Gonococcal Urethritis

Background

• Gonococcal urethritis (GU) is a sexually transmitted infection caused by Neisseria gonorrhoeae.
• GU in males is usually symptomatic and characterized by mucopurulent urethral discharge, dysuria, and urethral erythema.
• Serious complications such as disseminated gonococcal infection may arise when the infection is untreated.
• N. gonorrhoeae is capable of rapidly developing antibiotic resistance and extensively drug-resistant strains are emerging worldwide.

Evaluation

• Diagnosis of urethritis in men, of any cause, is based on any of the following (Strong recommendation).
  • Gram stain of urethral secretions with ≥ 2 white blood cells (WBCs) per oil immersion field (preferred method)
  • observation of mucopurulent or purulent discharge on exam
  • positive leukocyte esterase test on first-void urine
  • microscopic examination of first-void urine sediment demonstrating ≥ 10 WBCs per high power field
• For both suspected symptomatic infection and screening for asymptomatic infection, nucleic acid amplification tests (NAATs) are recommended for microbiologic diagnosis.
• In men with symptomatic urethritis, a Gram stain showing polymorphonuclear cells and gram-negative diplococci is highly sensitive and specific for diagnosis of Neisseria gonorrhoeae as the cause of urethritis.
• A first-void urine sample is the preferred specimen type for NAAT in men.
• Culture is reserved for cases of treatment failure when antibiotic susceptibility testing is needed or in cases of child sexual assault.
• Patients with gonorrhea infection should be tested for other sexually transmitted infections including Chlamydia trachomatis, syphilis, and HIV.

Management

• Due to the high rates of Chlamydia trachomatis coinfection, concurrent treatment for both gonorrhea and chlamydia is recommended if chlamydia infection has not been ruled out.
• First-line recommendation from Centers for Disease Control and Prevention (CDC) for adults with uncomplicated gonococcal infection consists of single dose of ceftriaxone:
  • 500 mg intramuscularly in a single dose for patients weighing < 150 kg (300 lbs)
  • 1 g intramuscularly in a single dose for patients weighing ≥ 150 kg (300 lbs)
  • if chlamydial coinfection has not been excluded, additional treatment recommended:
    • for nonpregnant patients, give doxycycline 100 mg orally twice daily for 7 days
    • for pregnant patients, give azithromycin 1 g orally in a single dose
• With the emergence of drug-resistant gonococci:
  • CDC no longer recommends oral cephalosporins as first line therapy for the treatment of gonorrhea and no longer recommends empiric azithromycin if chlamydial coinfection has been ruled out.
  • European International Union against Sexually Transmitted Infections/World Health Organization (IUSTI/WHO) recommends higher-dose therapy with ceftriaxone 1 g intramuscularly PLUS azithromycin 2 g orally in a single dose.
  • alternatives to cephalosporins include spectinomycin, gentamicin, and higher-dose azithromycin but each has limitations
• Counsel patients to avoid sexual activity until ≥ 7 days after treatment is complete and both patient and partner no longer have symptoms.
• Treatment recommendations do not differ for patients with HIV.
• Patients should be instructed to refer sex partners (persons having sexual contact with the infected patient < 60 days preceding onset of symptoms or gonorrhea diagnosis) for evaluation and treatment.
• A test-of-cure is not routinely recommended by the CDC for patients who are treated with any of the recommended or alternative regimens, though it is recommended by IUSTI/WHO to identify persistent or drug-resistant infection.
• All persons treated for gonorrhea should be retested at 3 months due to high rates of reinfection; if the patient does not return in 3 months, retesting should occur when the patient next visits the office, if within 12 months.