Gonorrhoea

Question 1

Gonorrhoea - epi

Answer 1

1. Neisseria gonorrhoeae - intracellular gram-negative diplococcus
2. Affects mucosal and glandular structures in the genital tract, rectum, oropharynx and conjunctiva
3. Incubation period usually 2-7d but may be longer in some cases
4. Number of notifications increasing in Australia, but infection remains relatively uncommon (except in subgroups - e.g. MSM, rural and Indigenous communities)
5. In 2010, 10,000 Australians were diagnosed (25% increase from previous year)

Question 2

Gonorrhoea - symptoms and transmission

Answer 2

Males
1. 75% of urethral infections are symptomatic
Most common symptoms:
2. Purulent urethral discharge
3. Dysuria
Less commonly, the infection ascends to the epididymis, testes or prostate gland, leading to:
4. Scrotal pain
5. Scrotal swelling

Females
1. 60% of cases silent or minimally symptomatic; may only be diagnosed if male partner develops symptoms
Remaining 40% present with:
2. Dyspareunia
3. Irregular bleeding, change in vaginal discharge
Less commonly:
4. Woman may present with secondary Bartholin’s abscess
5. Ascending infection may lead to PID, tubal factor infertility, ectopic pregnancy and chronic pelvic pain

Other

1. Depending on sexual practices, gonorrhoea may also infect the anus and throat
2. Most infections in these sites are asymptomatic, although pts may present with rectal discharge, bleeding or pain, or with pharyngitis as their primary symptom
3. Gonococcal conjunctivitis (through auto-transmission via the fingers) may also occur - usually unilateral
4. Dissemniated infection follows 1-3% of anogenital gonococcal infections. Pts are often extremely unwell = rash, fever, arthralgia, reactive arthritis, septic arthritis, tendonitis, endocarditis, meningitis
5. More rarely - RUQ pain from peri-hepatitis (Fitz-Hugh-Curtis syndrome) -> may cause altered LFTs. Occurs following spread of organisms upwards along peritoneal planes

Question 3

Gonorrhoea - ix

Answer 3

Two tests - microscopy/culture, PCR

1. Dx confirmed by confirming the presence of the organism on microscopy and culture
2. Sexual hx should guide the sites from which swabs are taken
3. Whenever gonorrhoea is suspected, the specimens should be transported promptly to the pathology laboratory, since the organism is quite fragile
4. PCR testing for gonorrhoea is available and usually performed at the same time as culture, since it provides a more rapid result
5. But PCR testing does not provide antibiotic sensitivities (an important consideration bc multi-resistant gonorrhoea is common)

Question 4

Gonorrhoea - mx

Answer 4

1. IM ceftriaxone 500mg single dose
2. Plus azithromycin 1g orally, single dose (irrespecrtive of results of testing for chlamydial infection)
3. If pharyngeal or anorectal infection, give cetriaxone 500mg IM or IV as single dose
4. Prolonged duration of tx required for pts with complications, including pts with concomitant reactive arthritis - seek expert advice
5. Notifiable disease. Also - contact tracing, notification and treatment of partners, sexual health counselling (?)