history, diagnosis, clinical features, management

1. BY DR. BHAGWAN DASS

2.  Gonorrhea (Greek, “flow of seed”) is attributed to Galen
(130 A.D.), who is said to have believed that urethral
exudate in males with gonorrhea was semen.
 In 1879, Neisseria gonorrhoeae was demonstrated by
Neisser in stained smears of urethral, vaginal, and
conjunctival exudates, making gonococcus 2nd identified
bacterial pathogen following discovery of Bacillus
anthracis.
 First cultured in vitro by Leistikow in 1882
 Effective antimicrobial therapy in form of sulfonamides
was first applied in 1930s.

3.  Thayer- Martin medium for culture:- 1962
 Risk of infection for a man after single episode of vaginal
intercourse with an infected woman is estimated to be 20%
and 60-80% after 4 exposure.
 Prevalence of infection in women is 50-90%.
 N. Gonorrhoeae is gram –ve, nonmotile, non-spore
forming diplococci.
 Present intracellularly in neutrophils.

4. Pathogenesis

5.  Only mucous membranes lined by columnar or cuboidal,

1.
2.

noncornified epithelial cells are susceptible to gonococcal
infection.
Steps in pathogenesis:Adherence :- initial event , N. gonorrhoeae adhere to mucosal
cells , mediated by pili, Opa, and other surface proteins.
Invasion :-Organism is then pinocytosed by epithelial cells,
which transport gonococci from mucosal surface to
subepithelial spaces.
Simultaneous with attachment of gonococci to nonciliated
epithelial cells, gonococcal LOS(endotoxin) impairs ciliary
motility and contributes to destruction of surrounding ciliary
cells.

6.  This process may promote further attachment of additional
organisms.
3. Tissue damage :-Progressive mucosal cell damage and
submucosal invasion are accompanied by a vigorous
neutrophil response, submucosal microabscess
formation, and exudation of purulent material into
lumen of the infected organ.
4. Dissemination:- ability to resist the killing activity of
antibodies and complement in normal human serum is
closely related to the ability of gonococci to cause
bacteremic illness with or without septic arthritis

7. CLINICAL MANIFESTATIONS

8. URETHRAL INFECTION IN MEN
 Acute anterior urethritis is most common in men.
 incubation period ranges from 1 to 14 days or even longer;
however, majority of men develop symptoms within 2–5
days, as was the case in 36 (82%) of 44 men with
uncomplicated gonorrhea in one of few studies in which
time of exposure could be clearly defined.
 Predominant symptoms are urethral discharge or dysuria
 initially scant and mucoid or mucopurulent in appearance,
in most males urethral exudate becomes frankly purulent
and relatively profuse within 24 hours of onset.
 Dysuria usually begins after onset of discharge.

9.  Variable degrees of
edema and erythema of
the urethral meatus
commonly accompany
gonococcal urethritis.

10. UROGENITAL INFECTION IN WOMEN
 Primary site:- endocervical
canal
 Urethral colonization :70–90% of infected
women, but is uncommon
in absence of endocervical
infection.
 Infection of Bartholin’s
gland ducts is also
common.
 IP:- variable but usually 10
days

11.  Most common symptoms
are those of most lower
genital tract infections in
women: increased vaginal
discharge, dysuria,
intermenstrual uterine
bleeding, and
menorrhagia.
 Purulent exudate
occasionally may be
expressed from urethra or
Bartholin’s gland duct.

12. RECTAL INFECTION
 Rectal mucosa is infected in 35–50% of women with
gonococcal cervicitis. Only rectum is involved in 5%
women.
 40% in homosexual men.
 Symptoms range from minimal anal pruritus, painless
mucopurulent discharge (often manifested only by a
coating of stools with exudate), or scant rectal bleeding, to
symptoms of overt proctitis, including severe rectal pain,
tenesmus, and constipation.

13.  External inspection :- only occasionally shows erythema
and abnormal discharge
 On Anoscopy:- mucoid or purulent exudate ( localized to
anal crypts), erythema, edema, friability, or other
inflammatory mucosal changes.

14. PHARYNGEAL INFECTION
 3–7% of heterosexual men, 10–20% of heterosexual women,
and 10–25% of homosexually active men.
 acute pharyngitis or tonsillitis and occasionally is
associated with fever or cervical lymphadenopathy.
 >90% are asymptomatic

15. INFECTION OF OTHER SITES
 Gonococcal conjunctivitis is rare.
 Primary cutaneous infection i.e. localized ulcer of genitals,
perineum, proximal lower extremities, or finger is rare.

16. COMPLICATED GONOCOCCAL
INFECTIONS
 LOCAL COMPLICATIONS IN MEN: Epididymitis:-present in upto 20%. most common causes of acute
epididymitis in patients under age 35 are C. trachomatis, N.
gonorrhoeae
 Penile lymphangitis:- penile edema (“bull-headed clap”)
 Post-inflammatory urethral strictures
 Periurethral abscesses
 LOCAL COMPLICATIONS IN WOMEN: PID:- most common of all complications of gonorrhea, as well
as the most important in terms of public-health impact
 10–20% of those with acute gonococcal infection.

17.  Bartholin’s gland abscess
 SYSTEMIC COMPLICATIONS:
 DISSEMINATED GONOCOCCAL INFECTION:- More
common in female.
 DGI, usually manifested by acute arthritis-dermatitis
syndrome, is most common systemic complication of
acute gonorrhea.
 “classic” skin lesion of gonococcal dermatitis:- a tender,
necrotic pustule on an erythematous base,
 may present as, macules, papules, pustules, petechiae,
bullae, or ecchymoses

18.  Located on distal portions of extremities and <30.
 Gonococcal endocarditis and meningitis:- Occurs in 1–3% of
patients with DGI.

19. LABORATORY DIAGNOSIS
 Gram’s stain:- Microscopic
examination of stained smears
shows gram –ve diplococci in
PMN are seen.
 Culture:- antibiotic-containing
selective media (e.g., modified
Thayer- Martin medium) have
diagnostic sensitivities of 80–
95% for promptly incubated
specimens, depending in part on
anatomic site being cultured.
 Small pinpoint colonies can be
seen.
 90% within 12 hrs and 100%
within 6 hrs of sample collection

20.  Oxidase reaction:- aids to identify gonococci from mixed




culture
A drop of tetra methyl-p-phenylene diamine hydrochloride
is poured over suspected colonies, which turn pink and
then dark blue
Nonculture diagnostic techniques:Nucleic acid amplification tests (NAATs):- polymerase
chain reaction (PCR), transcription-mediated
amplification (TMA), and other nucleic acid amplification
technologies.
More sensitive than culture for gonorrhea diagnosis and
specificities are nearly as high as for culture.

21.  Immunologic or biochemical detection of gonococcal
antigens or metabolic products, including surface proteins,
endotoxin and oxidase or other enzymes also has been
investigated in past but currently seem less promising than
nucleic acid detection.
 Fluorescein-conjugated antibodies detection give positive
results 24 hours before conventional culture technique.

22. SEROLOGICAL DIAGNOSIS
 complement fixation, immunoprecipitation, bacterial lysis,
immunofluorescence, hemagglutination, latex
agglutination, enzyme-linked immunoabsorbance, and
other techniques.
 sensitivities of about 70% and specificities of about 80%.
 Rapid carbohydrate utilization test(RCUT):-used to detect
β lactamase production by Neisseria species.
 Detected by change in colour of phenol red pH indicator
from red to yellow.

23. Treatment
Uncomplicated Gonococcal
infection of cervix, urethra
and rectum
 Single dose of Tab. cefixime
400mg, Inj. Ceftriaxone 125
mg IM, tab. Ciprofloxacin
500mg, tab. Ofloxacin 400mg,
or tab. Levofloxacin 250mg
PLUS
 If chlamydial infection is not
ruled out- tab. Azithromycin 1
g single dose or tab.
Doxycyclin 100mg BID x
7days.
Uncomplicated Gonococcal
infection of pharynx
 Single dose of Inj. Ceftriaxone
125 mg IM, or tab.
Ciprofloxacin 500mg
PLUS
 If chlamydial infection is not
ruled out- tab. Azithromycin
1 g single dose or tab.
Doxycyclin 100mg BID x
7days

24. Disseminated gonococcal
infection (DGI)_
 Inj. Ceftriaxone 1 g IM or IV daily
Alternative regimens
 Inj. Cefotaxime 1 g IV 8 hourly, Inj.
Ceftizoxime 1 g IV 8 hourly, Inj.
Ciprofloxacin 400 mg IV BD, Inj.
Ofloxacin 400mg IV BD, Inj.
Levofloxacin 250mg IV daily OR
Inj. Spectinomycin 2 g IM BD
 All of the preceding regimens
should be continued for 24-48 hrs
after improvement begins, at
which time therapy may be
switched to one of the following
regimens to complete at least 1
week of therapy
 Tab. Cefixime 400mg BD, tab.
Ciprofloxacin 500mg BD,
ofloxacin 400mg BD OR tab.
Levofloxacin 500mg OD
Gonococcal conjuctivitis:Inj. Ceftriaxone 1 g IM single dose
 Gonococcal meningitis:- Inj.
Ceftriaxone 1-2 g IV every 12 hrs
x 10-14 days.
 Gonococcal endocarditis:- Inj.
Ceftriaxone 1-2 g IV every 12 hrs
for at least 4 weeks
 Ophthalmia neonatorum:Inj. Ceftriaxone 25-50 mg/kg
IV/IM single dose( not more
than 125 mg)


25.  Management of Sex partners:- all sex partners of patient
who have N. gonorroeae infection should be evaluate and
treated for both N. gonorroeae and C. trachomatis if their
last sexual contact with patient was within 60 days before
onset of symptoms or diagnosis.
 Follow up:- Treated patients with CDC regimen need not
follow up to confirm their cure but the patient with
persistent symptoms may be tested for antimicrobial
susceptibility and other cause and tested accordingly.

26. Flowchart for management of urethral discharge(NACO 2007)
Syndrome:- urethral discharge in man
History of:-Urethral discharge
•Pain or burning while passing urine, increased frequency of urination
•Sxual exposure to high risk practices including oro-genital sex
Examination:•Look for urethral meatus for redness and swelling
•If urethral discharge is not seen, then gently masage the urethra from ventral part
of penis towards meatus and thick, creamy greenish-yellow or mucoid discharge
Lab investigations:•Gram stain examination of urethral smear will show G –ve intracellular diplococci in
case of gonorrhoea
•In non gonocacal urethritis more than 5 PMN cells per oil immersion field in
urethral smear or >10 PMN cells/high power field in the sediment of first void urine
are observed.

27. TREATMENT
Dual infection is common, t/t should cover all the 3 organism
Regimen for uncomplicated gonorrhoea + chlamydia
•Tab. Cefixime 400 mg stat + Tab. Azithromycin 1 g stat, and advise client to return
after 7 days.
When the symptoms persist or recur in patient or partner then
•Tab secnidazole 2 g stat
SYNDROME SPECIFIC GUIDELINES FOR
PARTNER MANAGEMENT
•Treat all recent partners
•Treat partners on same lines
•Advise sexual absinence durind the course of
treatment or provide condoms.
•Refer for voluntary counselling and testing for
HIV, syphilis and hepatitis B.
•Advise to return after 7 days.
FOLLOW UP AFTER 7 DAYS
•See reports of HIV, syphilis and hepatitis B
•If symptoms persist, to assess t/t failure or
reinfection
MANAGEMENT OF
PREGNANT PARTNER
•Tab. Cefixime 400 mg stat or
Inj. Ceftriaxone 125 mg IM
stat
PLUS
•Tab. Erythromycin 500 mg
QID x 7 days or Cap.
Amoxicillin 500 mg TDS x 7
days.

28. Management of vaginal discharge syndrome
(NACO 2007)
History :- menstrual history to rule out pregnancy
•Nature and type of discharge(amount, smell, consistency)
•Genital itching
•Burning micturation, frequrncy of urination
•Presence of any ulcer, swelling on the vulval or inguinal region
•Genital complaints in sexual partners
•Low backache
EXAMINATION
•Per speculum examination to differntiate b/w vaginitis and cervicitis.
a) Vaginitis:• Trichomoniasis:- greenish frothy discharge
• Candidiasis:- curdy white discharge
• Bacterial vaginosis:- adherent discharge
• Mixed infection may present with atypical discharge.
b) Cervicitis:• Cervical erosion/ cervical ulcer/ mucopurulent cervical discharge.
• Bimanual pelvic examination to rule out PID
• If speculum examination is not possible or client is hesitant, treat both for
vaginitis and cervicitis

29. Lab investigations
•Wet mount microscopy of the discharge for trichomonas vaginalis and clue cells
•10% KOH for candidiasis
•Grams stain of vaginal smear for clue cells
•Grams stain of endocervical smear to detect gonococci.
TREATMENT
•VAGINITIS (TV+BV+Candida):•Tab. Fluconazole 150 mg stat or Local clotrimazole 500 mg vaginal pessary
once
•Tab. Secnidazole 2 g stat or Tab. Tinidazole 500 mg BD x 5 days .
•CERVICAL INFECTION( chlamydia and gonorrhoea ):•Tab. Cefixime 400 mg stat + Tab. Azithromycin 1 g stat
Management of pregnant women
•Vaginitis :•First trimester of pregnancy:- local t/t with
clotrimazole vaginal pessary/cream
•Local Metronitazole pessary/cream.
•Second trimester of pregnancy:- Tab.
Secnidazole 2 g stat or tab tinidazole 500 mg BD
x5 days
Partner treatment guideline
•Treat partner only if no
improvement after initial t/t or
partner is symptomatic.

30. THANK YOU