What is Gonorrhoea?
Gonorrhoea is a sexually transmitted disease caused by the gram-negative bacterium Neisseria Gonorrhoeae. It can also be transmitted to infant during childbirth resulting in infantile conjunctivitis.
Neisseria Gonorrhoeae is a gram negative bacteria that is coffee beaned shaped usually intracellular diplococci arranged in pairs or in 4s. The incubation period ranges from 2 to 7 days.
Clinical Presentation of Gonorrhoea
The common sites of infection caused by gonorrhoea include the endocervix, urethra, rectum, pharynx and the conjunctivitis depend on the sexual practice of infected persons.
10% of patients with urethra; infection, more than 50% of those with cervical infection as well as more than 90% of those with pharynx and rectum infections may not present with any symptoms.
Those with symptoms typically present with a profuse purulent discharge from the urethra in male and from the cervix in females. This may be associated with painful urination, local genitalia pain and discomfort. The rectum may be affected if there is anal sex involved. The oral pharynx area maybe infected if there is oral sex involved.
Complications of gonorrhoea when it spread to the neighboring sites include epididymo-orchitis (inflammation of the tube attached to the upper part of testes and testes), prostatitis (inflammation of prostate gland in males), endometritis (inflammation of the lining of uterus), acute bartholinitis (inflammation of the bartholin glands on the vagina), salpingo-oophoritis (inflammation of fallopian tube and ovary), pelvic inflammatory disease (inflammation of the female genital tract above the cervix) and pelvic abscesses.
Haematogenous spread (spread via blood circulation) will lead to disseminated infections throughout the body to cause polyarthralgia (multiple joint pain), dermatitis (inflammation of skin), meningitis (inflammation of protective membranes covering brain and spinal cord), endocarditis (inflammation of the inner lining of heart muscles and heart valves) and tenosynovitis (inflammation of tendon and synovial sheath).
Specimens collection for Gonorrhoea testing
For women, pelvic examination if a speculum is used to expose the cervix and an Endocervical sample is taken for testing. Swabs from the rectum and pharynx may be taken also if there’s sexual activity involving those sites. Alternative specimens like urine sample and vaginal swab can be used for NAAT tests.
For men, urethra swab is usually the specimen of choice. Swabs from the rectum or pharynx may be taken also if there’s sexual activity involving those sites. First Void Urine (FVU) can also be used as alternative for NAAT test.
Confirmation tests for Gonorrhoea
1.Microscopy Examination: Urethral samples from men and Endocervical specimens are examined to identify the Gram Negative Intracellular diplococci on the smear. This is a presumptive diagnosis of gonorrhoea. It is not recommended for rectal and pharyngeal specimens. Confirmatory diagnosis is the identification of the organism on the selective culture media.
2.NAAT (PCR) Nucleic Acid-based Amplification Test: This is more sensitive than culture. It can be used as screening and diagnostic tests.
3.Blood tests: Gonococcal complement fixation test (GC-CFT) is useless in diagnosing gonorrhoea.
Treatment of uncomplicated gonorrhoea (urethral, Endocervical and rectal infection) in adults
Certain antibiotics are not recommended as in certain parts of the world the gonorrhoea bacterium is resistant to certain group of antibiotics. Treatment involves intramuscular injection of ceftriaxone 250 mg single dose or oral cefixime 400 mg tablet single dose. Alternative treatments include intramuscular spectinomycin 2 gram single dose or intramuscular cefotaxime 1 gram single dose.
Patients down with gonorrhoea often also has chlamydia infection hence co-treatment of chlamydia should be commenced.
Gonorrhoea treatment during pregnancy
Antibiotic group cephalosporin in the recommended dosage is effective and safe to use in pregnancy. If pregnant women cannot tolerate cephalosporins, spectinomycin can be used as an alternative. Co-treatment of chlamydia with antibiotic erythromycin 500 mg orally 4 times daily for 1-2 weeks is commenced.
Treatment of gonorrhoea pharyngeal infection
Treatment recommended is intramuscular ceftriaxone 250 mg single dose.
This is should be treated together with anti-chlamydia therapy.
Treatment of disseminated gonorrhoea infection
In this case, the gonorrhoea bacterium has spread throughout the body affecting multiple sites. Hospitalization under specialist care is recommended for this group of patients. Initial treatment involves intramuscular/intravenous ceftriaxone 1 gram or intramuscular spectinomycin 2 gram every 12 hourly or intravenous cefotaxime 1 gram 8 hourly.
The above therapy should continue for 1-2 days. When there is improvement then the therapy can be changed to oral cephalosporin antibiotics for a week.Anti-chlamydia treatment should be given too.
Treatment of acute epididymitis and epididymo-orchitis in males
Gonorrhoea may cause infection of the epididymis (tube that stores sperm and is attached to the upper part of the testes) and the testes. Treatment is intramuscular ceftriaxone 500 mg daily for 1-3 days. Anti-chlamydia treatment should be given too.
Treatment of adults with gonorrhoea eye infection
The infected eyes should be irrigated with normal saline. Topical antibiotic eye drops does not eradicate the infection. Treatment is intramuscular ceftriaxone 1 gram single shot. An ophthalmologist should be consulted for a full ophthalmic assessment.
Treatment of neonates with gonorrhoea eye infection
The infected eyes should be irrigated with normal saline. Topical antibiotic eye drops does not eradicate the infection. Mothers of affected neonate and her sexual partners should be screened for gonorrhoea and other sexually transmitted disease. If positive they should be treated.
Treatment is intramuscular ceftriaxone 25-50 mg per kg one single shot not exceeding 125 mg or intramuscular cefotaxime 100 mg per kg one single shot. An ophthalmologist should be consulted for a full ophthalmic assessment.
Treatment of uncomplicated gonorrhoea urethral, vaginal, cervical, pharyngeal and rectal infections in older children
For children above 12 years old or those who weigh above 45 kg should be treated like the adults.
For children below 12 years old or weigh less than 45 kg can be treated with intramuscular cefotaxime 125 mg single dose or intramuscular ceftriaxone 125 mg single dose.
Follow up post treatment
Usually repeat test to prove cure has been achieved is not done routinely. Repeat test of cure can be done if symptoms persist, re-exposed to the bacteria via sexual activity or if patient needs reassurance.
Gonorrhoea pharyngeal infection is less easily eradicated, follow up test is recommended for this site. For guys with gonorrhoea urethritis (inflammation of urethra), review in 2 weeks post treatment for follow up is recommended to make sure gonorrhoea is eradicated.
For patients with gonorrhoea eye infection, while on therapy daily cultures should be done and again on day 5 and 14 after treatment to prevent further eye complications.
Patients with gonorrhoea should be encouraged to be tested for HIV and syphilis. If negative the test should be repeated in 3 months due to the window period which will cause an initial false negative result.
All sexual contacts in the preceding 2 months should be contacted, traced, screened and treated if tested positive.