Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Without antibiotic treatment, complications can occur. Complications for men may include epididymitis, prostatitis, balanitis, and periurethral abscess. Women may develop pelvic inflammatory disease, which can cause perihepatitis and fertility issues. Disseminated gonococcal infection is associated with fever, dermatitis, tenosynovitis, septic arthritis, and (rarely) endocarditis or meningitis. Gonorrhea diagnosis is made by microscopy, culture, or nucleic acid amplification tests. Management generally involves ceftriaxone, but treatment with doxycycline should be pursued if a coinfection with Chlamydia trachomatis (C. trachomatis) is not excluded.
2nd most common bacterial STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs) in both the United States and the United Kingdom (chlamydiaChlamydiaChlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae.Chlamydia is the most common )
Worldwide annual incidenceIncidenceThe number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time.Measures of Disease Frequency: approximately 80–100 million people:
Higher incidenceIncidenceThe number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time.Measures of Disease Frequency in developing countries, including Africa and the Western Pacific
United States new cases in 2018: approximately 600,000
IncidenceIncidenceThe number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time.Measures of Disease Frequency appears to be increasing globally.
GenderGenderGender Dysphoria differences: men > women (particularly in men who have sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria with men (MSM))
Most common age groups:
Men: 20–29 years old
Women: 15–24 years old
Factors sustaining gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea in the population:
A recent reversing trend in safe sexual practices
Asymptomatic cases
Antibiotic-resistant strains
GonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea is a notifiable disease.
Etiology[1,2,8]
GonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea is caused by the pathogen Neisseria gonorrhoeaeNeisseria gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseria (N. gonorrhoeaeN. gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseria):
Grows best in aerobic conditions, but can grow in anaerobic conditions
Medium: modified Thayer-Martin (MTMMTMEnriched chocolate agar with antimicrobial agents that selectively favor growth of Neisseria by inhibiting growth of other bacteria and fungiNeisseria) agar in 5% CO2 atmosphere:
Antimicrobial agents are used to selectively favor NeisseriaNeisseriaNeisseria is a genus of bacteria commonly present on mucosal surfaces. Several species exist, but only 2 are pathogenic to humans: N. gonorrhoeae and N. meningitidis. Neisseria species are non-motile, gram-negative diplococci most commonly isolated on modified Thayer-Martin (MTM) agar. Neisseria growth by inhibiting the growth of fungiFungiA kingdom of eukaryotic, heterotrophic organisms that live parasitically as saprobes, including mushrooms; yeasts; smuts, molds, etc. They reproduce either sexually or asexually, and have life cycles that range from simple to complex. Filamentous fungi, commonly known as molds, refer to those that grow as multicellular colonies.Mycology and other bacteriaBacteriaBacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology.
OxidaseOxidaseNeisseria and catalaseCatalaseAn oxidoreductase that catalyzes the conversion of hydrogen peroxide to water and oxygen. It is present in many animal cells. A deficiency of this enzyme results in acatalasia.Nocardia/Nocardiosis positive:
Only oxidizes glucoseGlucoseA primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement.Lactose Intolerance
History of STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs)
GonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea is an independent factor for the transmission of HIVHIVAnti-HIV Drugs.
A 3-dimensional (3D) computer-generated image of N. gonorrhoeae bacteria: Typical diplococci and multiple pili
Image: “3-dimensional computer-generated image” by Centers for Disease Control and Prevention. License: Public Domain, cropped by Lecturio.
Gram stain of purulent exudate containing N. gonorrhoeae: N. gonorrhoeae are seen as gram-negative diplococci. As seen here, the bacteria usually provoke a marked neutrophilic response with several neutrophils containing many phagocytized bacteria. Although not present in the image, gram staining would also reveal the bacteria within infected epithelial cells.
Image: “Gonorrhea Neisseria gonorrhoeae” by Joe Miller, USCDCP. License: Public Domain
Sexual contact with the penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy, vaginaVaginaThe vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery.Vagina, Vulva, and Pelvic Floor: Anatomy, mouth, or anus of an infected individual
Perinatal (during vaginal delivery)
Virulence factorsVirulence factorsThose components of an organism that determine its capacity to cause disease but are not required for its viability per se. Two classes have been characterized: toxins, biological and surface adhesion molecules that affect the ability of the microorganism to invade and colonize a host.Haemophilus[1,6,8]
Antigenic variation:
Allows expression of distinct surface antigens
Impedes recognition by the host’s immune systemImmune systemThe body’s defense mechanism against foreign organisms or substances and deviant native cells. It includes the humoral immune response and the cell-mediated response and consists of a complex of interrelated cellular, molecular, and genetic components.Primary Lymphatic Organs
PiliPiliFilamentous or elongated proteinaceous structures which extend from the cell surface in gram-negative bacteria that contain certain types of conjugative plasmid. These pili are the organs associated with genetic transfer and have essential roles in conjugation. Normally, only one or a few pili occur on a given donor cell. This preferred use of ‘pili’ refers to the sexual appendage, to be distinguished from bacterial fimbriae, also known as common pili, which are usually concerned with adhesion.Salmonella (fimbriaeFimbriaeThin, hairlike appendages, 1 to 20 microns in length and often occurring in large numbers, present on the cells of gram-negative bacteria, particularly enterobacteriaceae and Neisseria. Unlike flagella, they do not possess motility, but being protein (pilin) in nature, they possess antigenic and hemagglutinating properties. They are of medical importance because some fimbriae mediate the attachment of bacteria to cells via adhesins. Bacterial fimbriae refer to common pili, to be distinguished from the preferred use of ‘pili’.Escherichia coli):
Long, hair-like appendages on the bacterial surface
Able to lengthen and retract
Initiate attachment to host cells
Furnish resistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing to phagocytosisPhagocytosisThe engulfing and degradation of microorganisms; other cells that are dead, dying, or pathogenic; and foreign particles by phagocytic cells (phagocytes).Innate Immunity: Phagocytes and Antigen Presentation
Provide antigenic variation among different strains
Opacity-associated protein:
Outer membrane protein
Aids in attachment to host cell receptorsReceptorsReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors
EndotoxinEndotoxinToxins closely associated with the living cytoplasm or cell wall of certain microorganisms, which do not readily diffuse into the culture medium, but are released upon lysis of the cells.Proteus
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
Ciliary loss
Mucosal cell deathCell deathInjurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. Apoptosis is programmed cell death, a mechanism with both physiologic and pathologic effects.Cell Injury and Death
Renders some strains resistant to complement activationComplement ActivationThe sequential activation of serum complement proteins to create the complement membrane attack complex. Factors initiating complement activation include antigen-antibody complexes, microbial antigens, or cell surface polysaccharides.Systemic Lupus Erythematosus and deposition
Interferes with phagosome-lysosome fusion and may prevent intracellular killing by neutrophilsNeutrophilsGranular leukocytes having a nucleus with three to five lobes connected by slender threads of chromatin, and cytoplasm containing fine inconspicuous granules and stainable by neutral dyes.Innate Immunity: Phagocytes and Antigen Presentation
IgAIgARepresents 15-20% of the human serum immunoglobulins, mostly as the 4-chain polymer in humans or dimer in other mammals. Secretory iga is the main immunoglobulin in secretions.Immunoglobulins: Types and FunctionsproteaseProteaseEnzyme of the human immunodeficiency virus that is required for post-translational cleavage of gag and gag-pol precursor polyproteins into functional products needed for viral assembly. HIV protease is an aspartic protease encoded by the amino terminus of the pol gene.HIV Infection and AIDS:
Cleaves and inactivates IgA-1 immunoglobulin
Reduces the host’s immune defense
Pathogenesis[1,6,8,12]
Bacterium adheres to the mucosal epitheliumEpitheliumThe epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology → competes with microbiota → colonizes and invades the epitheliumEpitheliumThe epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology via transcytosis with the help of piliPiliFilamentous or elongated proteinaceous structures which extend from the cell surface in gram-negative bacteria that contain certain types of conjugative plasmid. These pili are the organs associated with genetic transfer and have essential roles in conjugation. Normally, only one or a few pili occur on a given donor cell. This preferred use of ‘pili’ refers to the sexual appendage, to be distinguished from bacterial fimbriae, also known as common pili, which are usually concerned with adhesion.Salmonella and opacity-associated proteinsOpacity-associated proteinsNeisseria
LOSLOSNeisseria is released → activates toll-like receptorReceptorReceptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell.Receptors (TLR) and nucleotide-binding oligomerization domain-containing protein (NOD) signaling in:
Epithelial cells
MacrophagesMacrophagesThe relatively long-lived phagocytic cell of mammalian tissues that are derived from blood monocytes. Main types are peritoneal macrophages; alveolar macrophages; histiocytes; kupffer cells of the liver; and osteoclasts. They may further differentiate within chronic inflammatory lesions to epithelioid cells or may fuse to form foreign body giant cells or langhans giant cells.Innate Immunity: Phagocytes and Antigen Presentation
Dendritic cellsDendritic cellsSpecialized cells of the hematopoietic system that have branch-like extensions. They are found throughout the lymphatic system, and in non-lymphoid tissues such as skin and the epithelia of the intestinal, respiratory, and reproductive tracts. They trap and process antigens, and present them to T-cells, thereby stimulating cell-mediated immunity. They are different from the non-hematopoietic follicular dendritic cells, which have a similar morphology and immune system function, but with respect to humoral immunity (antibody production).Skin: Structure and Functions
Production of cytokinesCytokinesNon-antibody proteins secreted by inflammatory leukocytes and some non-leukocytic cells, that act as intercellular mediators. They differ from classical hormones in that they are produced by a number of tissue or cell types rather than by specialized glands. They generally act locally in a paracrine or autocrine rather than endocrine manner.Adaptive Immune Response and chemokinesChemokinesClass of pro-inflammatory cytokines that have the ability to attract and activate leukocytes. They can be divided into at least three structural branches: c; cc; and cxc; according to variations in a shared cysteine motif.Adaptive Cell-mediated Immunity → influx of neutrophilsNeutrophilsGranular leukocytes having a nucleus with three to five lobes connected by slender threads of chromatin, and cytoplasm containing fine inconspicuous granules and stainable by neutral dyes.Innate Immunity: Phagocytes and Antigen Presentation → phagocytosisPhagocytosisThe engulfing and degradation of microorganisms; other cells that are dead, dying, or pathogenic; and foreign particles by phagocytic cells (phagocytes).Innate Immunity: Phagocytes and Antigen Presentation of harmful bacteriaBacteriaBacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology → neutrophil-rich purulent exudateExudateExudates are fluids, cells, or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues.Pleural Effusion
Since N. gonorrhoeaeN. gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseriahas defense mechanismsDefense mechanismsDefense mechanisms are normal subconscious means of resolving inner conflicts between an individual’s subjective moral sense and their thoughts, feelings, or actions. Defense mechanisms serve to protect the self from unpleasant feelings (anxiety, shame, and/or guilt) and are divided into pathologic, immature, mature, neurotic, and other types.Defense Mechanisms to resist being killed, the bacteria-laden neutrophilsNeutrophilsGranular leukocytes having a nucleus with three to five lobes connected by slender threads of chromatin, and cytoplasm containing fine inconspicuous granules and stainable by neutral dyes.Innate Immunity: Phagocytes and Antigen Presentation act as agents of transmission to another host.
Pathogenesis of N. gonorrhoeae:
DC: dendritic cell
LOS: lipooligosaccharide
TLR: toll-like receptor
NOD: nucleotide-binding oligomerization domain-containing protein
NLR: NOD-like receptor
Image by Lecturio.
Antimicrobial resistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing[2,13]
PenicillinPenicillinRheumatic Fever and tetracyclineTetracyclineA naphthacene antibiotic that inhibits amino Acyl tRNA binding during protein synthesis.Drug-Induced Liver InjuryresistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing occurs from the acquisition of R factor (plasmid) coding for:
TetM protein → prevents tetracyclineTetracyclineA naphthacene antibiotic that inhibits amino Acyl tRNA binding during protein synthesis.Drug-Induced Liver Injury from binding to its target 30S ribosomal subunit site
Quinolone resistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing occurs from alterations in DNADNAA deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine).DNA Types and Structure gyrase and topoisomerase IVTopoisomerase IVA bacterial DNA topoisomerase II that catalyzes ATP-dependent breakage of both strands of DNA, passage of the unbroken strands through the breaks, and rejoining of the broken strands. Topoisomerase IV binds to DNA as a heterotetramer consisting 2 parc and 2 pare subunits. Topoisomerase IV is a decatenating enzyme that resolves interlinked daughter chromosomes following DNA replication.Fluoroquinolones.
Macrolide (e.g., azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides) resistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing can result from either:
Alterations in the ribosomal binding target
Under- and overexpression of influx and efflux systems
3rd-generation cephalosporinsCephalosporinsCephalosporins are a group of bactericidal beta-lactam antibiotics (similar to penicillins) that exert their effects by preventing bacteria from producing their cell walls, ultimately leading to cell death. Cephalosporins are categorized by generation and all drug names begin with “cef-” or “ceph-.” Cephalosporins (e.g, ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins):
Remain highly effective as a single dose, but resistant strains have been isolated in Japan and in Europe
Resistant strains may have mutations in:
PenAgeneGeneA category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms.Basic Terms of Genetics → encodes a penicillin-binding protein
Multiple transferable resistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing regulator (mtrR)geneGeneA category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms.Basic Terms of Genetics → ↑ drug efflux
PenBgeneGeneA category of nucleic acid sequences that function as units of heredity and which code for the basic instructions for the development, reproduction, and maintenance of organisms.Basic Terms of Genetics → ↓ drug influx through por proteinsPor proteinsNeisseria
Clinical Presentation
Urogenital infection in men[2,3,9,17,18]
IncubationIncubationThe amount time between exposure to an infectious agent and becoming symptomatic.Rabies Virus period: 2–7 days
Most will be symptomatic.
Acute urethritisUrethritisInflammation involving the urethra. Similar to cystitis, clinical symptoms range from vague discomfort to painful urination (dysuria), urethral discharge, or both.Urinary Tract Infections (UTIs)(most common presentation):
Regional lymphadenopathyLymphadenopathyLymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy
Complications:
EpididymitisEpididymitisEpididymitis and orchitis are characterized by acute inflammation of the epididymis and the testicle, respectively, due to viral or bacterial infections. Patients typically present with gradually worsening testicular pain and scrotal swelling along with systemic symptoms such as fever, depending on severity. Epididymitis and Orchitis:
ProstatitisProstatitisProstatitis is inflammation or an irritative condition of the prostate that presents as different syndromes: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain, and asymptomatic. Bacterial prostatitis is easier to identify clinically and the management (antibiotics) is better established. Prostatitis:
Enlarged prostateProstateThe prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. gland
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and tenderness to palpationPalpationApplication of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs.Dermatologic Examination
BalanitisBalanitisInflammation of the head of the penis, glans penis.Penile Anomalies and Conditions (inflammationInflammationInflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the glans penisGlans PenisPenis: Anatomy):
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and pruritusPruritusAn intense itching sensation that produces the urge to rub or scratch the skin to obtain relief.Atopic Dermatitis (Eczema)
Swollen foreskinforeskinThe double-layered skin fold that covers the glans penis, the head of the penis.Penis: Anatomy
PhimosisPhimosisA condition in which the foreskin cannot be retracted to reveal the glans penis. It is due to tightness or narrowing of the foreskin opening.Penile Anomalies and Conditions
Periurethral abscessAbscessAccumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection.Chronic Granulomatous Disease:
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Cowper (bulbourethral) gland inflammationInflammationInflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation or abscessAbscessAccumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection.Chronic Granulomatous Disease:
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and tenderness to palpationPalpationApplication of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs.Dermatologic Examination of the perineumPerineumThe body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male.Vagina, Vulva, and Pelvic Floor: Anatomy
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
Perineal painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Ejaculation of purulent material
Purulent penile discharge due to urogenital gonorrhea infection
Vaginal pruritusPruritusAn intense itching sensation that produces the urge to rub or scratch the skin to obtain relief.Atopic Dermatitis (Eczema)
Mucopurulent vaginal discharge
Physical examination:
May be normal
Mucopurulent cervical discharge
Friable cervical mucosa
UrethritisUrethritisInflammation involving the urethra. Similar to cystitis, clinical symptoms range from vague discomfort to painful urination (dysuria), urethral discharge, or both.Urinary Tract Infections (UTIs):
Pelvic inflammatory diseasePelvic inflammatory diseasePelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Gardnerella vaginalis. Pelvic Inflammatory Disease (PIDPIDPelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis.Pelvic Inflammatory Disease):
Occurs in 10%–20% of women with cervical gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea
Pelvic painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
DyspareuniaDyspareuniaRecurrent genital pain occurring during, before, or after sexual intercourse in either the male or the female.Primary Ovarian Insufficiency
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
Cervical motion tenderness
Adnexal tenderness
Perihepatitis (Fitz-Hugh-Curtis syndrome):
Occurs in 4% of infected women; associated with PIDPIDPelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis.Pelvic Inflammatory Disease
InflammationInflammationInflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the liverLiverThe liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: AnatomycapsuleCapsuleAn envelope of loose gel surrounding a bacterial cell which is associated with the virulence of pathogenic bacteria. Some capsules have a well-defined border, whereas others form a slime layer that trails off into the medium. Most capsules consist of relatively simple polysaccharides but there are some bacteria whose capsules are made of polypeptides.Bacteroides
InfectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease in individuals following genital reconstructive surgery (GRS)[17]
Location of infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease have been reported in:
UrethraUrethraA tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm.Urinary Tract: Anatomy
SigmoidSigmoidA segment of the colon between the rectum and the descending colon.Volvulus neovagina
Penile skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions–lined neovagina
The susceptibility of the site is thought to be related to the nature of the reconstructive tissue: mucosal tissue from the vaginaVaginaThe vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery.Vagina, Vulva, and Pelvic Floor: Anatomy or bowel is more susceptible than skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions.
Extragenital infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease[2,3,9]
Ocular gonorrheaOcular gonorrheaPurulent infections of the conjunctiva by several species of gram-negative, gram-positive, or acid-fast organisms. Some of the more commonly found genera causing conjunctival infections are Haemophilus, Streptococcus, Neisseria, and Chlamydia.Gonorrhea(conjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis):
Manifestations range in severity from asymptomatic to sight threatening.
Signs and symptoms:
Eyelid edemaEdemaEdema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
Hyperemic conjunctivaConjunctivaThe mucous membrane that covers the posterior surface of the eyelids and the anterior pericorneal surface of the eyeball.Eye: Anatomy
PhotophobiaPhotophobiaAbnormal sensitivity to light. This may occur as a manifestation of eye diseases; migraine; subarachnoid hemorrhage; meningitis; and other disorders. Photophobia may also occur in association with depression and other mental disorders.Migraine Headache
PainPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
PerforationPerforationA pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force.Esophagitis
BlindnessBlindnessThe inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of eye diseases; optic nerve diseases; optic chiasm diseases; or brain diseases affecting the visual pathways or occipital lobe.Retinopathy of Prematurity
Pharyngeal gonorrheaPharyngeal GonorrheaGonorrhea(pharyngitisPharyngitisPharyngitis is an inflammation of the back of the throat (pharynx). Pharyngitis is usually caused by an upper respiratory tract infection, which is viral in most cases. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, and hoarseness. Pharyngitis):
Due to orogenital sexual exposure
Often coexists with genital infection
Usually mild or asymptomatic
Signs and symptoms:
Sore throatSore throatPharyngitis is an inflammation of the back of the throat (pharynx). Pharyngitis is usually caused by an upper respiratory tract infection, which is viral in most cases. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, and hoarseness.Pharyngitis
Pharyngeal exudates
Cervical lymphadenopathyLymphadenopathyLymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy
Most often occurs concurrently with cervicitisCervicitisInflammation of the uterine cervix.Gonorrhea
Usually asymptomatic
In men:
More often associated with MSM
More likely to exhibit symptoms
Possible symptoms:
Rectal painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and fullness
PruritusPruritusAn intense itching sensation that produces the urge to rub or scratch the skin to obtain relief.Atopic Dermatitis (Eczema)
Hyperemia, chemosis, and purulent discharge due to gonococcal conjunctivitis: The patient developed partial blindness as a result of the infection.
Image: “Eye infection due to gonorrhea” by CDC/Arthur E. Kaye. License: Public Domain
Disseminated gonococcal infection[3,10,17]
BacteremiaBacteremiaThe presence of viable bacteria circulating in the blood. Fever, chills, tachycardia, and tachypnea are common acute manifestations of bacteremia. The majority of cases are seen in already hospitalized patients, most of whom have underlying diseases or procedures which render their bloodstreams susceptible to invasion.Glycopeptides:
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
ChillsChillsThe sudden sensation of being cold. It may be accompanied by shivering.Fever
EndocarditisEndocarditisEndocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis (common before antibiotics were available)
MeningitisMeningitisMeningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
OsteomyelitisOsteomyelitisOsteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus.Osteomyelitis
Close-up view of a gonococcal lesion on the skin of a patient’s arm: A gray pustule associated with disseminated gonococcal infection
Image: “2038” by CDC/Emory University, Dr. Thomas F. Sellers. License: Public Domain
Caused by exposure to infected cervical secretions at birth
Ophthalmia neonatorumOphthalmia NeonatorumAcute conjunctival inflammation in the newborn, usually caused by maternal gonococcal infection. The causative agent is Neisseria gonorrhoeae. The baby’s eyes are contaminated during passage through the birth canal.Gonorrhea:
Purulent conjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
Corneal ulcerations
PanophthalmitisPanophthalmitisAcute suppurative inflammation of the inner eye with necrosis of the sclera (and sometimes the cornea) and extension of the inflammation into the orbit. Pain may be severe and the globe may rupture. In endophthalmitis the globe does not rupture.Relapsing Fever
BlindnessBlindnessThe inability to see or the loss or absence of perception of visual stimuli. This condition may be the result of eye diseases; optic nerve diseases; optic chiasm diseases; or brain diseases affecting the visual pathways or occipital lobe.Retinopathy of Prematurity
Other mucosal sites of infection (usually asymptomatic):
Vaginitis
Anorectal infection
Pharyngeal infection
Disseminated gonococcal infection:
FeverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
LethargyLethargyA general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction.Hyponatremia
Poor feeding
VomitingVomitingThe forcible expulsion of the contents of the stomach through the mouth.Hypokalemia
ArthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis (refusal to move the affected limb)
Scalp abscesses
A newborn presenting with gonococcal ophthalmia neonatorum, caused by a maternally transmitted gonococcal infection.
Image: “Gonococcal ophthalmia neonatorum” by CDC/J. Pledger. License: Public Domain
After the neonatal period:
Suspect sexual abuseSexual AbuseSexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse if gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea (or any other STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs)) is diagnosed.
VulvovaginitisVulvovaginitisThe term vulvovaginitis is used to describe an acute inflammation of the vulva and vagina. Vulvovaginitis can be caused by several infectious and non-infectious etiologies, and results from disruption of the normal vaginal environment. Common signs and symptoms include pain, pruritus, erythema, edema, vaginal discharge and dyspareunia. Vulvovaginitis is the most common manifestation.
Anorectal and pharyngeal infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease are also common, but are usually asymptomatic.
GonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea is diagnosed based on laboratory assessments that identify the presence of N. gonorrhoeaeN. gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseria.
Who to test[17]
Individuals who request testing
Individuals with suspicious signs/symptoms:[18]
Urethral discharge in men (and other individuals with a penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy)
Cervical or vaginal discharge with a risk factor for an STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs)
Mucopurulent cervicitisCervicitisInflammation of the uterine cervix.Gonorrhea
Acute pelvic painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways or other signs of PIDPIDPelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis.Pelvic Inflammatory Disease
Purulent conjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis (both the child and the mother)
All sexually active women (including pregnant persons) ≤ 24 years of age
Sexually active women (including pregnant persons) ≥ 25 years of age at increased risk for infection:
A previous or coexisting STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs) (e.g., C. trachomatis)
A new or more than 1 sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria partner
A sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria partner who is also having sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria with other partners
A sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria partner with an STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs) or PIDPIDPelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis.Pelvic Inflammatory Disease
Inconsistent condom use when not in a mutually monogamous relationship
A history of exchanging sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria for money or drugs
Prior to intrauterine interventions in populations of high gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. GonorrheaprevalencePrevalenceThe total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time.Measures of Disease Frequency
ScreeningScreeningPreoperative Care is not recommended in asymptomatic heterosexual men and women ≥ 25 years at low risk for infection[14]
When to test
Symptomatic individuals: at the time of presentation
Asymptomatic individuals:
According to the U.S. Preventive Services Task Force (USPSTF), “a reasonable approach would be to screen patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship whose sexual history reveals new or persistent risk factors since the last negative test result.”[14]
At least annually in female individuals ≤ 24 years of age
Every 3‒6 months in MSM (at all potentially infected anatomic sites)
Individuals with sexual contact with an infected partner:[17]
At the time of presentation/diagnosis of the partner
Repeat testing at 2 weeks following the sexual contact (since it may take up 2 weeks for infection to develop)
Laboratory evaluation[2,13,16,18]
Specimens:[17]
Endocervical or vaginal swab (women only)
1st-pass urine samples
Individuals with a penisPenisThe penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy or neopenis
Can also be analyzed for concurrent C. trachomatis infection
Collect the first 20 mL of the voided urine, sampled > 1 hour after the last micturition.
Urethral swab (men only)
OropharynxOropharynxThe middle portion of the pharynx that lies posterior to the mouth, inferior to the soft palate, and superior to the base of the tongue and epiglottis. It has a digestive function as food passes from the mouth into the oropharynx before entering esophagus.Pharynx: Anatomy swab
Rectal swab
Individuals following GRS with a neovagina: samples should include both swabs from the neovagina and a 1st-pass urine sample
Individuals following GRS with a neopenis:
1st-pass urine considered specimen of choice
A vaginal swab should be considered (if a vaginaVaginaThe vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery.Vagina, Vulva, and Pelvic Floor: Anatomy is present) based on history and symptoms.
Individuals following a hysterectomy:
No evidence on optimal sampling site
British Association for Sexual Health and HIVHIVAnti-HIV Drugs (BASHH) recommends considering a urine sample and vulvovaginal swab with subsequent culture if positive.
Nucleic acid amplificationNucleic acid amplificationLaboratory techniques that involve the in-vitro synthesis of many copies of DNA or RNA from one original template.Septic Arthritis test (NAAT):
The test of choice
Can use specimens collected from any anatomic site
Recommended as 1st line by the WHO, CDC, USPSTF, BASHH, and the International Union against STIsSTIsSexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs) (IUSTI).
> 95% sensitive and specific
Amplifies N. gonorrhoeaeN. gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.NeisseriaDNADNAA deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine).DNA Types and Structure or RNARNAA polynucleotide consisting essentially of chains with a repeating backbone of phosphate and ribose units to which nitrogenous bases are attached. RNA is unique among biological macromolecules in that it can encode genetic information, serve as an abundant structural component of cells, and also possesses catalytic activity.RNA Types and Structure sequences
Does not provide antibiotic susceptibility information
Best used as a rapid diagnostic test in symptomatic men with urethral discharge
Sensitivity varies among sites:
> 90% in urethral exudates from men
50% for endocervical exudates
< 10% for joint fluid
Gram stainGram stainKlebsiella is not helpful for oropharynxOropharynxThe middle portion of the pharynx that lies posterior to the mouth, inferior to the soft palate, and superior to the base of the tongue and epiglottis. It has a digestive function as food passes from the mouth into the oropharynx before entering esophagus.Pharynx: Anatomy or rectal samples because nonpathogenic NeisseriaNeisseriaNeisseria is a genus of bacteria commonly present on mucosal surfaces. Several species exist, but only 2 are pathogenic to humans: N. gonorrhoeae and N. meningitidis. Neisseria species are non-motile, gram-negative diplococci most commonly isolated on modified Thayer-Martin (MTM) agar. Neisseria often colonize the sites.
Findings: gram-negative intracellular diplococci
Cultures:[17]
Provides antibiotic susceptibility data
Helpful if suspicious of treatment failure
Lower sensitivity (especially for rectal and pharyngeal specimens), but highly specific
Sensitivity:
72%–95% in symptomatic patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship
50%–85% in asymptomatic patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship
Cannot be ordered with urine or vulvovaginal swabs
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship should also be evaluated for other STIsSTIsSexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs):
C. trachomatis
SyphilisSyphilisSyphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis
HSVHSVHerpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals.Herpes Simplex Virus 1 and 2
Hepatitis BHepatitis BHepatitis B virus (HBV) is a partially double-stranded DNA virus, which belongs to the Orthohepadnavirus genus and the Hepadnaviridae family. Most individuals with acute HBV infection are asymptomatic or have mild, self-limiting symptoms. Chronic infection can be asymptomatic or create hepatic inflammation, leading to liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis B Virus and C
Disseminated gonococcal infection evaluation
In addition to the laboratory evaluations above, the following testing may be performed in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship suspected of having disseminated gonococcal infection:
Workup for disseminated gonococcal infection should be considered in at-risk individuals presenting with arthralgias that are worrisome for septic arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis, especially when vesiculopustular skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions lesions are also present.
History: suggests an individual at high risk for gonococcal infection, especially:
Individuals > 40 years of age
MSM
Those with multiple partners
Physical exam:
Musculoskeletal exam:
Joint painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways/tenderness (small or large joints)
SkinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions exam:
Look for vesiculopustular skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions lesions
May be mistaken for furuncles or pimples
Urogenital exam:
Look for purulent drainage/discharge from the penile urethraPenile urethraUrinary Tract: Anatomy or cervixCervixThe uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium.Uterus, Cervix, and Fallopian Tubes: Anatomy
Signs of inflammationInflammationInflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
Specimen testing (NAAT, Gram stainGram stainKlebsiella, culture) from potential sites of infection:
↓ GlucoseGlucoseA primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement.Lactose Intolerance
Presence of purulent urogenital discharge on exam when rapid diagnostic testsDiagnostic testsDiagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests are not available (and after specimens are collected and sent for laboratory testing)
Recent sexual contact has confirmed gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea (expedited partner therapy)
Mother of a neonateNeonateAn infant during the first 28 days after birth.Physical Examination of the Newborn with confirmed gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea
Gonococcal infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease should be reported to the appropriate health agency.
Uncomplicated gonococcal infection management
Antibiotic management:
Single IM dose of ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins with or without a single oral dose of azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides (guidelines vary)
WHO: combination therapy[15,16]
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins PLUS azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides
Cefixime PLUS azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides
CDC: ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins monotherapy[13]
BASHH: monotherapy[17]
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins recommended for all individuals
CiprofloxacinCiprofloxacinA broad-spectrum antimicrobial carboxyfluoroquinoline.Fluoroquinolones may be preferred over ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins in individuals at low risk of serious side effects from fluoroquinolonesFluoroquinolonesFluoroquinolones are a group of broad-spectrum, bactericidal antibiotics inhibiting bacterial DNA replication. Fluoroquinolones cover gram-negative, anaerobic, and atypical organisms, as well as some gram-positive and multidrug-resistant (MDR) organisms. Fluoroquinolonesif the strain is shown to be susceptible prior to initiating treatment (may help delay emergence of ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.CephalosporinsresistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing)
IUSTI:[18]
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins PLUS azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins may be used as monotherapy when:
Local ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins susceptibility testing shows low levels of local resistanceResistancePhysiologically, the opposition to flow of air caused by the forces of friction. As a part of pulmonary function testing, it is the ratio of driving pressure to the rate of air flow.Ventilation: Mechanics of Breathing.
The individual is highly likely to return for their test of cure (which is mandatory).
The individual is treated concurrently for C. trachomatis (if it has not been excluded by NAAT) with doxycycline 100 mg orally twice daily for 7 days.
Alternative regimens in individuals with severe hypersensitivity reactions:
Spectinomycin 2 g IM once PLUS azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides 2 g orally once[17,18]
GentamicinGentamicinAminoglycosides 240 mg IM once PLUS azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides 2 g orally once[13,17,18]
CiprofloxacinCiprofloxacinA broad-spectrum antimicrobial carboxyfluoroquinoline.Fluoroquinolones 500 mg orally once when testing shows susceptibility[18]
Doxycycline should be added if C. trachomatis coinfection has not been excluded.
Doxycycline 100 mg twice daily for 7 days
Repeat testing 3 months after treatment to look for reinfection.[13]
Table: Antibiotic options for uncomplicated gonococcal infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease
Guideline
Antibiotic options
WHO[15,16]
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins 250 mg IM PLUS
AzithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides 1 g orally once
Cefixime 400 mg orally once PLUS
AzithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides 1 g orally once
CDC[13]
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins:
For individuals < 150 kg: 500 mg IM once
For individuals ≥ 150 kg: 1 g IM once
BASHH[17]
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins 1 g IM once
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins 1 g IM once PLUS
AzithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides 2 g orally once
Additional measures:
Individuals should abstain from sexual intercourse for 7 days after they and all sexual partners have completed treatment.[19,20]
Pharyngeal infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease:
Use the same regimens as above.
More difficult to cure
Retest 7‒14 days after initial treatment to confirm that treatment was effective.[13]
Repeat testing 3 months after treatment to look for reinfection.
Ocular gonorrheaOcular gonorrheaPurulent infections of the conjunctiva by several species of gram-negative, gram-positive, or acid-fast organisms. Some of the more commonly found genera causing conjunctival infections are Haemophilus, Streptococcus, Neisseria, and Chlamydia.Gonorrhea:
Ophthalmology evaluation
Treatment:
CDC and BASHH: ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins 1 g IM once[13,17]
IUSTI: ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins 1 g IM once PLUS azithromycinAzithromycinA semi-synthetic macrolide antibiotic structurally related to erythromycin. It has been used in the treatment of Mycobacterium avium intracellulare infections, toxoplasmosis, and cryptosporidiosis.Macrolides and Ketolides 2 g orally once[18]
Neonates: ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins 25–50 mg/kg IV or IM as a single dose (not to exceed 125 mg)[18,21]
Topical fluoroquinolonesFluoroquinolonesFluoroquinolones are a group of broad-spectrum, bactericidal antibiotics inhibiting bacterial DNA replication. Fluoroquinolones cover gram-negative, anaerobic, and atypical organisms, as well as some gram-positive and multidrug-resistant (MDR) organisms. Fluoroquinolones
Saline irrigation
EpididymitisEpididymitisEpididymitis and orchitis are characterized by acute inflammation of the epididymis and the testicle, respectively, due to viral or bacterial infections. Patients typically present with gradually worsening testicular pain and scrotal swelling along with systemic symptoms such as fever, depending on severity. Epididymitis and Orchitis and proctitisProctitisInflammation of the mucous membrane of the rectum, the distal end of the large intestine.Chronic Granulomatous Disease: CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins is followed by a course of doxycycline.
PIDPIDPelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and gardnerella vaginalis.Pelvic Inflammatory Disease: ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins IM once PLUS doxycycline and metronidazoleMetronidazoleA nitroimidazole used to treat amebiasis; vaginitis; trichomonas infections; giardiasis; anaerobic bacteria; and treponemal infections.Pyogenic Liver Abscess twice daily for 14 days
HospitalizationHospitalizationThe confinement of a patient in a hospital.Delirium is recommended during initial therapy.
Regimens:
IUSTI, BASHH, CDC:
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins 1 g IM or IV every 24 hours OR
CefotaximeCefotaximeSemisynthetic broad-spectrum cephalosporin.Cephalosporins 1 g IV every 8 hours OR
Spectinomycin 2 g IM every 12 hours
May be switched to an oral regimen following 24–48 hours of substantial clinical improvement
All individuals who had sexual contact within the past 60 days with the patient should be notified for evaluation and treatment.
Expedited partner therapy (EPT):
A prescription for cefixime 800 mg orally once is provided for sexual partners without a formal evaluation.[13]
If chlamydiaChlamydiaChlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae.Chlamydia has not been excluded, an additional prescription should be provided for doxycycline 100 mg orally twice daily for 7 days.[13]
Limited to heterosexual contacts
Depends on individual country and state regulations
Not recommended for MSM due to the high risk of:
Coexisting infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease (especially HIVHIVAnti-HIV Drugs)
Treatment failure (especially for pharyngeal infection)
Prevention and risk reduction[3,12,13,14]
Latex condomsCondomsA sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease.Nonhormonal Contraception are one of the most effective preventative measures.
STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs) testing every year if:
Multiple sexSexThe totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism.Gender Dysphoria partners
History of STISTISexually transmitted infections (STIs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease.Sexually Transmitted Infections (STIs)
≤ 24 years of age
Educate regarding the transmission of gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea to other mucosal surfaces.
Complications[12,14,18]
InfertilityInfertilityInfertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
Chronic pelvic painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Fetal loss
Ectopic pregnancyEctopic pregnancyEctopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. Ectopic Pregnancy
Nongonococcal pelvic inflammatory diseasePelvic inflammatory diseasePelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Gardnerella vaginalis. Pelvic Inflammatory Disease: an ascending mono- or polymicrobial infection caused by C. trachomatis (most common), Mycoplasma genitaliumMycoplasma genitaliumA species of gram-negative bacteria originally isolated from urethral specimens of patients with non-gonococcal urethritis. In primates it exists in parasitic association with ciliated epithelial cells in the genital and respiratory tracts.Mycoplasma(M. genitalium), anaerobic organisms, enteric gram-negative rods, streptococci, genital mycoplasmas, and Gardnerella vaginalisGardnerella vaginalisPolymicrobial, nonspecific vaginitis associated with positive cultures of gardnerella vaginalis and other anaerobic organisms and a decrease in lactobacilli. It remains unclear whether the initial pathogenic event is caused by the growth of anaerobes or a primary decrease in lactobacilli.Vulvovaginitis. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may have cervical discharge, vaginal bleeding, lower abdominal painAbdominal PainAcute Abdomen, and feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever. Nuclear acid amplification tests and cultures of the endocervixEndocervixUterus, Cervix, and Fallopian Tubes: Anatomy aid in diagnosis, and management is usually with empiric antibiotics.
Nongonococcal cervicitisCervicitisInflammation of the uterine cervix.Gonorrhea: other acute, infectious causes includeTrichomonasTrichomonasA genus of parasitic flagellate eukaryotes distinguished by the presence of four anterior flagella, an undulating membrane, and a trailing flagellum.Nitroimidazoles vaginalis (T. vaginalis), C. trachomatis, or M. genitalium. Chronic cervicitisCervicitisInflammation of the uterine cervix.Gonorrhea usually has a noninfectious cause, most often either mechanical or chemical irritation (e.g., tampon, diaphragmDiaphragmThe diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force.Diaphragm: Anatomy, or latex). PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may have vaginal discharge, bleeding, and an erythematous, friable cervixCervixThe uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium.Uterus, Cervix, and Fallopian Tubes: Anatomy. The etiology can be diagnosed by nuclear acid amplification tests: Gram stains and cultures are not as sensitive. Management involves antibiotics for the causative organism.
Nongonococcal urethritisUrethritisInflammation involving the urethra. Similar to cystitis, clinical symptoms range from vague discomfort to painful urination (dysuria), urethral discharge, or both.Urinary Tract Infections (UTIs) in men: Gonococcal urethritisUrethritisInflammation involving the urethra. Similar to cystitis, clinical symptoms range from vague discomfort to painful urination (dysuria), urethral discharge, or both.Urinary Tract Infections (UTIs) (GU) is usually more severe than nongonococcal urethritisUrethritisInflammation involving the urethra. Similar to cystitis, clinical symptoms range from vague discomfort to painful urination (dysuria), urethral discharge, or both.Urinary Tract Infections (UTIs), including those caused by C. trachomatis and M. genitalium. However, most cases of urethritisUrethritisInflammation involving the urethra. Similar to cystitis, clinical symptoms range from vague discomfort to painful urination (dysuria), urethral discharge, or both.Urinary Tract Infections (UTIs) in the United States are caused by neither gonorrheaGonorrheaGonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea nor chlamydiaChlamydiaChlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae.Chlamydia. Diagnosis of GU is by gram stainingGram stainingBacteriology and nuclear acid amplification tests. Other possible pathogens, which can be differentiated by specific laboratory testing, include Neisseria meningitidisNeisseria meningitidisA species of gram-negative, aerobic bacteria. It is a commensal and pathogen only of humans, and can be carried asymptomatically in the nasopharynx. When found in cerebrospinal fluid it is the causative agent of cerebrospinal meningitis. It is also found in venereal discharges and blood. There are at least 13 serogroups based on antigenic differences in the capsular polysaccharides; the ones causing most meningitis infections being a, b, c, y, and w-135. Each serogroup can be further classified by serotype, serosubtype, and immunotype.Neisseria, T. vaginalis, HSVHSVHerpes simplex virus (HSV) is a double-stranded DNA virus belonging to the family Herpesviridae. Herpes simplex virus commonly causes recurrent infections involving the skin and mucosal surfaces, including the mouth, lips, eyes, and genitals.Herpes Simplex Virus 1 and 2, and syphilisSyphilisSyphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis.
EpididymitisEpididymitisEpididymitis and orchitis are characterized by acute inflammation of the epididymis and the testicle, respectively, due to viral or bacterial infections. Patients typically present with gradually worsening testicular pain and scrotal swelling along with systemic symptoms such as fever, depending on severity. Epididymitis and Orchitis:Acute epididymitisAcute EpididymitisEpididymitis and Orchitis is usually infectious. The most common organisms responsible for acute epididymitisAcute EpididymitisEpididymitis and Orchitis in men < 35 years of age are N. gonorrhoeaeN. gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseria and C. trachomatis. Coliform (e.g.,Escherichia coliEscherichia coliThe gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli) and PseudomonasPseudomonasPseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonasspecies are more frequent in older men. Viral and mycotic causes of epididymitisEpididymitisEpididymitis and orchitis are characterized by acute inflammation of the epididymis and the testicle, respectively, due to viral or bacterial infections. Patients typically present with gradually worsening testicular pain and scrotal swelling along with systemic symptoms such as fever, depending on severity. Epididymitis and Orchitis are rare. Nuclear acid amplification tests and cultures should be performed for diagnosis. Management depends on the etiology but can include antibiotics, scrotal elevation, ice packs, and analgesics.
Urinary tractUrinary tractThe urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra.Urinary Tract: Anatomy infection: an infection (usually due to bacteriaBacteriaBacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology) of the urinary system. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may develop urinary frequency, urgency, and/or suprapubic painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways. Urinary tractUrinary tractThe urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra.Urinary Tract: AnatomyinfectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease usually do not have vaginal discharge, but may have feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever and flank painFlank painPain emanating from below the ribs and above the ilium.Renal Cell Carcinoma if the kidneysKidneysThe kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine.Kidneys: Anatomy are affected. Nuclear acid amplification tests, microscopic examination, and urine specimen cultures help to diagnose the disease. Management includes appropriate antibiotic coverage for the causative organism.
ConjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis: Acute conjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis usually has a viral etiology, but bacterial causes include Staphylococcus aureusStaphylococcus aureusPotentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications.Brain Abscess, StreptococcusStreptococcusStreptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci.Streptococcus pneumoniae, HaemophilusHaemophilusHaemophilus is a genus of Gram-negative coccobacilli, all of whose strains require at least 1 of 2 factors for growth (factor V [NAD] and factor X [heme]); therefore, it is most often isolated on chocolate agar, which can supply both factors. The pathogenic species are H. influenzae and H. ducreyi.Haemophilus, and C. trachomatis. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may experience eye irritation, hyperemia, and discharge. The diagnosis of conjunctivitisConjunctivitisConjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis is clinical. Management is usually empirical with topical and/or systemic antibiotics.
Billing and Coding
Diagnosis Codes:
These codes are used to diagnose infection with Neisseria gonorrhoeaeNeisseria gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseria. The codes are specific to the site of infection, such as the lower genitourinary tract or the pharynxPharynxThe pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx: Anatomy.
Coding System
Code
Description
ICD-10-CM
A54.00
Gonococcal infection of lower genitourinary tract, unspecified
ICD-10-CM
A54.5
Gonococcal pharyngitisPharyngitisPharyngitis is an inflammation of the back of the throat (pharynx). Pharyngitis is usually caused by an upper respiratory tract infection, which is viral in most cases. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, and hoarseness. Pharyngitis
Evaluation & Workup:
This code is for a Nucleic Acid AmplificationNucleic acid amplificationLaboratory techniques that involve the in-vitro synthesis of many copies of DNA or RNA from one original template.Septic Arthritis Test (NAAT), which is the most sensitive and recommended test for detecting N. gonorrhoeaeN. gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseria from urine, urethral, or cervical samples.
Coding System
Code
Description
CPT
87591
Infectious agent detection by nucleic acid (DNADNAA deoxyribonucleotide polymer that is the primary genetic material of all cells. Eukaryotic and prokaryotic organisms normally contain DNA in a double-stranded state, yet several important biological processes transiently involve single-stranded regions. DNA, which consists of a polysugar-phosphate backbone possessing projections of purines (adenine and guanine) and pyrimidines (thymine and cytosine), forms a double helix that is held together by hydrogen bonds between these purines and pyrimidines (adenine to thymine and guanine to cytosine).DNA Types and Structure or RNARNAA polynucleotide consisting essentially of chains with a repeating backbone of phosphate and ribose units to which nitrogenous bases are attached. RNA is unique among biological macromolecules in that it can encode genetic information, serve as an abundant structural component of cells, and also possesses catalytic activity.RNA Types and Structure); Neisseria gonorrhoeaeNeisseria gonorrhoeaeA species of gram-negative, aerobic bacteria primarily found in purulent venereal discharges. It is the causative agent of gonorrhea.Neisseria, amplified probeProbeA device placed on the patient’s body to visualize a targetUltrasound (Sonography) technique
Medications:
This code is for ceftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins, which is given as a single intramuscular injection and is the recommended first-line treatment for uncomplicated gonococcal infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease.
Coding System
Code
Description
RxNorm
2240
CeftriaxoneCeftriaxoneA broad-spectrum cephalosporin antibiotic and cefotaxime derivative with a very long half-life and high penetrability to meninges, eyes and inner ears.Cephalosporins (ingredient)
References
Riedel, S., Hobden, J.A. (2019). In Riedel, S, Morse, S.A., Mietzner, T., Miller, S. (Eds.), Jawetz, Melnick, & Adelberg’s Medical Microbiology (28th ed, pp. 295-301).
Ram, S., Rice, P.A. (2018). In Jameson, J.L., et al. (Ed.), Harrison’s Principles of Internal Medicine (20th ed. Vol 1, pp. 1122-1129).
Cyr, S. S. (2020). Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR. Morbidity and Mortality Weekly Report, 69. Retrieved on January 29, 2021, fromhttps://www.cdc.gov/nndss/
Lovett, A., Duncan, J. A. (2019). Human immune responses and the natural history of Neisseria gonorrhoeae infection. Frontiers in Immunology, 9. https://doi.org/10.3389/fimmu.2018.03187
World Health Organization. (2021). Vaginal discharge syndrome. Chapter 8 of Guidelines for the management of symptomatic sexually transmitted infections. Retrieved July 18, 2022, from https://www.who.int/publications/i/item/9789240024168
Fifer, H., Saunders, J., Soni, S., et. al. (2020). British Association for Sexual Health and HIV (2018). UK national guideline for the management of infection with Neisseria gonorrhoeae. Int J STD AIDS 31(1):4–15. doi.org/10.1177/0956462419886775
Unemo, M., Ross, J.D.C., Serwin, A.B., et al. International Union against Sexually Transmitted Infections (IUSTI). (2020). 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS. doi.org/10.1177/0956462420949126
Centers for Disease Control and Prevention. (2021). Guidance on the use of expedited partner therapy in the treatment of gonorrhea. Retrieved July 22, 2022, from https://www.cdc.gov/std/ept/gc-guidance.htm