Gonococcal Infections

Key Features

Essentials of Diagnosis

• Purulent, profuse urethral discharge with dysuria, especially in men; yields positive gram-stained smear

• In men

  • Urethritis

  • Epididymitis

  • Prostatitis

  • Proctitis

  • Pharyngitis

• In women

  • Asymptomatic or cervicitis with purulent discharge

  • Vaginitis, salpingitis, proctitis also occur

• Disseminated disease

  • Fever

  • Rash

  • Tenosynovitis

  • Septic arthritis

• Nucleic acid amplification is preferred diagnostic test

General Considerations

• Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus

Demographics

• Gonorrhea is transmitted as a result of sexual activity and has its greatest incidence in the 15- to 29-year-old age group

Clinical Findings

Symptoms and Signs

• Asymptomatic infection is common and occurs in both sexes

• Other sites of primary infection (eg, the pharynx) must always be considered

Urethritis

• In men

  • Initially, burning on urination and a serous or milky discharge

  • One to 3 days later, more pronounced urethral pain and the discharge becomes yellow, creamy, and profuse, sometimes blood tinged

  • May regress and become chronic or progress to involve the prostate, epididymis, and periurethral glands with acute, painful inflammation

  • Rectal infection is common in homosexual men

• In women

  • Dysuria

  • Urinary frequency and urgency, with a purulent urethral discharge

Cervicitis

• Infection may be asymptomatic, with only slightly increased vaginal discharge and moderate cervicitis on examination

• Vaginitis and cervicitis with purulent discharge and inflammation of Bartholin glands are common

• Infection may remain as a chronic cervicitis

• It may progress to involve the uterus and fallopian tubes with acute and chronic salpingitis and ultimate scarring of tubes and sterility

• In pelvic inflammatory disease, anaerobes and chlamydiae often accompany gonococci

Conjunctivitis

• Direct inoculation of gonococci into the conjunctival sac occurs by autoinoculation from a genital infection

• The purulent conjunctivitis may rapidly progress to panophthalmitis and loss of the eye unless treated promptly

Differential Diagnosis

• Nongonococcal urethritis

• Cervicitis or vaginitis due to

  • Chlamydia trachomatis

  • Gardnerella vaginalis

  • Trichomonas

  • Candida

  • Other pathogens associated with sexually transmitted diseases

• Pelvic inflammatory disease

• Proctitis

• Reactive arthritis

Diagnosis

Laboratory Tests

• In men, Gram stain of urethral or rectal discharge, especially during the first week after onset, typically shows gram-negative diplococci within polymorphonuclear leukocytes

• Gram stain is less often positive in women

• Nucleic acid amplification tests

  • The preferred testing method for diagnosing gonococcal infection at all sites due to its excellent sensitivity and specificity

  • Recommended by the CDC for oropharyngeal and rectal site swab testing (urine testing does not detect oropharyngeal and rectal gonorrhea unless there is concurrent genital infection)

  • Have largely replaced culture

• Cultures should still be ...