AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

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Background

Gonorrhea is one of the most common and oldest known sexually transmitted diseases (STDs). It causes urethritis, cervicitis, epididymitis, pharyngitis, proctitis, and pelvic inflammatory disease (PID) and can spread throughout the body to cause both localized and disseminated disease. Most commonly, the term gonorrhea refers to urethritis and/or cervicitis in a sexually active person.

In the pediatric population, the importance of gonorrhea is 3-fold, as follows:

• As a common and preventable STD in the sexually active teenage population
• As a perinatal infection at childbirth
• As a forensic aid in investigating sexual abuse

Pathophysiology

Neisseria gonorrhoeae is a gram-negative, intracellular diplococcus that grows best in the laboratory in an environment rich in carbon dioxide. Organisms are spread by sexual contact and can also be vertically transmitted during childbirth. N gonorrhoeae has a predilection for columnar mucosal cells. The physiologic ectopy of the squamocolumnar junction onto the ectocervix in the adolescent female is one factor that causes particular susceptibility to this infection.

Frequency

United States

Gonorrhea is the second most commonly reported infectious disease in the United States, after chlamydia. Actual incidence is difficult to determine due to high rates of asymptomatic carriage, as well as underreporting; however, in 2005, 339,593 cases were reported in the United States (up slightly from 2004).¹ The national average is 115.6 cases per 100,000 population, with considerable state-to-state variation.² The rate is up slightly from 2004, when it was at its lowest level since 1941. The estimate of total cases is approximately 700,000 cases per year. In children who have been sexually abused, rates of recovery of gonorrhea range from 1-30%. In female adolescents who are sexually active, asymptomatic carriage of gonorrhea occurs in 1-5%.

Within the United States, carriage rates highly depend on the geographical area, the racial and ethnic group, and sexual preferences.

The South-Eastern States have the highest rates of infection; the rates in the midwest and northeast are much lower. Rates of infection range from about 250 cases per 100,000 population in Mississippi to 8.5 cases per 100,000 population in Idaho. The Centers for Disease Control and Prevention (CDC) has a campaign (Healthy People 2010) that targets an incidence rate of 19 cases per 100,000 population. Maine, Vermont, Wyoming, New Hampshire, Montana, and Idaho are the only states currently exceeding that target. See Media file 1.

International

Disease rates are unknown for most developing countries. In much of Western Europe, rates approximate those in the United States.

Mortality/Morbidity

When untreated, gonorrhea may progress locally to cause PID in females, epididymitis and orchitis in males, and sterility in both sexes. It can also spread to cause septic arthritis, perihepatitis (Fitz-Hugh-Curtis syndrome), and disseminated gonococcal infection (DGI). In newborns, vertical transmission can cause conjunctivitis, known as ophthalmia neonatorum, and blindness, if untreated. Oral sex with an infected partner can result in pharyngitis, and, similarly, anal infection can arise from anal sex or local spread from a vaginal source. PID often causes decreased fertility and can lead to tubo-ovarian abscess and, rarely, tubal perforation with peritonitis and death, especially if recurrent. Females with recurrent PID have high rates of ectopic pregnancy and infertility (approximately 8% after 1 episode, 20% after 2 episodes, and 40% after 3 or more episodes).

Race

Frequency is increased among individuals of lower socioeconomic status and among minorities of any population because of decreased access to diagnosis and treatment. Lack of adequate care (ie, education, diagnosis, and treatment) leads to increased transmission rates.

Sex

• The male-to-female ratio is approximately 1.2:1; females may be asymptomatic, whereas males are rarely asymptomatic.
• Men who have sex with men are much more likely to acquire and carry gonorrhea and also have far higher rates of antibiotic-resistant bacteria.

Age

The highest incidence in the United States is among persons aged 15-24 years. This is likely due to the following:

• Increased numbers of sexual partners
• Decreased access to or use of health care
• Physiologic ectopy of the squamocolumnar junction in females
• Decreased use of barrier contraceptives

CLINICAL

Section 3 of 11  

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History

The incubation period usually is 2-7 days after exposure to an infected partner.

• Males
• • Urethral discharge (drip)
  • Dysuria
  • Condom nonuse or condom failure
  • Infected contact
  • Proctitis and/or pharyngitis, depending on types of intercourse and partners
• Females
• • Dysuria
  • Vaginal discharge
  • Abnormal vaginal bleeding (spotting)
  • Dyspareunia (painful intercourse)
  • Condom nonuse or condom failure
  • Proctitis and/or pharyngitis, depending on type of partners and intercourse
  • Slow onset and progression of lower abdominal pain, especially in progression to PID
• Neonates
• • Ophthalmia neonatorum presents with eye pain, redness, and a purulent discharge. The organism is acquired during birth from the infected mother.
  • If unrecognized and untreated, the infection can lead to serious destruction of the cornea and blindness.
  • Infection may also occur at the site of placement of scalp electrodes.

Physical

• Males
• • Urethral discharge, obtained by milking the urethra along the shaft of the penis
  • Possible epididymitis
• Females
• • Vaginal, urethral, or cervical discharge
  • Cervical friability (tendency to bleed upon manipulation)
  • Cervical tenderness during bimanual pelvic examination
  • Fullness and/or tenderness of the adnexa (eg, ovaries, fallopian tubes)
  • Lower abdominal pain
  • Possible low back pain (more common in progression to PID)
  • Vaginal bleeding
• Neonates
• • Purulent discharge from the eyes or other infected sites
  • Temperature instability (fever, hypothermia) in disseminated sepsis

Causes

Risk factors for gonorrhea include the following:

• Sex with an infected partner
• Multiple sex partners
• Low socioeconomic status
• Minority status (African Americans, Hispanics, and Native Americans have the highest rates in the United States.)
• Failure to use a condom or condom failure
• History of concurrent or past STDs
• Exchange of sex for drugs or money
• Use of crack cocaine
• Early age of onset of sexual activity

DIFFERENTIALS

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Other Problems to be Considered

Bacterial Vaginosis
Ectopic Pregnancy
Epididymitis
Hepatitis
Orchitis
Pregnancy
Rat-bite Fever
Tubo-ovarian Abscess
Vaginitis

WORKUP

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Lab Studies

• Culture is the most common diagnostic test, followed by the DNA probe, and then polymerase chain reaction (PCR) and ligand chain reaction (LCR).
• • The DNA probe is an antigen detection test that uses a probe to detect gonorrhea DNA in specimens.
  • PCR and LCR are gene amplification techniques that markedly increase the sensitivity of specimen testing. Both techniques amplify the genetic fingerprint of specimens with very few organisms present in order to more easily detect and identify the organisms. Although the sensitivity is significantly increased, these methods of diagnosis are many times more expensive than culture or DNA probe. In many settings, PCR and LCR are not readily available because they may require a specialized lab facility. False positives are generally due to laboratory error (inadvertent contamination).
  • Perform a culture or nonculture detection test for N gonorrhoeae on endocervical, urethral, pharyngeal, or rectal discharge. Because organisms are intracellular, attempt to obtain specimen in a manner that will contain mucosal cells and not merely discharge (similar to a Papanicolaou smear).
• Nonculture tests are less accurate in the presence of blood or during menses. Use culture instead at these times.
• Culture is performed on Thayer-Martin plates that must be stored refrigerated but warmed to room temperature before obtaining sample. The plate is then incubated in a carbon dioxide atmosphere. Poor technique drastically reduces test sensitivity.
• Medicolegal cases (eg, child abuse, rape) require culture due to the possibility of false-positive results with nonculture methods. However, performing the more sensitive PCR-based tests to raise the likelihood of detecting an infection, and then following up with culture to produce admissible evidence, is appropriate.

Imaging Studies

• Ultrasonography may be indicated in women to investigate suspected PID and to visualize the appendix and ovaries as other possible causes of the symptoms.

Other Tests

• Other tests that might be indicated are those for concurrent STDs, such as chlamydia (especially because of the high rate of asymptomatic carriage), herpes, hepatitis B, syphilis, and human immunodeficiency virus (HIV) (with counseling). The need for additional testing depends on the situation; they are often performed as a battery of tests in suspected rape and child abuse cases.
• HIV testing in cases of rape or new-onset abuse does not acutely diagnose a new infection but does establish a baseline status of the patient such that subsequent seroconversion might be linked back to the event in question.

Procedures

• In women with symptoms and signs suggestive of PID who are difficult to diagnose clinically, laparoscopy may be indicated to rule out (and, if need be, treat) appendicitis, ovarian torsion, ectopic pregnancy, or other surgical emergencies.
• Imaging studies such as ultrasonography are obviously a less invasive means of obtaining diagnostic information, but potentially emergent cases may require a more definitive examination, which permits rapid intervention if required.

Histologic Findings

A Gram stain of urethral or cervical discharge may show gram-negative intracellular diplococci (diagnostic in the male) and polymorphonuclear cells. This is very useful if the physician has easy access to a microscope because the diagnosis may be made without waiting for culture results.

TREATMENT

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Medical Care

The main decision once a diagnosis has been made, either definitively or presumptively, is whether to treat as an outpatient or to hospitalize.

• For males, treatment is always outpatient for genital infection; however, admission may be necessary for complications such as DGI or gonococcal arthritis.
• In females, the decision is much more difficult because the risk of complications is much higher. In light of high rates of noncompliance, reinfection, and poor follow-up, some clinicians advocate admitting whenever a question of a complication such as PID is present, particularly in the adolescent population.
• Many institutions have attempted to quantify abnormalities found on pelvic examination (ie, the PID score) in an attempt to admit those patients with a higher likelihood of complications.
• In cases in which future fertility is at risk, most physicians are fairly aggressive, especially in situations in which the patient is very young or unfamiliar to them.

Consultations

In cases of suspected rape or child abuse, seeking specialist help (in the form of specialist nurses or physicians) to interview and collect specimens (if necessary) for testing is prudent. Careful documentation of physical findings, even if apparently normal, is crucial for medicolegal reasons. Notification of child-protective services is required if abuse is suspected.

MEDICATION

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In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions.¹ Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States and other parts of the world where resistance has become common, but they can be considered in areas where quinolone resistance has not yet emerged.

The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP).³ The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone resistant reached 6.7%, an 11-fold increase from 0.6% in 2001. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg intramuscularly 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.

Drug Category: Antibiotic agents

Medical therapy requires an antibiotic with efficacy against N gonorrhoeae. Until several years ago, the treatment of choice involved oral medication for as long as 10 days or an injection; however, patients tend to be poorly compliant with medications for various reasons, and the availability of newer medications has allowed in-office, single-dose, oral treatment to ensure compliance.

Many practitioners presumptively treat patients after obtaining specimens for diagnosis, based on history and examination, because of the risk of poor follow-up, complications, and continuing spread to other partners. In addition, because gonorrhea is often simultaneously diagnosed with chlamydia, many practitioners treat patients for both diseases when treating for either beyond the newborn period. Diagnosis and treatment of the patient's partner and any partners of the partner are important to prevent reinfection and complications.

Disseminated or complicated infections (eg, endocarditis, meningitis) require more prolonged inpatient therapy. For example, ceftriaxone 50 mg/kg IV bid for 7 days plus a macrolide such as azithromycin administered for simple disseminated infection (10-14 d for meningitis or 28 d for endocarditis). Fluoroquinolones are no longer recommended for gonorrhea because of increased resistance.

If cephalosporins are not an option for disseminated gonorrhea or PID, fluoroquinolones may be considered if the local data suggests antimicrobial susceptibility. For these cases, an infectious disease consult is essential. Children older than 8 years may omit the macrolide in cases of endocarditis.

Drug Name	Ceftriaxone (Rocephin)
Description	Second DOC because of higher cost, discomfort, and the additional administration expense of injection. Often used as first-line therapy when cefixime is unavailable.
Adult Dose	Uncomplicated gonococcal infections: 125 mg IM once Disseminated gonococcal infection: 1 g IV/IM qd for 7 d (10-14 days for meningitis); not to exceed 1 g/d; administer with azithromycin or erythromycin Gonococcal endocarditis: 1-2 g/d IV/IM for 28 d Epididymitis: 250 mg IM once; administer with 10 d of doxycycline Conjunctivitis: 1 g IM with azithromycin or erythromycin
Pediatric Dose	Uncomplicated gonococcal infection: 125 mg IM once Disseminated gonococcal infection: 50 mg/kg/d IV/IM qd for 7 d (10-14 days for meningitis); not to exceed 1 g/d; administer in combination with azithromycin or erythromycin Gonococcal endocarditis: 50 mg/kg/d IV/IM qd for 28 d; not to exceed 2 g/d Conjunctivitis: 50 mg/kg IM once; not to exceed 1 g/d; administer with azithromycin or erythromycin
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Local administration site reactions (eg, redness, pain) occur in 10-17% of adults

Drug Name	Spectinomycin (Trobicin)
Description	Inhibits protein synthesis in bacterial cells. Site of action is 30S ribosomal subunit and is structurally different from related aminoglycosides. May be used in instances of allergy to cephalosporins.
Adult Dose	2 g IM as a single dose
Pediatric Dose	Infants and children: 40 mg/kg IM as a single dose; not to exceed 2 g (with erythromycin or azithromycin to treat chlamydia)
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Benzyl alcohol used as a diluent associated with fatal gasping syndrome in infants; antibiotics may mask or delay symptoms of incubating syphilis; perform a serologic test for syphilis in all patients with gonorrhea at time of diagnosis followed by additional test after 3 mo; monitor clinical effectiveness to detect resistance by N gonorrhea

Drug Name	Erythromycin (E-Mycin)
Description	Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult Dose	Not recommended
Pediatric Dose	50 mg/kg/d (as base) PO divided qid for 10-14 d; not to exceed 2 g/d (for chlamydia, administer with ceftriaxone or spectinomycin)
Contraindications	Documented hypersensitivity; hepatic impairment
Interactions	Inhibits CYP450 3A4; coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Drug Name	Azithromycin (Zithromax)
Description	Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Treats mild to moderate microbial infections.
Adult Dose	1 g PO once (for chlamydia, administer with cefixime or ceftriaxone)
Pediatric Dose	Infants and children: 20 mg/kg PO as a single dose; not to exceed 1 g (with ceftriaxone or spectinomycin) Adolescents: 1 g PO once (for chlamydia, administer with cefixime or ceftriaxone)
Contraindications	Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Interactions	May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Drug Name	Doxycycline (Bio-Tab, Vibramycin, Doryx)
Description	Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose	100 mg PO bid for 7 d (for chlamydia, administer with cefixime or ceftriaxone)
Pediatric Dose	Adolescents: 100 mg PO bid for 7 d (for chlamydia, administer with cefixime or ceftriaxone)
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions	Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

FOLLOW-UP

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Deterrence/Prevention

Proper education may be more effective than simplistic instructions to avoid sex, especially in the teenaged population. Teenagers involved with abstinence-only campaigns have unchanged STD rates and disproportionately acquire anal and oral infections, rather than vaginal infections (the perception is that if an activity is not vaginal sex, it is not sex).

The discussion of responsible sexual behavior should not be limited or withheld because of personal religious or moral views because these may not be shared by the patient and teenagers are notorious for sexual experimentation; evidence suggests that this limited discussion does the teenage population a huge disservice. This advice is especially pertinent in states where sexual education is almost nonexistent in the school system because of abstinence-only teaching, which is misleading and factually inaccurate.

Although the most effective prevention is abstinence from sex, this is oftentimes an unrealistic expectation, especially in the teenaged population; in fact, 88% of teenagers who pledged abstinence in middle and high school still engaged in premarital sex. Moreover, they tend to have riskier, unprotected sex because of their lack of education; those who pledge before having sex have a 33% higher prevalence rate of STDs than those who had sex and then retrospectively pledged, with nonpledgers falling in between. This is despite a lower number of partners and an older age at first intercourse in pledgers.

Of course, abstinence should be explained to be the best option, but a more practical expectation is abstinence from sex with someone known or suspected of having an STD until treatment is obtained and completed. In light of the difficulty in knowing a potential partner's sexual history (or honesty), strongly recommend the use of condoms as a reasonable alternative to abstinence.

Pledgers are actually less likely to be aware of their STD status and are less likely to seek testing, even if their STD rates are similar overall (again highlighting a lack of appropriate sexual education). Stress that oral or anal sex can also transmit disease.

Patients should also be counseled about the additional risks of unprotected sex, such as the acquisition of more serious or lifelong infections such as herpes, hepatitis B and HIV, and, of course, about the risks of pregnancy. The emotional aspect of sexual relationships may also need to be addressed, especially in teenage girls. Teenagers are vulnerable in that they are sexually mature but not yet emotionally mature.

Prevention of neonatal disease is with the use of silver nitrate 1% eye drops or 1% tetracycline or 0.5% erythromycin ophthalmic ointment within 1 hour of birth.

Complications

• PID is generally the most feared complication of gonococcal infection because it is one of the leading causes of female infertility and often leads to hospitalization. This can be devastating to any woman, especially an adolescent who potentially has many years of childbearing ahead of her.
• Epididymitis and orchitis occur infrequently in males who go untreated. These conditions usually respond well to the same antibiotics used for uncomplicated urethritis but administered for a longer course.
• Arthritis (septic or reactive) is a rare complication of gonorrhea; however, because it mimics septic arthritis, excluding the possibility of gonococcal infection in any adolescent with acute onset of pyogenic arthritis is important. Gonorrhea is the most common cause of arthritis in the adolescent. Adequate diagnosis may require culturing extraarticular sites for N gonorrhoeae.
• Perihepatitis secondary to gonorrhea (Fitz-Hugh-Curtis syndrome) presents as right upper quadrant pain and nausea in patients with untreated gonorrhea. 
• DGI is an acute illness that causes fever, asymmetric polyarthralgias, and skin pustules overlying small joints in patients with gonorrhea.
• Neonatal infection of the eyes may lead to permanent damage and blindness.

Prognosis

• The prognosis for patients with gonorrhea is excellent if the diagnosis is made and treatment is started before progression or complications occur.

Patient Education

• Patients should know the method of disease transmission and the adverse impact of recurrent infections on future fertility.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education articles Gonorrhea and Sexually Transmitted Diseases.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Failure to diagnose gonorrhea may occur if the physician fails to obtain a sexual history from adolescents with dysuria or genital symptoms. This often leads to inadequate treatment for a presumed urinary tract infection. A sexual history should be obtained on any adolescent encounter, and testing may need to be performed if suspicions arise, even with denial of sexual activity.
• If undiagnosed, gonorrhea may progress to orchitis or PID. As a result, fertility may be permanently impaired.

Special Concerns

• Females with diagnosed or suspected STDs should also have a concomitant pregnancy test. This guides further care and allows treatment with medications that are not approved for use in pregnancy.
• Identification and treatment of the patient's partner and any partners of the partner are important to prevent reinfection and complications.
• Children and adolescents in whom gonococcal disease is suspected should be evaluated for syphilis, HIV infection, hepatitis B, herpes simplex virus, and any other STDs that are suggested by the history and physical examination findings. Administer hepatitis B vaccination to these children and adolescents unless they have received the full vaccine series.
• Discuss safe sexual practices with all adolescents in whom gonorrhea is suspected.

MULTIMEDIA

Section 10 of 11  

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• Miscellaneous
• Multimedia
• References

Media file 1:  Rates of gonococcal infection per 100,000 by state, courtesy of The Centers for Disease Control and Prevention (CDC).
	View Full Size Image
Media type:  Image

REFERENCES

Section 11 of 11

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1. 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].
2. CDC. Increases in gonorrhea--eight western states, 2000--2005. MMWR Morb Mortal Wkly Rep. Mar 16 2007;56(10):222-5. [Medline].
3. Gonococcal Isolate Surveillance Project (GISP) Annual Report 2005. Sexually Transmitted Disease Surveillance 2005 Supplement. CDC; January 2007. [Full Text].
4. American Academy of Pediatrics. 2006 Red book: Report of the committee on infectious diseases. 27^th ed. 2006:301-9.
5. Behrman RE. Nelson's Textbook of Pediatrics. 14^th ed. Philadelphia, PA: WB Saunders Co; 1992:536-7.
6. Blake D, Woods E. The future is here: Noninvasive diagnosis of STDs. Contemp Pediatr. Feb 2001;71-87.
7. Bruckner H, Bearman PS. After the promise: the STD consequences of adolescent virginity pledges. J Adolesc Health. 2005;4:271-8. [Medline]. [Full Text].
8. 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].
9. Kerr-Layton JA, Stamm CA, Peterson LS. Chronic plasma cell endometritis in hysterectomy specimens of HIV- infected women: a retrospective analysis. Infect Dis Obstet Gynecol. 1998;6(4):186-90. [Medline].
10. McCormack WM. Pelvic inflammatory disease. N Engl J Med. Jan 13 1994;330(2):115-9. [Medline].
11. Palusci VJ, Reeves MJ. Testing for genital gonorrhea infections in prepubertal girls withsuspected sexual abuse. Pediatr Infect Dis J. Jul 2003;22(7):618-23. [Medline].

Article Last Updated: Dec 6, 2007