Gonorrhoea Overview and Clinical Manifestations

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Questions and Answers

What is the primary treatment recommended for uncomplicated gonorrhoea?

Ciprofloxacin 500mg twice a day

Ampicillin/Amoxicillin 3gm with probenecid (correct)

Ceftriaxone 1gm IM

Doxycycline 100mg twice daily

Which species are responsible for chlamydial urethritis?

Chlamydia trachomatis serotypes D-K (correct)

Chlamydia pneumoniae

Ureaplasma urealyticum

Chlamydia psittaci

What is a common complication of chlamydial infection in females?

Pelvic Inflammatory Disease (PID) (correct)

Urethral stricture

Prostatitis

Gonococcal meningitis

What treatment is recommended for a pregnant woman diagnosed with chlamydial infection?

Erythromycin 500mg Signup and view all the answers

Which of the following is NOT a treatment option for disseminated gonorrhoea?

Procaine Penicillin 2-4 million units IM Signup and view all the answers

Which of the following statements about non-gonococcal urethritis is true?

Can occur with no identifiable cause Signup and view all the answers

What is the incubation period for chlamydial infection?

2-3 weeks Signup and view all the answers

What is a risk factor commonly associated with neonatal chlamydial infections?

Maternal chlamydial infection Signup and view all the answers

What type of bacteria is primarily responsible for gonorrhoea?

Neisseria gonorrhoeae Signup and view all the answers

Which complication is more commonly associated with gonorrhoea in females?

Pelvic inflammatory disease Signup and view all the answers

In which cell type does Neisseria gonorrhoeae primarily infect?

Columnar cells Signup and view all the answers

Which population group has a high prevalence of gonorrhoea based on sexual orientation?

Homosexual men Signup and view all the answers

What is a common characteristic of gonococcal vulvovaginitis in female children?

Indicates sexual abuse Signup and view all the answers

Which of the following best describes the typical presentation of gonorrhoea in males?

Dysuria with greenish discharge Signup and view all the answers

What is a severe complication that can occur in neonates infected with gonorrhoea?

Ophthalmia neonatorum Signup and view all the answers

What factor contributes to the lower susceptibility of certain epithelial tissues to Neisseria gonorrhoeae infection?

Differences in epithelial cell type Signup and view all the answers

Study Notes

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)

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Description

This quiz covers critical aspects of gonorrhoea, including its causative agent, transmission methods, pathogenesis, and clinical manifestations in both males and females. Understand the key details about the disease and its impact on human health.