History

Fact Explanation
Purulent urethral discharge in males and vaginal discharge in females. Lipooligosaccharides expressed by gonococci are associated with the formation of leukorrhoea [1].
Dysuria. Due to urethral inflammation [2].
Lower abdominal pain and dyspareunia in the female. Due to pelvic inflammatory disease which occurs as a complication [3].
Labial pain and swelling. Bartholin's abscess occurs as a complication [4].
Scrotal pain and swelling. Due to epididymo-orchitis which occurs as a complication [5].
Suprapubic and/or perineal pain in the male. Due to prostatitis which occurs as a complication [6].
Blood stained, purulent discharge from rectum and painful defecation. Due to gonococcal infection of the rectum during anal sex [7].
Painful joints and skin rash. Occurs due to hematogenous dissemination of gonococcal infection [8].
References
  1. SCHNEIDER H., et al. Expression of paragloboside-like lipooligosaccharides may be a necessary component of gonococcal pathogenesis in men. JEM[online]. December 1991. vol. 174(6): 1601-1605 [viewed 4 April 2014] Available from DOI: 10.1084/jem.174.6.1601
  2. GILLESPIE C.W., L.E. Mamhart, M.S. LOWENS, and M.R GOLDEN. Asymptomatic urethritis is common and is associated with characteristics that suggest sexually transmitted etiology. Sex Transm Dis.[online] March 2013, vol 40(3):271-4. [viewed 8 April 2014] Available from DOI:10.1097/OLQ.0b013e31827c9e42.
  3. SIMMS I. and J.M. STEPHENSON. Pelvic inflammatory disease epidemiology: what do we know and what do we need to know? Sex Transm Infect [online].2000, 76:80-87 [viewed 5 April 2014] Available from DOI:10.1136/sti.76.2.80
  4. BLEKER O.P., D.J. SMALBRAAK and M.F. SCHUTTE. Bartholin's abscess: the role of Chlamydia trachomatis. Genitourin Med. [online]1990, 66:24-25 [viewed 5 April 2014] Available from DOI:10.1136/sti.66.1.24
  5. OCHSENDORF F.R. Sexually transmitted infections: impact on male fertility. Andrologia [online] 2008, 40: 72–75. [viewed 5 April 2014] Available from DOI: 10.1111/j.1439-0272.2007.00825.x
  6. SUTCLIFFE Siobhan, et al. Sexually Transmitted Infections, Prostatitis, Ejaculation Frequency, and the Odds of Lower Urinary Tract Symptoms. Am. J. Epidemiol. [online] November 2005, vol 162 (9): 898-906. [viewed 8 April 2014] Available from DOI: 10.1093/aje/kwi299
  7. DEHERAGODA P. Diagnosis of rectal gonorrhoea by blind anorectal swabs compared with direct vision swabs taken via a proctoscope. Br J Vener Dis[online]1977, 53:311-313 [viewed 5 April 2014] Available from DOI:10.1136/sti.53.5.311
  8. MEHRANY K., J. M. KIST, W. J. O'CONNOR and D. J. DICAUDO. Disseminated gonococcemia. International Journal of Dermatology[online] 2003, 42: 208–209. [viewed 5 April 2014] Available from DOI: 10.1046/j.1365-4362.2003.01720.x

Examination

Fact Explanation
Bead of pus at external urethral meatus in males and a thick yellowish discharge from the vagina in females. Due to the leukorrhoea associated with lipooligosaccharides expressed by gonococci [1].
Tender, boggy prostate on digital rectal examination. Due to prostatitis which occurs as a complication [2].
Tender scrotum. Due to epididymo-orchitis which occurs as a complication [3].
Inflamed cervix on speculum examination. Due to cervicitis which occurs as a complication [4].
References
  1. SCHNEIDER H., et al. Expression of paragloboside-like lipooligosaccharides may be a necessary component of gonococcal pathogenesis in men. JEM[online]. December 1991. vol. 174(6): 1601-1605 [viewed 4 April 2014] Available from DOI: 10.1084/jem.174.6.1601
  2. PEREZ-PLAZA M., R. S. PADRON, J. MAS and H. PERALTA. Semen analyses in men with asymptomatic genital gonorrhoea. International Journal of Andrology[online] 1982, 5: 6–10. [viewed 5 April 2014] Available from DOI:10.1111/j.1365-2605.1982.tb00227.x
  3. OCHSENDORF F.R. Sexually transmitted infections: impact on male fertility. Andrologia [online] 2008, 40: 72–75. [viewed 5 April 2014] Available from DOI: 10.1111/j.1439-0272.2007.00825.x
  4. MARRAZZO Jeanne M., and David H. MARTIN. Management of Women with Cervicitis. Clin Infect Dis.[online] 2007, 44 (3): 102-110. [viewed 5 April 2014] Available from DOI:10.1086/511423

Differential Diagnoses

Fact Explanation
Non gonococcal urethritis. should be considered when gram stain of urethral discharge fails to show gram negative diplococci [1].
Vaginal candidiasis. Presents as a thick curd like discharge associated with vulval soreness [2].
Bacterial vaginosis. Discharge is watery grey and a fishy odour is characteristic [3].
Reiter's disease in males. Associated with peripheral arthritis [4].
References
  1. BURSTEIN Gale R. and Jonathan M. ZENILMAN. Nongonococcal Urethritis—A New Paradigm. Clin Infect Dis.[online] 1999, 28 (1): 66-73. [viewed 5 April 2014] Available from DOI: 10.1086/514728
  2. ERDEM H., et al. Identification of yeasts in public hospital primary care patients with or without clinical vaginitis. Australian and New Zealand Journal of Obstetrics and Gynaecology[online] 2003, 43: 312–316. [viewed 5 April 2014] Available from DOI:10.1046/j.0004-8666.2003.00089.x
  3. DONDERS G.G.G., et al. Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. BJOG: An International Journal of Obstetrics & Gynaecology[online] 2002, 109: 34–43.[viewed 5 April 2014] Available from DOI: 10.1111/j.1471-0528.2002.00432.x
  4. WILLKENS R. F., et al. Reiter's syndrome. Arthritis & Rheumatism[online] 1981, 24: 844–849. [viewed 5 April 2014] Available from DOI:10.1002/art.1780240612

Investigations - for Diagnosis

Fact Explanation
Gram stain of urethral/vaginal discharge. Appearance of gram negative diplococci is characteristic [1].
Culture of discharge using Thayer-Martin meduim. This medium inhibits the growth of other organisms via the incorporation of various antibiotics [2].
Oxidase test. Neisseria gonorrhoeae is an oxidase positive organism, having the ability to produce indophenol by the oxidation of dimethyl-p-phenylenediamine and alpha naphthol [3].
References
  1. BURSTEIN Gale R. and Jonathan M. ZENILMAN. Nongonococcal Urethritis—A New Paradigm. Clin Infect Dis.[online] 1999, 28 (1): 66-73. [viewed 6 April 2014] Available from DOI: 10.1086/514728
  2. RIDDELL R. H. and A. C. BUCK. Trimethoprim as an additional selective agent in media for the isolation of N. gonorrhoeae. J Clin Pathol[online]1970, 23:481-483 [viewed 6 April 2014] Available from DOI:10.1136/jcp.23.6.481
  3. STEEL K.J. The Oxidase Reaction as a Taxonomic Tool. Microbiology [online]. June 1961, vol. 25 (2): 297-306 [viewed 7 April 2014] Available from DOI:10.1099/00221287-25-2-297

Investigations - Followup

Fact Explanation
Culture of urethral secretions 7 days after treatment. It is a 'test of cure' so that treatment failure as well as future risk of spread of gonococcal infection from the patient can be ascertained [1].
References
  1. JUDSON F. N. and F C WOLF. Rescreening for gonorrhea: an evaluation of compliance methods and results. American Journal of Public Health[online]. November 1979, Vol. 69(11):1178-1180.{viewed 7 April 2014] Available from: DOI:10.2105/AJPH.69.11.1178 http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.69.11.1178

Investigations - Screening/Staging

Fact Explanation
Screening for other sexually transmitted infections including VDRL for syphilis and ELISA for HIV. Many patients with a sexually transmitted disease(STD) are usually co-infected with other STD's so screening and treatment of these would prevent further spread of such infections [1].
References
  1. FARLEY Thomas A., Deborah A COHEN and Whitney ELKINS. Asymptomatic sexually transmitted diseases: the case for screening. Preventive Medicine[online] April 2003. Vol 36(4): 502–509 [Viewed 7 April 2014] Available from: DOI: 10.1016/S0091-7435

Management - General Measures

Fact Explanation
Advice patient to use barrier methods (eg: condoms) during sexual intercourse with high risk partners. Condoms provide a physical barrier through which infection cannot be transmitted to either partner [1].
Trace and treat sexual partners of the patient. To prevent repeat infection [2].
References
  1. HOLMES King K., Ruth LEVINE and Marcia WEAVER. Effectiveness of condoms in preventing sexually transmitted infections. Bull World Health Organ[online] June 2004 vol.82(6) [viewed 7 April 2014] Available from: DOI: 10.1590/S0042-96862004000600012
  2. CAMERON S., et al. Willingness of gynaecologists, doctors in family planning, GPs, practice nurses and pharmacists to adopt novel interventions for treating sexual partners of women with chlamydia. BJOG: An International Journal of Obstetrics & Gynaecology[online] 2007,114: 1516–1521.[viewed 7 April 2014] Available from: DOI:10.1111/j.1471-0528.2007.01506.x

Management - Specific Treatments

Fact Explanation
Ceftriaxone (intramuscular) as a single dose. Cephalosporins are the best alternatives since resistance to fluoroquinolones and penicillin is now wide spread [1].
Azithromycin single dose therapy. It is active against Chlamydia trachomatis and Treponema pallidum, both of which could cause co-infection along with Gonorrhoea[2].
References
  1. ISON C.A., at al. Which cephalosporin for gonorrhoea? Sex Transm Infect[online]. 2004, vol 80: 386-3881 [viewed 7 April 2014] Available from: DOI:10.1136/sti.2004.012757
  2. WAUGH M.A. Azithromycin in gonorrhoea.Int J STD AIDS.[online]. January 1996, vol 7(1): 2-3 [viewed 7 April 2014] Available from: DOI: 10.1258/0956462961917212