Gonorrhoea

Last Updated: 2020-11-19

Author(s): -

Neisser 1879.

Gonorrhea, Neisser's disease.

A sexually transmitted infectious disease (STI or STD) caused by Neisseria gonorrhoeae that occurs worldwide. It is seen as an indicator for the prevention of HIV and other STDs, as it is often a co-infection (ulcers serve as entry portal).

  • Worldwide approx. 300-600 million
  • Incidence: 2-5/100000/year
    • Saxony: 10,1 /100000/year
  • Men: Women = 2:1
  •  Since the invention of penicillin in Europe, the incidence of the disease has been declining, and has been rising again since 2001.
  • Occurring mainly in the 3rd and 4th decade of life
  • With the exception of neonatal conjunctivitis, the transmission is only sexual.
  • Risk factors
    • High number of sexual partners
    • Promiscuity
    • Not using a condom
    • Anal sex
    • Oral sex
  • Incubation period: 2-7 days
  • Often indistinguishable from Chlamydia infection.
  • Mostly a urethritis or a cervicitis appears. The distal rectal mucosa can also be affected. Hematogenic scattering is possible.
  • Men:

    • Serous or purulent exclusion
    • Burning during urination 
    • The urethra opening may be red.
    • Balanitis, sometimes paraphimosis
    • Pain in the perineum and lower abdomen
  • Women:

    • 80% asymptomatic
    • Serous or purulent discharge
    • Burning and pain during urination
    • Local redness and swelling, erosions and ulcerations
    • Peritoneal pain (pelvic inflammatory disease)
    • Bleeding disorder
    • Swelling of the adnexa
  • Extra-genital manifestation

    •  Pharyngitis (almost all cases of pharyngeal gonorrhoea are asymptomatic)
    • Proctitis (often asymptomatic in both sexes)
    • Sepsis
    • Deteriorated general condition, fever attacks
  • Urethritis: All patients with urethritis should undergo the diagnostic steps listed in Table 1. If the complaint persists, the steps are described in Table 2.
  • Pharyngeal or anal complaints: For pharyngitis and anal complaints see Table 3.

 

Table 1. diagnostic steps in all urethritis patients step

Sample collection

Processing

For the detection of

1)

Men: Swab from the urethra with the eSwab with thin swab (Figure 1):

  • urethral discharge; spontaneously or smear out urethra or

  • Urethral swab; cotton swab 2cm into urethra and turn slightly

Women: If culture is desired, take a smear of endocervix in gynaecology.

Step 1a:


Smear swab on slide for Gram staining

Gram-negative diplococci (Neisseria gonorrhoeae),


Other bacteria,


Leukocytes

Step 1b):


Swab immediately into the medium 


Neisseria gonorrhoeae culture (including resistance)

Step 2)

Men: first urine (at least 2 hours after last micturition)


alternatively, if micturition is not possible:


for urethral swab from step 1 additionally require PCR


Women: Vaginal swab

Maintenance

Neisseria gonorrhoeae - PCR,

Chlamydia trachomatis - PCR

Step 3)

Blood sample collection

Maintenance

Lues serology,

HIV Test

 

Table 2: Diagnostic steps in case of persistent symptoms after therapy (after consultation with a management physician)

Sample collection

Processing

Detection of

Step 1)

Urethral smear

Put the smear into the medium

Mycoplasma genitalium - PCR,

Trichomonas vaginalis - PCR

 

Genito-anal, pharyngeal, less frequently other localizations.

  • Men

    • Urethritis gonorrhoica posterior
    • Prostatitis
    • Epididymitis
    • Spermatocystis
    • Vesiculitis
    • Funiculitis
    • Cowperitis
    • Cavernitis
    • Anal infestation
    • Perihepatitis gonorrhoica
    • Endocarditis
    • Gonarthritis
    • Meningitis
    • Gonococcal sepsis
  • Women

    • Salpingitis
    • Endometritis gonorrhoica
    • Perioophoritis
    • Oophoritis
    • Adnexitis gonorrhoica
    • Peritonitis gonorrhoica
    • Rectal gonorrhoea
    • Vulvovaginitis gonorrhoica adultorum
    • Gonococcal sepsis
    • Perihepatitis gonorrhoica
    • Endocarditis
    • Gonarthritis
    • Meningitis

Barrier measures (attention oral sex).

In general, the therapy recommendation is based on the pathogen detection.
The therapy during the first visit to the clinic depends on the results of the direct preparation (Table 1.)

Table 1. therapy recommendation according to the result of the direct preparation test result

Interpretation Procedure / Therapy
Direct preparation not conspicuous Unclear urethritis

No therapy

Protected sex only,

Control in 1 week

In the direct preparation gram-negative diplococci (especially intracellular) and leukocytes (> 5/visual field)

Gonorrhea

Ceftriaxone i.m. 1.0g single dose 

In the direct preparation leucocytes (> 5/visual field) and possibly bacteria

Non-gonorrheic urethritis

Doxycycline p.o. 100 mg 2x/d for 7 days


Alternative:


Second line: Azithromycin 500mg "single dose", then 250mg 1xtgl. for 4 days (IUSTI 2016)

 

Further recommendations

  • Patients with documented urethritis should be tested for other STIs, including syphilis and HIV
  • Clinical follow-up after 1 week (e.g. when discussing test results)
  • Microbiological follow-ups are indicated for therapy with second-line therapy or persistent urethritis after pathogen-appropriate therapy
  • Prohibition of unprotected sexual intercourse for 7 days after single-dose therapy or until completion of 7-day therapy
  • Sexual partners of patients with gonorrhoea in the last 60 days should be tested for N. gonorrhoea by PCR and culture due to the high infection rate and treated on the same day, i.e. before the test result is available
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  7. Lebwohl, Mark. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. Elsevier, 2014. Print.
  8. British Association for Sexual Health and HIV national guideline for the management of infection with Neisseria gonorrhoeae (2019)
  9. Horner P. et al. 2016 European guideline on the management of non-gonococcal urethritis. International Journal of STD & AIDS 2016; 27: 928–937