Gonorrhoea Update

1. Scientific PresentationScientific Presentation
on on
Gonorrhoea Gonorrhoea
Speaker:Speaker:
Dr. Md. Shahidul IslamDr. Md. Shahidul Islam
Assistant Professor of Dermatology & VD, Assistant Professor of Dermatology & VD,
CBMC’BCBMC’B

Chairperson:Chairperson:
Professor. Hasibur RahmanProfessor. Hasibur Rahman
Head of the Department of Dermatology & VD, CBMC’BHead of the Department of Dermatology & VD, CBMC’B

2. IntroductionIntroduction
Gonorrhea has affected humans for centuries and remains common. Gonorrhea has affected humans for centuries and remains common.
Worldwide, an estimated 106.1 million cases occur annually. Worldwide, an estimated 106.1 million cases occur annually.
Significant public health problems are now-a-days occurring in Significant public health problems are now-a-days occurring in
BangladeshBangladesh
Increasing proportion of gonococcal infections caused by resistant Increasing proportion of gonococcal infections caused by resistant
organismsorganisms
Gono  seeds, rhoea  flow.

So gonorrhoea means abnormal flow of semen

3. HistoryHistory
Neisseria gonorrhoeaeNeisseria gonorrhoeae described by Albert described by Albert
Neisser in 1879Neisser in 1879
Observed in smears of purulent exudates of Observed in smears of purulent exudates of
urethritis, cervicitis, opthalmia neonatorumurethritis, cervicitis, opthalmia neonatorum
Thayer Martin medium enhanced isolation of Thayer Martin medium enhanced isolation of
gonococcus in 1960gonococcus in 1960

4. Risk FactorsRisk Factors
Multiple or new sex partnersMultiple or new sex partners
Inconsistent condom use Inconsistent condom use
Urban residence Urban residence
Adolescents, females particularlyAdolescents, females particularly
Lower socio-economic statusLower socio-economic status
Drug addictsDrug addicts
Exchange of sex for drugs or money Exchange of sex for drugs or money

5. TransmissionTransmission
Efficiently transmitted by sexual contactEfficiently transmitted by sexual contact
–Male to female via semen Male to female via semen
–Female to male urethraFemale to male urethra
–Anal intercourse Anal intercourse
–Oro-genital sex (pharyngeal infection)Oro-genital sex (pharyngeal infection)
–Peri-natal transmission (mother to infant) Peri-natal transmission (mother to infant)
Gonorrhea associated with increased Gonorrhea associated with increased
transmission and susceptibility to HIV infectiontransmission and susceptibility to HIV infection

6. PATHOGENESIS PATHOGENESIS :
Gonococci  get attached by Pilli  to columnar epithelial cells
(urethra )

Produce marked polymorphonuclear response in the submucosa
(Anterior urethra )

Purulent exudates fill up the anterior urethra (male )

Inflammatory process extends to the posterior urethra

Granular tissue formed in mucosa and submucosa

Eventual fibrosis and scarring

 Stricture urethra ( complication )

7. Urethritis is uncommon in females
because of small urethra
Both transitional and stratified
squamous epithelium are highly
resistant to the organism, therefore
in adult vaginal canal is not
affected

8. MicrobiologyMicrobiology
Etiologic agent: Etiologic agent: Neisseria Neisseria
gonorrhoeae gonorrhoeae
Gram-negative intracellular Gram-negative intracellular
diplococcusdiplococcus
Infects mucus-secreting epithelial cellsInfects mucus-secreting epithelial cells

9. Gonorrhea: Gram’s Stain Gonorrhea: Gram’s Stain
of of
Urethral DischargeUrethral Discharge

10. Genital Infection in MenGenital Infection in Men
Urethritis – Inflammation of urethraUrethritis – Inflammation of urethra
Epididymitis – Inflammation of the Epididymitis – Inflammation of the
epididymisepididymis

11. Male UrethritisMale Urethritis
SymptomsSymptoms
–Typically purulent or mucopurulent urethral Typically purulent or mucopurulent urethral
discharge discharge
–Often accompanied by dysuriaOften accompanied by dysuria
–Discharge may be clear or cloudyDischarge may be clear or cloudy
Asymptomatic in 10% of casesAsymptomatic in 10% of cases
Incubation period: usually 1-14 days for Incubation period: usually 1-14 days for
symptomatic disease, but may be longersymptomatic disease, but may be longer

12. Gonococcal Urethritis: Gonococcal Urethritis:
Purulent DischargePurulent Discharge

19. EpididymitisEpididymitis
Symptoms: unilateral testicular pain and Symptoms: unilateral testicular pain and
swellingswelling
Infrequent, but most common local Infrequent, but most common local
complication in malescomplication in males
Usually associated with overt or Usually associated with overt or
subclinical urethritissubclinical urethritis

20. Swollen or Tender Swollen or Tender
Testicles (Epididymitis)Testicles (Epididymitis)

22. LOCAL COMPLICATIONS in Male
Urethral strictureUrethral stricture
Periurethral abscessPeriurethral abscess
ProstatitisProstatitis
Prostatic abscessProstatic abscess
Seminal vasiculitis Seminal vasiculitis
EpidedymitisEpidedymitis
OrchitisOrchitis

23. Genital Infection in WomenGenital Infection in Women
Most infections are asymptomaticMost infections are asymptomatic
Cervicitis – inflammation of the cervixCervicitis – inflammation of the cervix
Urethritis – inflammation of the urethraUrethritis – inflammation of the urethra

24. CervicitisCervicitis
Non-specific symptoms: abnormal vaginal discharge, Non-specific symptoms: abnormal vaginal discharge,
intermenstrual bleeding, dysuria, lower abdominal pain, intermenstrual bleeding, dysuria, lower abdominal pain,
or dyspareuniaor dyspareunia
Clinical findings: mucopurulent or purulent cervical Clinical findings: mucopurulent or purulent cervical
discharge, easily induced cervical bleedingdischarge, easily induced cervical bleeding
50% of women with clinical cervicitis have no symptoms50% of women with clinical cervicitis have no symptoms
Incubation period unclear, but symptoms may occur Incubation period unclear, but symptoms may occur
within 10 days of infectionwithin 10 days of infection

25. Gonococcal CervicitisGonococcal Cervicitis

26. UrethritisUrethritis
Symptoms: dysuria, however, most Symptoms: dysuria, however, most
women are asymptomaticwomen are asymptomatic
40%-60% of women with cervical 40%-60% of women with cervical
gonococcal infection may have gonococcal infection may have
urethral infectionurethral infection

27. LOCAL COMPLICATIONS
(Female)
Salpingo Oophoritis--- fallopian tube Salpingo Oophoritis--- fallopian tube
blockblock
Bartholein abscessBartholein abscess
Pelvic peritonitisPelvic peritonitis

28. Bartholin’s AbscessBartholin’s Abscess

29. Gonococcal complications in Gonococcal complications in
PregnancyPregnancy
Postpartum endometritisPostpartum endometritis
Septic abortionsSeptic abortions
Post-abortal PIDPost-abortal PID
Possible role in:Possible role in:
Gestational bleedingGestational bleeding
Preterm labor and deliveryPreterm labor and delivery
Premature rupture of membranesPremature rupture of membranes

30. Gonorrhea Infection in Gonorrhea Infection in
ChildrenChildren
Perinatal: infections of the Perinatal: infections of the
conjunctiva, pharynx, respiratory conjunctiva, pharynx, respiratory
tracttract
Older children (>1 year): considered Older children (>1 year): considered
possible evidence of sexual abusepossible evidence of sexual abuse

31. Gonococcal OphthalmiaGonococcal Ophthalmia

32. LOCAL COMPLICATIONS
BOTH SEXBOTH SEX
Proctitis (Anogenital sex)Proctitis (Anogenital sex)
Pharyngitis (Oragenital sex )Pharyngitis (Oragenital sex )
Ophthalmia neonatumOphthalmia neonatum

33. Remote / Metastatic
complications (Both sex)
Septicaemia/ Disseminated
Gonococcal Infection (DGI)
Gonococcal arthritis
Perihepatitis
Gonococcal Dermatitis

34. Disseminated Gonorrhea—Disseminated Gonorrhea—
Skin LesionSkin Lesion

35. Diagnostic MethodsDiagnostic Methods
1. 1. Gram’s stain for microscopic Gram’s stain for microscopic
examinationexamination
– P/S or urethral discharge (male) P/S or urethral discharge (male)
– Cervical swab (female)Cervical swab (female)
2. 2. Culture testsCulture tests
3. 3. OthersOthers
Polymerase chain reaction (PCR)Polymerase chain reaction (PCR)
DNA probeDNA probe
NAATsNAATs

36. Gonorrhea Diagnostic Gonorrhea Diagnostic
TestsTests
Gram stain Gram stain
(male urethra exudate)(male urethra exudate)
DNA probeDNA probe
CultureCulture
NAATs NAATs **
SensitivitySensitivity
90-95%90-95%
85-90%85-90%
80-95%80-95%
90-95%90-95%
Specificity
> 95%
> 95%
> 99%
> 98%
* Able to use URINE specimens

37. GC Gram StainGC Gram Stain
In symptomatic male urethritis:In symptomatic male urethritis:
–>95% sensitivity and specificity: reliable >95% sensitivity and specificity: reliable
to diagnose and exclude GCto diagnose and exclude GC
In cervicitis:In cervicitis:
–50-70%sensitivity, 95% specificity50-70%sensitivity, 95% specificity
Not useful in pharyngeal infectionsNot useful in pharyngeal infections
Accessory gland infection: similar to male Accessory gland infection: similar to male
urethritisurethritis
Proctitis: similar to cervicitisProctitis: similar to cervicitis

38. Specific diagnosis of infection with Specific diagnosis of infection with N. N.
gonorrhoeaegonorrhoeae can be performed by testing can be performed by testing
endocervical, vaginal, urethral (men only), or endocervical, vaginal, urethral (men only), or
urine specimens. Culture, nucleic acid urine specimens. Culture, nucleic acid
hybridization tests, and NAATs are available hybridization tests, and NAATs are available
for the detection of genitourinary infection for the detection of genitourinary infection
with with N. gonorrhoeaeN. gonorrhoeae. .
Culture and nucleic acid hybridization tests Culture and nucleic acid hybridization tests
require female endocervical or male urethral require female endocervical or male urethral
swab specimens.swab specimens.

39. • NAATs allow testing of the widest variety of
specimen types including endocervical swabs,
vaginal swabs, urethral swabs (men), and urine
(from both men and women), and they are FDA-
cleared for use .
•The sensitivity of NAATs for the detection of
N. gonorrhoeae in genital and nongenital
anatomic sites is superior to culture but varies
by NAAT type.

40. Gram Stain for GC: Gram Stain for GC:
Urethral SmearUrethral Smear
Numerous
PMNs
Gram
negative
intracellular
diplococci

41. Gram Stain for GC: Gram Stain for GC:
Cervical SmearCervical Smear
PMN with
Gram
negative
intracellular
diplococci

42. GC CultureGC Culture
Requires selective media with antibiotics to Requires selective media with antibiotics to
inhibit competing bacteria (Modified Thayer inhibit competing bacteria (Modified Thayer
Martin Media, NYC Medium) Martin Media, NYC Medium)
Sensitive to oxygen and cold temperatureSensitive to oxygen and cold temperature
Requires prompt placement in high-CO2 Requires prompt placement in high-CO2
environment (candle jar, bag and pill, CO2 environment (candle jar, bag and pill, CO2
incubator)incubator)
In cases of suspected sexual abuse, culture In cases of suspected sexual abuse, culture
is the only test accepted for legal purposesis the only test accepted for legal purposes

43. GC Culture Candle JarGC Culture Candle Jar

44. GC Culture Specimen GC Culture Specimen
Streaking Streaking
Cervical and UrethralCervical and Urethral

45. GC Culture After 24 GC Culture After 24
HoursHours

46. ManagementManagement
It is important to receive treatment for gonorrhoea quickly. It is important to receive treatment for gonorrhoea quickly.
 PPatients with gonorrhea frequently also have chlamydia, atients with gonorrhea frequently also have chlamydia,
they are treated for both diseases they are treated for both diseases
In recent years, drug resistant gonorrhea has become In recent years, drug resistant gonorrhea has become
more problematic, both in the United States and worldwidemore problematic, both in the United States and worldwide
In the summer of 2012, the CDC updated the guidelines In the summer of 2012, the CDC updated the guidelines
again - recommending that all gonorrhea cases be treated again - recommending that all gonorrhea cases be treated
with injectable, rather than oral, antibiotics.with injectable, rather than oral, antibiotics.

47. Treatment depends on the site of involvement. Treatment depends on the site of involvement.
Infections that have spread beyond the primary Infections that have spread beyond the primary
site of infection like DGI,pelvic inflammatpory site of infection like DGI,pelvic inflammatpory
diseses or epididymitis, may also require more diseses or epididymitis, may also require more
intense treatment. intense treatment.
When you are being treated for gonorrhea it is When you are being treated for gonorrhea it is
important that your sexual partners are treated important that your sexual partners are treated
as well. as well.
People who are infected with gonorrhea once are People who are infected with gonorrhea once are
likely to become infected again, so 3 months likely to become infected again, so 3 months
later for a check up is necesssary.later for a check up is necesssary.

48. Single-dose cephalosporin regimens Single-dose cephalosporin regimens
(Both sex partners)(Both sex partners)
Inj.Ceftriaxon (Ceftron) I/V or I/MInj.Ceftriaxon (Ceftron) I/V or I/M
oror
– Inj Spectinomycin 2 g Inj Spectinomycin 2 g
in a single IM dosein a single IM dose

49. Fluoroquinolones are no longer Fluoroquinolones are no longer
recommended for therapy for recommended for therapy for
gonorrhea acquired in Asia, the gonorrhea acquired in Asia, the
Pacific Islands (including Hawaii), Pacific Islands (including Hawaii),
and California. and California.

50. Pregnant women should not be Pregnant women should not be
treated with quinolones .Treat treated with quinolones .Treat
with alternate cephalosporinwith alternate cephalosporin
If cephalosporin is not If cephalosporin is not
tolerated, treat with tolerated, treat with
spectinomycin 2 g IM oncespectinomycin 2 g IM once

51. Co-treatment for Co-treatment for
ChlamydiaChlamydia
If chlamydial infection is not ruled out:
Tab.Azithromycin 1 gm (Tab.Zimax-500mg)Tab.Azithromycin 1 gm (Tab.Zimax-500mg)OrallyOrally
Once Once
oror
DoxycyclineDoxycycline(Cap.Doxacil-100 mg)(Cap.Doxacil-100 mg)
OrallyOrallyTwice a day for 7 daysTwice a day for 7 days

52. DGI TreatmentDGI Treatment
Initial IV TherapyInitial IV Therapy
Begin IV therapy for 24-48 hrs, switch to oral therapy for a Begin IV therapy for 24-48 hrs, switch to oral therapy for a
total of 1 weektotal of 1 week
Recommended regimen:Recommended regimen:
–Ceftriaxone 1g IV or IM q 24 h Ceftriaxone 1g IV or IM q 24 h
Alternative Regimens:Alternative Regimens:
–Cefotaxime 1 g IV q 8 hCefotaxime 1 g IV q 8 h
–Ceftizoxime 1 g IV q 8 hCeftizoxime 1 g IV q 8 h
–Ciprofloxacin 400 mg IV q 12 hCiprofloxacin 400 mg IV q 12 h
–Ofloxacin 400 mg IV q 12 hOfloxacin 400 mg IV q 12 h
–Levofloxacin 250 mg IV q 24 hLevofloxacin 250 mg IV q 24 h
–Spectinomycin 2 g IM q 12 hSpectinomycin 2 g IM q 12 h

53. DGI TreatmentDGI Treatment
Subsequent Oral TherapySubsequent Oral Therapy
Oral therapy for total treatment of 1 week:Oral therapy for total treatment of 1 week:
Recommended Regimes:Recommended Regimes:
–Cefixime 400 mg PO BIDCefixime 400 mg PO BID
–Ciprofloxacin 500 mg PO BIDCiprofloxacin 500 mg PO BID
–Ofloxacin 400 mg PO BIDOfloxacin 400 mg PO BID
–Levofloxacin 500 mg PO QDLevofloxacin 500 mg PO QD

54. Follow-UpFollow-Up
A test of cure is not A test of cure is not
recommended if a recommended recommended if a recommended
regimen is administered.regimen is administered.
If symptoms persist, perform If symptoms persist, perform
culture for N. gonorrhoeae.culture for N. gonorrhoeae.
–Any gonococci isolated should be Any gonococci isolated should be
tested for antimicrobial tested for antimicrobial
susceptibility. susceptibility.

55. Prevention strategies:Prevention strategies:
Health promotion, education & Health promotion, education &
counselingcounseling
Increased access to condomsIncreased access to condoms
Early detection through screening in Early detection through screening in
selected high risk populationsselected high risk populations
Effective diagnosis & treatment Effective diagnosis & treatment
Partner managementPartner management
Risk reduction counselingRisk reduction counseling

56. Home messages:Home messages:
–Gonorrhoea is usually Gonorrhoea is usually
symptomatic in males and symptomatic in males and
asymptomatic in femalesasymptomatic in females
–Untreated infections can result in Untreated infections can result in
PID, infertility, and ectopic PID, infertility, and ectopic
pregnancy in women and pregnancy in women and
epididymitis and stricture urethra epididymitis and stricture urethra
in menin men

57. It can be acquired from asymptomatic It can be acquired from asymptomatic
partner.partner.
Both sex partners need to be treated at a Both sex partners need to be treated at a
time.time.
Over diagnosis of gonorrhoea should be Over diagnosis of gonorrhoea should be
avoidedavoided
Mainly transmited by sexual contact.Mainly transmited by sexual contact.
Rarely children may be affected as result Rarely children may be affected as result
of sexual abuse.of sexual abuse.

58. All persons found to have who have All persons found to have who have
gonorrhea also should be tested for other gonorrhea also should be tested for other
STDs, including chlamydia, syphilis, and STDs, including chlamydia, syphilis, and
HIV.HIV.
A growing number of cases are being A growing number of cases are being
reported globally of an antibiotic-resistant reported globally of an antibiotic-resistant
strain known as HO41strain known as HO41
Safe sex practice and sex with legal partners Safe sex practice and sex with legal partners
can prevent gonorrhoea in our societycan prevent gonorrhoea in our society

59. AcknowledgementsAcknowledgements
Prof. Hasibur RahmanProf. Hasibur Rahman
Dr.HadiuzzamanDr.Hadiuzzaman
Dr.Nahida Islam NipaDr.Nahida Islam Nipa
Dr.Sabrina Alam MumuDr.Sabrina Alam Mumu
Dr. Atia Afrose Jecy.Dr. Atia Afrose Jecy.
Square Pharmaceuticals LimitedSquare Pharmaceuticals Limited