminal vesiculitis

Complications (Females)

• Skenitis
• Bartholinitis
• Pelvic inflammatory disease (PID) --> ectopic pregnancy or infertility
• PID --> Perihepatitis (Fitz-Hugh-Curtis syndrome) --> adhesions (violin string)
• Salpingitis --> adhesions

Investigations

• Gram stain: urethral/endocervical discharge smear under microscopy shows gram-negative kidney-shaped diplococci within polymorphs cells
• Culture: selective media (Thayer-Martin)
• Indications for culture include female cases, chronic male cases, asymptomatic cases, rectal/oropharyngeal infections, disseminated infections, detection of antibiotic sensitivity, and medico-legal purposes. Culture is more reliable than smear in these cases

Differential Diagnosis

• Non-gonococcal urethritis: Chlamydia urethritis, non-specific urethritis (ureaplasma urealyticum)

Treatment (General)

• Avoid sexual activity
• Avoid self-examination
• Avoid local antiseptics (risk of chemical urethritis)
• Trace and treat sexual partner(s)

Treatment (Uncomplicated Gonorrhoea)

• Procaine penicillin (2-4 million units IM + probenecid 1 gm orally) or
• Ampicillin/Amoxicillin (3 gm single oral dose + probenecid 1 gm orally)

Treatment (Penicillin Allergy)

• Ciprofloxacin (500 mg single oral dose) or
• Ceftriaxone (250 mg single IM)
• Azithromycin (1 gm single oral dose) for coexisting chlamydial infections

Treatment (Disseminated Gonorrhoea)

• Admission to hospital
• Trace and treat partner(s)
• Benzathine penicillin (10 million units IV daily for 3 days, then Amoxicillin 500mg orally for 4 days) or
• Ceftriaxone (1 gm IM/IV) or Ciprofloxacin (500 mg twice/day) for 7 days (in case of penicillin allergy)

Non-Gonococcal Urethritis

• Inflammation of the urethra due to factors other than Neisseria gonorrhoeae
• Causes include Chlamydia trachomatis, Ureaplasma urealyticum, Trichomonas vaginalis, Candida spp, and bacteria like group B streptococci
• Some cases have no detectable cause (non-specific urethritis)

Chlamydial Infection

• Obligatory intracellular parasite
• 3 species: C. trachomatis, C. psittaci, C. pneumoniae
• C. trachomatis serotypes D-K cause chlamydial urethritis

Chlamydial Urethritis

• Transmission: sexual, through the birth canal
• Incubation period: 2-3 weeks
• Clinically: mild urethritis, mucoid discharge, worsens in morning, asymptomatic in females
• Tendency for chronicity and recurrence

Complications (Chlamydial Infections)

• Males: prostatitis, epididymitis, urethral stricture, infertility
• Females: PID, Perihepatitis, cervical intraepithelial neoplasia, decreased fertility, abortions, prematurity, and stillbirth

Neonatal Chlamydial Infection

• Conjunctivitis (7-14 days after birth)
• Infantile pneumonia (4-12 weeks)
• Otitis media

Investigations (Chlamydia)

• Gram stain: Polymorphs + high epithelial cells without bacterial identification
• Culture in tissue media: McCoy cells
• Antigen detection tests: ELISA
• Antichlamydial antibody detection

Treatment (Chlamydia)

• General management: Tetracycline (500 mg 4 times daily) or Doxycycline (100 mg orally twice daily) for 7 days
• Azithromycin (1 gm orally, single dose)
• Pregnancy: Erythromycin (500 mg 4 times daily) for 7 days

STI Diagnosis and Management (Low Resource Settings)

• Similar STI presentation and management globally, but vigilance needed for resistant strains (e.g., gonorrhea)
• Epidemiology varies by region (e.g., syphilis, gonorrhea, LVG, chancroid)
• Accurate diagnosis requires capable labs, rapid turnaround times and resources
• Alternative population-based approaches needed for sensitivity and specificity

High Risk Groups

• Adolescent boys and girls
• Women with multiple partners
• Sex workers and their clients
• Men who have sex with men
• Partners of high-risk groups

Syndromic STI Case Management (5 Steps)

• History and examination
• Syndromic diagnosis and treatment (flow charts)
• Education and counseling on HIV testing, safer sex, and condom promotion
• Management of sexual partners
• Recording and reporting

Syndromic Management Advantages

• Diagnosis and treatment in one visit
• Highly effective for most syndromes
• Relatively inexpensive
• No need for repeat lab testing
• All STIs are potentially managed at once
• Easy for health workers to learn
• Integrated into primary care
• Can be used by all providers

Syndromic Management Disadvantages

• Possible overdiagnosis and overtreatment (increased drug costs, side effects, alterations in vaginal flora, increased drug resistance)
• Cannot detect infections in asymptomatic individuals
• Presence of vaginal discharge not necessarily predictive of chlamydial or gonococcal infection
• Treatment of partners may lead to social consequences
• Not easily accepted by some doctors

Identifying Syndromes

• (table of syndromes and most common cause)

Flowcharts (Urethral Discharge, Genital Ulcer, Lower Abdominal Pain, Vaginal Discharge, Scrotal Swelling)

• Detailed flowcharts (visual aids ) for diagnosis and management by symptom

Partner Treatment

• (table outlining necessary partner treatment based on index patient diagnosis)