AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Gonorrhea (also called "the clap"), caused by Neisseria gonorrhoeae, is a public health problem and is the most common reportable infectious disease. Gonorrhea is most frequently spread during sexual contact; however, it can also be transmitted from the mother's genital tract to the newborn during birth to cause ophthalmia neonatorum and systemic neonatal infection. The incubation period is usually 2-8 days.

In women, the cervix is the most common site of infection, resulting in endocervicitis and urethritis, which can be complicated by pelvic inflammatory disease (PID). In men, infection causes anterior urethritis.

Pathophysiology

N gonorrhoeae is a gram-negative, intracellular, aerobic diplococcus. It mainly affects host columnar or cuboidal epithelium. Several factors influence the manner in which gonococci mediate their virulence and pathogenicity. Pili help in attachment of gonococci to mucosal surfaces and also contribute to resistance by preventing ingestion and killing by neutrophils. Outer membrane proteins such as opacity-associated (Opa) proteins increase adherence between gonococci (forming opaque colonies on culture media) and also increase adherence to phagocytes. Plasmid-mediated production of TEM-1–type beta-lactamase (penicillinase) also contributes to virulence.

Gonococci attach to the host mucosal cell (with the help of pili and Opa proteins) and then penetrate through and between cells into the subepithelial space. A typical host response is characterized by invasion with neutrophils, followed by epithelial sloughing, formation of submucosal microabscesses, and purulent discharge. If left untreated, macrophages and lymphocyte infiltration replace the neutrophils. Some strains cause an asymptomatic infection, leading to an asymptomatic carrier state in persons of either sex.

Frequency

United States

Incidence is 600,000 new infections annually. The reported rate is approximately 240 cases per 100,000 population. However, the incidence has declined considerably in the modern West in recent years. The rate of gonorrhea is much higher in African Americans compared to other racial groups and is much higher in the rural southeastern United States and in inner cities, presumably because of an association with socioeconomic and behavioral factors.

International

Disease rates are unknown for most developing countries. In much of western Europe, rates approximate those in the United States. The incidence is substantially lower in most European countries, and indigenous gonorrhea has virtually been eliminated in Sweden. The highest incidence of gonorrhea and its complications occurs in developing countries. The median prevalence of gonorrhea in unselected populations of pregnant women has been estimated to be 10% in Africa, 5% in Latin America, and 4% in Asia.

Mortality/Morbidity

• The major complication of gonococcal infections in women is tubal scarring and infertility. The incidence of involuntary infertility is estimated at 15% after one attack of PID and approximately 50-80% after 3 attacks. The incidence of ectopic pregnancy is increased from 7-fold to 10-fold in women with previous salpingitis, with resultant increased fetal and maternal mortality rates. Failure to diagnose PID can result in acute morbidity, including tuboovarian abscess, endometritis, or Fitz-Hugh and Curtis syndrome (perihepatitis), and the chronic sequelae noted earlier. Women may also develop gonococcal urethritis or infection of periurethral (Skene) glands or Bartholin glands.
• Infertility may be more common after chlamydial PID than after gonococcal PID, presumably because the more acute inflammatory signs associated with gonorrhea prompt women to seek diagnosis and treatment sooner.
• Urethral stricture caused by gonorrhea in men is less common than previously believed; some strictures in the preantibiotic era likely resulted from treatment by urethral irrigation using caustic compounds rather than from the gonorrhea itself.

Race

• All sexually active populations are at risk, and the level of risk rises with the number of sexual partners and the presence of other sexually transmitted diseases (STDs).
• The incidence ratio of African Americans to white persons rose from 12:1 in the early 1980s to 37:1 in 1995. This trend was driven by a substantial rise in the number of cases and incidence rates in African Americans, followed by modest declines in African Americans and greater declines in white persons after 1985.
• Rates in persons of Hispanic ethnicity and among Native Americans also remained higher compared to the rates in white persons, whereas the lowest rates were observed in persons of Asian or Pacific Island ancestry.

Sex

• Symptomatic disease occurs more predominantly in males than in females.
• An asymptomatic carrier state can occur in both sexes but is believed to occur more frequently in females than in males.
• Serious sequelae are much more common in women than in men. PID in women may lead to ectopic pregnancy or infertility, and women are more likely than men to develop disseminated gonococcal infection (DGI).

Age

• In the United States, the highest rates of gonorrhea are found in young (15-30 y) unmarried persons and in groups of low educational and socioeconomic status.
• Infection in children is a marker for child sexual abuse.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

In all patients presenting with possible STDs, the history should include past history of STDs (including HIV and viral hepatitis), known symptoms of STDs in current or past partners, type of contraception, and any history of sexual assault. In women, the history should also include the date of the last menstrual period and the details of parity, including any history of ectopic pregnancies.

• Female genitourinary tract
• • The most common site of gonococcal infection in women is the endocervix (80-90%), followed by the urethra (80%), rectum (40%), and pharynx (10-20%).
  
  
  • Major symptoms include vaginal discharge, dyspareunia, and mild lower abdominal pain.
  
  
  • When gonococcal cervicitis is either asymptomatic or unrecognized, the patient may progress to PID, often in proximity to a menstrual period. PID may also be asymptomatic or silent. Symptoms of PID include the following:
  • • Increased vaginal discharge or purulent urethral discharge
    
    
    • Dysuria (usually without urgency or frequency)
    
    
    • Lower abdominal pain, usually bilateral
    
    
    • Cervical motion tenderness
    
    
    • Adnexal tenderness
    
    
    • Intermenstrual bleeding
  
  
  • Acute perihepatitis (Fitz-Hugh and Curtis syndrome) occurs primarily through direct extension of N gonorrhoeae or Chlamydia trachomatis from the fallopian tube to the liver capsule and overlying peritoneum.


• Male genitourinary tract
• • In men, urethritis is the major manifestation.
  
  
  • Initial characteristics are burning upon urination and a serous discharge. A few days later, the discharge usually becomes more profuse, purulent, and, at times, blood-tinged. Acute epididymitis can also be caused by N gonorrhoeae, especially in men younger than 35 years. This is usually unilateral and often occurs in conjunction with a urethral exudate.


• Male and female involvement
• • Both men and women may exhibit gonococcal infection of the pharynx, rectum, and eye.
  
  
  • Gonococcal pharyngitis is most commonly acquired during orogenital contact, with fellatio rather than cunnilingus being the more efficient form of oral sex for transmitting disease. Pharyngitis often is asymptomatic; however, it may present as exudative pharyngitis with cervical lymphadenopathy.
  
  
  • Even though positive findings from rectal cultures for gonorrhea are noted in up to 40% of women with cervical gonorrhea (a similar percentage noted in infected homosexual men), symptoms of proctitis are unusual.
  
  
  • Eye involvement in adults occurs by autoinoculation of gonococci into the conjunctival sac from a primary site of infection such as the genitals. The most common form of presentation is a purulent conjunctivitis, which may rapidly progress to panophthalmitis and loss of the eye unless promptly treated.


• Neonates
• • In neonates, bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal delivery from an infected mother. However, transmission to the newborn can also occur in utero or in the postpartum period.
  
  
  • The symptoms of gonococcal conjunctivitis are eye pain, redness, and a purulent discharge. Neonates may also acquire pharyngeal, respiratory, or rectal infection or DGI.
  
  
  • The organism can cause permanent injury to the eye in a very short time; prompt recognition and treatment are essential to avoid blindness. Blindness from neonatal gonococcal infection is a serious problem in developing countries but is now uncommon in the United States and in other countries where neonatal conjunctival prophylaxis with antimicrobials is routine.


• Disseminated gonococcal infection
• • DGI follows 1-2% of mucosal infections and occurs because of hematogenous dissemination of gonococci from the primary site. The symptoms vary greatly from patient to patient. By the time the symptoms of DGI appear, many patients no longer have any localized symptoms of mucosal infection.
  
  
  • Risk factors are as follows:
  • • Complement deficiency
    
    
    • Female sex: Disseminated infection may occur more frequently in women because gonorrhea in women is often asymptomatic, allowing for dissemination before symptoms occur.
    
    
    • Menses: In menstruating females, the illness is observed shortly after the end of menstruation.
    
    
    • Pharyngeal infection and pregnancy: These may also be predisposing factors to gonococcal bacteremia.
  
  
  • The classic presentation of DGI is arthritis dermatitis syndrome. Joint or tendon pain is the most common presenting complaint in the early stage of infection. Many patients with DGI describe migratory polyarthralgia, especially of the knees, elbows, and more distal joints, and may also have tenosynovitis. The early tenosynovitis most commonly affects the flexor tendon sheaths of the wrist or the Achilles tendon ("lovers' heels"). The dermatitis consists of lesions varying from maculopapular to pustular, often with a hemorrhagic component. Lesions usually number 5-40, are peripherally located, and may be painful before they are visible. Fever is common, but the temperature is usually less than 39°C.
  
  
  • The second stage of DGI is characterized by septic arthritis, by which time the skin lesions have disappeared and blood culture results are nearly always negative. The knee is the most common site of purulent gonococcal arthritis.
  
  
  • Rare complications of DGI are gonococcal meningitis and endocarditis.
  
  
  • Gonococcal meningitis may be clinically indistinguishable from meningococcal meningitis upon presentation, although the course of gonococcal meningitis is usually less rapid than that of meningococcal meningitis.
  
  
  • Gonococcal endocarditis is more common in men than in women, with the aortic valve affected most commonly. A subacute onset of fever, chills, sweats, and malaise may indicate the presence of gonococcal endocarditis. Patients with endocarditis may develop atypical chest pain, cough, and dyspnea and may also develop the arthralgias and rash typical of DGI. Gonococcal endocarditis can cause severe valvular damage and death if not recognized and treated rapidly.

Physical

Patients may have the typical signs and symptoms of gonococcal diseases, especially in the genital tract. Sometimes however, patients may have no localized signs or symptoms.

• Female genitourinary tract
• • Mucopurulent or purulent cervical discharge
  • Vaginal discharge or bleeding; vulvovaginitis in children
  • Lower abdominal tenderness with or without rebound tenderness
  • Adnexal tenderness (associated with ascending infection)
  • Cervical motion tenderness (associated with ascending infection)
  • Fever
  • Upper right abdominal tenderness (with Fitz-Hugh and Curtis syndrome)

• Male genitourinary tract
• • Mucopurulent or purulent urethral discharge

  • Unilateral epididymal tenderness and edema

  • Penile edema without other overt inflammatory signs

  • Urethral stricture

• Rectal
• • Mucopurulent or purulent discharge with or without rectal bleeding
  • Mucopurulent exudate and inflammatory in the rectal mucosa

• Eyes: Purulent conjunctivitis is usually bilateral in ophthalmia neonatorum but most often is unilateral when caused by secondary self-inoculation.
• Disseminated gonococcal infection: Patients with DGI may present with any of the following nonspecific findings.
• • Fever (usually <39°C)
  • Polyarthralgia with pain
  • Oligoarthritis
  • Skin lesions: Skin lesion are characteristically few in number and are mostly found on the distal extremities as small papulopustular lesions with an erythematous periphery.

Causes

Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual contact or perinatally.

• Sexual contact
• • The risk of transmission of N gonorrhoeae from an infected woman to the urethra of her male partner is approximately 20% per episode of vaginal intercourse and rises to 60-80% after 4 or more exposures.
  • In contrast, the risk of male-to-female transmission approximates 50-70% per contact, with little evidence of increased risk with more sexual exposures.
  • Transmission through penile-rectal contact is fairly efficient.
  • Persons who have unprotected intercourse with new partners frequently enough to sustain the infection are defined as core transmitters.

• Neonatal infection may follow conjunctival inoculation during birth or direct infection through the scalp at the sites of fetal monitoring electrodes.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory diagnosis of gonococcal infections depends on identification of N gonorrhoeae at an infected site.
• Isolation through culture
• • This is the diagnostic standard and should be used whenever practical. A single culture on most selective media has a sensitivity of 95% or more for urethral specimens from men with symptomatic urethritis and 80-90% for endocervical infection in women. Simultaneous inoculation on selective and nonselective media may provide the highest yield.
  • Although the urethra is commonly infected in women with gonorrhea, culturing urethral specimens does not materially increase the diagnostic yield except in women who lack cervices because of hysterectomy.
  • Patients with possible DGI should have culture samples taken from all possible mucosal sites (ie, pharynx, urethra, cervix, rectum) and from blood and synovial fluid. Rectal and pharyngeal specimens are inoculated onto selective medium only.
  • When collecting specimens in males, any discharge present at the meatus can be easily recovered for examination. If no discharge is present at the meatus, urethral material must be recovered by inserting and rotating a small swab 2-3 cm into the urethra. A calcium alginate or Rayon swab on a metal shaft is recommended.
  • When collecting specimens in women, the exocervix is first wiped of exudate. A swab is then placed into the external os and rotated for several seconds. However, take care to avoid contact with vaginal mucosa or secretions.
  • In patients who may have DGI, all possible mucosal sites should be cultured (eg, pharynx, cervix, urethra, rectum), as should blood and synovial fluid (in cases of septic arthritis). Three sets of blood cultures should also be obtained. Specimens from any mucosal site should be inoculated immediately in selective media for gonorrheal organisms, such as modified Thayer-Martin, or on chocolate agar at room temperature, which should be incubated in an enriched carbon dioxide environment. The growth of typical oxidase-positive colonies that consist of gram-negative diplococci strongly suggests gonorrhea.

• Smears with Gram stain
• • In men, the diagnosis of urethritis can be performed using either of 2 methods of Gram staining.
    • The first is via a urine sample. Preferably, examine the patient at least 2 hours after micturition or before their first morning void. The patient should provide a first-morning void, and the first 10-15 mL of the urine is saved. The urine is centrifuged so that the sediment may be analyzed microscopically under high power or oil immersion. The presence of 10 or more polymorphonuclear leukocytes (PMNs) seen under high power is suggestive of urethritis.

    • The second method is a Gram stain of urethral exudate. The presence of 4 or more PMNs per oil-immersion field is diagnostic for urethritis. In symptomatic males, Gram staining of urethral exudate has a sensitivity of 90-98% and a specificity of 95-98%. However, in asymptomatic males, the sensitivity of the Gram stain is only 60%. Therefore, culture studies are recommended if an asymptomatic gonococcal infection is suggested.
  • The presence of typical gram-negative intracellular diplococci after Gram stain establishes a diagnosis of gonorrhea. If these organisms are not observed, the patient is said to have nongonococcal urethritis. Results are considered equivocal if typical morphotypes not associated with neutrophils are present or if cell-associated but morphologically atypical organisms are observed. A simple Gram stain is probably the method of choice for the detection of gonorrhea in symptomatic males because it is much less expensive and much more rapid than the Gen-Probe method.
  • In women with positive results from cervical cultures, the Gram stain results from the endocervix are 50-60% sensitive and 82-97% specific. Also, the presence of more than 10 PMNs per high-power field on an endocervical smear is consistent with cervicitis. In women who lack cervices because of hysterectomy, use urethral culture to make the diagnosis.

• No available serologic test is sufficiently sensitive and specific to merit use for screening or diagnostic purposes.

Imaging Studies

• Ultrasound or CT scan for PID
• • Pelvic ultrasound or CT scan images may show thick dilated fallopian tubes or abscess formation.
  • PID is uncommon in pregnancy. Therefore, ultrasound should be used to help rule out ectopic pregnancy whenever a pregnant patient has signs and symptoms of possible PID.
  • In current practice, vaginal ultrasonography and CT scan help to define the cause of pelvic pain syndromes.

Other Tests

• Various tests can be used, if available, to detect the antigen or the genome of gonococci in exudates.
• • Fluorescein-conjugated monoclonal antibodies for direct fluorescence microscopy can be used to detect antigen.
  • Enzyme-linked immunoassays for the detection of gonococcal antigen with polyclonal antigonococcal antibodies can also be used.
  • Polymerase chain reaction tests for gonococcal DNA amplification can be used, although they are quite expensive and do not contribute much in most settings.
  • Ligase chain reaction tests for the presence of gonococcal DNA are also becoming available. These tests are highly specific and extremely sensitive, but they are expensive.

Procedures

• In PID, culdocentesis may demonstrate free purulent exudate and may provide material for Gram staining and culture.
• In DGI, Gram stain of material from unroofed skin lesions may show typical organisms.

Histologic Findings

Exudate of PMNs is typical. In PID, loss of ciliated columnar epithelium from the fallopian tubes may occur. Tubes, pelvic mesentery, and ovaries may be bound together with dense fibrosis and abscess formation.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

The decision to implement antimicrobial therapy should be made quickly. The choice of which regimen to use should be based on the clinical presentation.

• Hospitalization is recommended for initial treatment of DGI, purulent joint infections, meningitis, and endocarditis.


• Hospitalization is also recommended for initial treatment of PID cases in the presence of the following factors:
  
  
  • Pregnancy
  
  
  • Failure of outpatient treatment
  
  
  • Tuboovarian abscess
  
  
  • Severe symptoms (eg, severe pain, high fever, persistent nausea and vomiting)
  
  
  • Immunodeficiency
  
  
  • Abdominal peritonitis or perihepatitis
  
  
  • Uncertain diagnoses, with any possibility of ectopic pregnancy or appendicitis masquerading as PID
  
  
  • Uncomplicated urethritis, cervicitis, or rectal or pharyngeal infection in adults


• Effective single-dose regimens currently recommended as initial therapy by the US Public Health Service for the treatment of uncomplicated gonorrhea in all patients in the United States are ceftriaxone (125 mg IM) or cefixime (400 mg PO).


• The 125-mg intramuscular dose of ceftriaxone is fully effective. Ceftriaxone is safe and effective in pregnant women, and it probably destroys incubating syphilis. Its major drawback is the necessity for intramuscular administration.


• Fluoroquinolones
  
  
  • Over the last decade, fluoroquinolones were the preferred class of antimicrobials for the treatment of gonorrhea; however, reports of N gonorrhoeae infection with decreasing susceptibilities and frank resistance have surfaced.
  
  
  • In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001.
  
  
  • The data were published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.


• Tetracyclines no longer are acceptable therapy for gonorrhea because of the prevalence of tetracycline-resistant strains. The incidence of such gonococci is increasing and is 5-15% in various US cities. Because gonococcal infections are commonly associated with genital chlamydial infection, most authorities now recommend a 7-day course of a tetracycline (usually doxycycline) for all patients with gonorrhea as follow-up care to initial ceftriaxone therapy.


• Other therapies include spectinomycin or azithromycin. Spectinomycin at 2 g intramuscularly once is effective and can be used in patients allergic to penicillin. Azithromycin at 2 g as single dose is also effective; however, its use is limited by its cost, adverse gastrointestinal effects, and lack of efficacy in pharyngeal infection.


• Therapy for gonococcal arthritis
  
  
  • Use ceftriaxone at 1 g/d IV/IM for a total of 7 days.
  
  
  • Oral therapy may be used initially in carefully selected compliant patients with a definite diagnosis and only mild infection. Antibiotics for oral use in this situation include cefixime (400 mg bid) for 7 days.


• Gonococcal conjunctivitis should be treated with immediate saline irrigation and intravenous ceftriaxone.


• For PID therapy for outpatients, use cefoxitin at 2 g IM plus probenecid at 1g PO as a single dose or ceftriaxone at 250 mg IM followed by a 14-day oral regimen of doxycycline at 100 mg bid. Also, examining and treating all sexual partners of women with gonococcal PID is crucial.


• For hospitalized patients with PID, use cefoxitin at 2 g parenterally every 6 hours or cefotetan at 2 g IV every 12 hours plus doxycycline. Alternative regimens are available. Again, examining and treating all sexual partners of women with gonococcal PID is crucial.

Surgical Care

• Most authorities recommend removal of intrauterine devices in women with PID.
• Examining and treating all sexual partners of women with gonococcal PID is crucial.
• Septic joints should be aspirated, both to make the initial diagnosis and to remove inflammatory exudate. Open drainage is rarely indicated, except in infections of the hip in children.

Consultations

• A gynecologist should be consulted for patients with severe PID and for any pregnant patient with an STD.
• A pediatrician should be consulted for any child with an STD.
• An ophthalmologist should be consulted for every patient with gonococcal conjunctivitis because this disease may progress rapidly and can cause permanent loss of vision.

Activity

• Patients with uncomplicated disease can remain fully active.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rapid cure of gonorrhea is critical to curtail transmission. Factors that influence therapeutic decisions include (1) antimicrobial susceptibility, (2) pharmacokinetic characteristics, (3) efficacy in complicated/uncomplicated infection, (4) differential efficacy at various anatomic sites of infection, (5) toxicity, (6) convenience of administration, and (7) cost.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in the context of this clinical setting.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Hospitalization is recommended for initial treatment of DGI purulent joint infections, meningitis, and endocarditis.

• Hospitalization is recommended for the initial treatment of PID cases in the presence of the following factors:
• • Pregnancy
  • Failure of outpatient treatment
  • Tuboovarian abscess
  • Severe symptoms (eg, severe pain, high fever, persistent nausea and vomiting)
  • Immunodeficiency
  • Abdominal peritonitis or perihepatitis
  • Uncertain diagnosis, with any possibility of ectopic pregnancy or appendicitis masquerading as PID

Further Outpatient Care

• Patients with DGI or PID who are treated in an outpatient setting must receive follow-up care within 24 hours.
• Early follow-up care and culture with antibiotic sensitivities are indicated for patients with unresolved or recurrent symptoms.
• Follow-up care for test of cure is indicated for all patients with pharyngitis treated with spectinomycin because its efficacy is less than 60%.
• Instruct patients with uncomplicated cases to follow up with a primary care physician or public health provider to reduce the risk of future infection.

Deterrence/Prevention

• Prevention is based on education, mechanical or chemical prophylaxis, and early diagnosis and treatment. Condoms offer partial protection.
• All sexual contacts should be treated.
• Effective antibiotics taken in therapeutic doses immediately before or soon after exposure can abort an infection.
• Preventive measures also include attention to partner notification. Patients should be encouraged to notify their sexual partners of their exposure and encourage them to seek medical care. This is patient referral. If patients are unwilling or unable to notify their partners, then the assistance of state and local departments of public health can be enlisted. This is provider referral.
• All infants born to mothers with untreated gonococcal infection should be treated prophylactically with a single dose of ceftriaxone (25-50 mg/kg IV/IM, not to exceed 125 mg).
• All neonates should undergo prophylaxis for ophthalmia neonatorum with silver nitrate (1%) aqueous solution in both eyes once or erythromycin (0.5%) ophthalmic ointment in both eyes once.

Complications

• Males
• • Urethral stricture in adult men is less common than previously thought. Some strictures in the preantibiotic era likely resulted from treatment by urethral irrigation using caustic compounds rather than from the gonorrhea itself.
  • Other complications, such as penile lymphangitis, periurethral abscess, acute prostatitis, seminal vesiculitis, and infection of the Tyson and Cowper glands, are now rare.

• Females
• • Tubal scarring and infertility are the major complications. The incidence of involuntary infertility is estimated at 15% after one attack of PID and approximately 50-80% after 3 attacks.
  • The incidence of ectopic pregnancy is increased from 7-fold to 10-fold in women with previous salpingitis, with resultant increased fetal and maternal mortality rates.
  • Failure to diagnose PID can result in acute morbidity, including tuboovarian abscess, endometritis, Fitz-Hugh and Curtis syndrome (perihepatitis), and other chronic sequelae.
  • Infertility may be more common after chlamydial PID than after gonococcal PID, presumably because the more acute inflammatory signs associated with gonorrhea prompt women to seek diagnosis and treatment sooner.

• Corneal scarring after eye infections
• Destruction of joint articular surfaces

• Destruction of cardiac valves

• Death from congestive heart failure related to endocarditis or from CNS complications of meningitis

Prognosis

• With adequate early therapy, complete cure and return to normal function are the rule.

Patient Education

• Discuss STDs and methods of prevention.
• Discuss HIV infection and risks; encourage patients and their partner(s) to be tested.
• Patients should avoid sexual contact until medical therapy is completed and until their partners are fully evaluated and treated. They should avoid unprotected contact thereafter.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education articles Sexually Transmitted Diseases and Gonorrhea.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to treat co-infection with chlamydia (High rates of co-infection with chlamydial organisms are well documented.)
• Failure to diagnose surgical emergencies (eg, ectopic pregnancy, appendicitis) in patients with a clinical diagnosis of PID
• Failure to evaluate culture results to confirm the clinical diagnosis in cases with associated legal issues
• Failure to recognize quinolone resistance (high in some countries)

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
• CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].
• Cook RL, Hutchison SL, Østergaard L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. Jun 7 2005;142(11):914-25. [Medline].
• Darville T. Gonorrhea. Pediatr Rev. Apr 1999;20(4):125-8. [Medline].
• Donders GG. Management of genital infections in pregnant women. Curr Opin Infect Dis. Feb 2006;19(1):55-61. [Medline].
• Donovan B. Sexually transmissible infections other than HIV. Lancet. Feb 14 2004;363(9408):545-56. [Medline].
• Miller KE. Diagnosis and treatment of Neisseria gonorrhoeae infections. Am Fam Physician. May 15 2006;73(10):1779-84. [Medline].
• O'Donnell JA. Gonorrhea. In: Rakel RE, Bope ET, eds. Conn's Current Therapy. 53^rd ed. Philadelphia, Pa: WB Saunders; 2001:765-8.
• Slater LN. Gonococcal infections. In: Dambro MR, Griffith JA, Winters R, Patterson D, Carley PJ, e. Griffith's 5-Minute Clinical Consult. 7^th ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:440-1.
• Sparling PF. Gonococcal Infections. In: Cecil RL, Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. ed. Philadelphia, Pa: WB Saunders; 2000:1743-5.
• Sparling PF, Handsfield HH. Neisseria gonorrhoeae. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 5^th ed. Philadelphia, Pa: Churchill Livingstone; 2000:2242-58.

Article Last Updated: May 7, 2007