Sexual Health
Question 209 of 300
A 28 year old man presents to the Emergency Department complaining of a profuse green muco-purulent urethral discharge and dysuria. He reports unprotected sexual intercourse with a new partner 3 days ago. What is the most likely causative organism?
Answer:
- Signs and symptoms in men:
- Genital gonorrhoea infection is usually symptomatic in men.
- Urethral infection causes a yellow/green mucopurulent or purulent urethral discharge in more than 80% of men, and dysuria in more than 50% of men within 2–5 days of exposure — usually there is no effect on frequency or urgency of urination.
- Rectal infection is usually asymptomatic, but may cause anal discharge (12% of men), acute proctitis, perianal/anal pain or discomfort (7% of men), tenesmus, or rectal bleeding.
- Pharyngeal infection is asymptomatic in more than 90% of men, but may cause cause tonsillitis or pharyngitis.
- Other symptoms may be caused by complications of gonorrhoea infection, including prostatitis, epididymitis and orchitis.
- N.B At least 50% of men with chlamydia are asymptomatic. If present, the typical discharge is more of a white, cloudy, pus-like or watery discharge.
Gonorrhoea
Sexual Health
Last Updated: 1st December 2023
Gonorrhoea is a sexually transmitted infection (STI) caused by Neisseria gonorrhoeae. Gonorrhoea is transmitted by direct inoculation of secretions from one mucous membrane to another.
- Uncomplicated gonorrhoea is localised and primarily affects the mucous membranes of the urethra, endocervix, rectum, pharynx, and conjunctiva.
- Disseminated gonorrhoea is uncommon. It may present as petechial or pustular acral skin lesions, asymmetrical arthralgia, tenosynovitis, or septic arthritis.
Uncomplicated gonorrhoea is most common in young adults aged 15–24 years.
Clinical features
- Signs and symptoms in men:
- Genital gonorrhoea infection is usually symptomatic in men.
- Urethral infection causes mucopurulent or purulent urethral discharge in more than 80% of men, and dysuria in more than 50% of men within 2–5 days of exposure — usually there is no effect on frequency or urgency of urination.
- Rectal infection is usually asymptomatic, but may cause anal discharge (12% of men), acute proctitis, perianal/anal pain or discomfort (7% of men), tenesmus, or rectal bleeding.
- Pharyngeal infection is asymptomatic in more than 90% of men, but may cause cause tonsillitis or pharyngitis.
- Other symptoms may be caused by complications of gonorrhoea infection, including prostatitis, epididymitis and orchitis.
- Signs and symptoms in women:
- Urogenital gonorrhoea is asymptomatic in up to 50% of women.
- Where present, symptoms usually develop within 10 days and can include:
- Increased or altered vaginal discharge (up to 50% of women).
- Lower abdominal pain (up to 25% of women).
- Dysuria (up to 12% of women) — usually there is no effect on frequency of urination.
- Intermenstrual bleeding or menorrhagia (rarely).
- Pain on intercourse (dyspareunia) if the infection spreads from the endocervix.
- Pharyngeal infection is asymptomatic in 90% of women, but it may cause tonsillitis or pharyngitis.
- In most women, no abnormal findings are present on examination. However, examination may show:
- Mucopurulent endocervical discharge (less than 50% of women).
- Easily induced endocervical bleeding.
- Pelvic or abdominal tenderness (less than 5% of women).
Diagnosis
- Ideally, refer all people with suspected gonorrhoea to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service for confirmation of diagnosis.
- If the person is unwilling, or unable, to attend a GUM clinic or other local specialist sexual health service, arrange a nucleic acid amplification test (NAAT) for the presence of Neisseria Gonorrhoeae in line with local procedures and protocols. In women, a vulvovaginal swab (which may be self-taken) should be used. In men, a first pass urine specimen should be used.
- A culture should be taken in all people who are NAAT positive for gonorrhoea before prescribing antibiotics to test for susceptibility and identify resistant strains.
Management
- Ideally, refer all people with confirmed or suspected gonorrhoea to a genito-urinary medicine (GUM) clinic or other local specialist sexual health service for further treatment.
- If the person is unwilling, or unable, to attend a GUM clinic or other local specialist sexual health service despite receiving appropriate information and advice, prescribe antibiotic treatment.
- Ideally, a culture should be taken before prescribing antibiotics, to test for susceptibility and identify resistant strains.
- For people with uncomplicated anogenital or pharyngeal infection:
- When the antimicrobial susceptibility is known prior to treatment, prescribe ciprofloxacin 500 mg orally as a single dose.
- When antimicrobial susceptibility is not known prior to treatment, prescribe ceftriaxone 1 g intramuscular (IM) injection as a single dose.
- Alternative treatments are recommended for people with an allergy, needle phobia, or other contraindications. These include gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally OR cefixime 400 mg orally as a single dose plus azithromycin 2 g orally (advisable only if an IM injection is contraindicated or refused by the person). When using alternative regimens without antibiotic susceptibility data, it is recommended to regularly review local and national trends in gonococcal antimicrobial resistance.
- Advise the person to abstain from sex until they, and any partners, have completed treatment.
- Offer screening for other sexually transmitted infections (STIs) and for HIV.
- Encourage patient-led partner notification.
- Provide appropriate information and advice.
- Follow-up after 1 week to verify the success of treatment. Test of cure is recommended for all people who have been treated for gonorrhoea.
- Although rare, consider the possibility of sexual abuse in any child or young person with gonorrhoea.
Complications
- Possible complications of gonorrhoea in men include:
- Epididymitis, or orchitis.
- Prostatitis.
- Urethral stricture.
- Infertility.
- Infection of Mullerian, or Cowper glands.
- Possible complications of gonorrhoea in women include:
- Pelvic inflammatory disease — occurs in up to one-third of women with gonorrhoea. This can result in chronic pelvic pain, tubal infertility, or ectopic pregnancy.
- Rarely, peritoneal spread including perihepatic abscesses may occur (Fitz-Hugh-Curtis syndrome).
- Gonorrhoea in pregnancy is associated with miscarriage, fetal loss and congenital infections.
- Disseminated gonorrhoea is an uncommon, but potentially serious complication of gonococcal infection and can cause skin lesions, arthralgia, arthritis and tenosynovitis. Rarely, it can cause meningitis, or endocarditis.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
