[MUSIC] Hello everyone, in this section I will be discussing gonorrhea and its clinical presentations. The learning objectives are to identify the elements of an initial assessment for a patient presenting with symptoms or risk factors of Gonorrhea infection. And to describe the current state of drug resistance among gonorrhea infections in the United States. So the symptoms of Gonorrhea are many and can occur at the site of inoculation. For example in men, infections of the throat may present as exudative pharyngitis, but this is rare. Symptoms of pharyngeal infection may include pharyngitis tonsillitis fever and maybe even cervical adenitis. Among men infections of the penis or urethra can present as purulent or mucopurulent discharge with or without dysuria, which is pain on urination. The discharge can be clear or cloudy also. Anorectal infections can present with anal irritation, painful defecation, constipation, scant rectal bleeding, painless mucopurulent discharge, anal itching, and tenesmus, which is the feeling that you have to move your bowels, but nothing comes out. Now among women infections of the throat can be the same. Urethra infections can present with pain with urination, urinary urgency or frequency, which is almost like a urinary tract infection. Infections of the cervix can present with vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, and pain during sex which is called dyspareunia. Anorectal infections can be the same presentation as among men. But remember that the probability of asymptomatic sexually transmitted diseases, and in this case we're talking about gonorrhea which is seen on the left hand side, is high. In other words most infections, whether it be of the urethra, the cervix, the rectum, the pharynx, are asymptomatic. So let's move on to some clinical presentations. Here we see pharyngeal gonorrhea and on the left hand side you can see exudate. Whereas on the right hand side there's some inflammation. But remember the throat can look completely normal and it will still have gonococcal infection. Here's male urethritis showing on the left hand side purulent discharge and on the right hand side mucopurulent discharge. Clinical findings of the female urethra are shown in a diagram where it is on the left, but on the right hand side, you can see inflammation of the urethra and a little discharge. Here our presentations of gonococcal cervicitis and on the top left, you'll see a normal cervix and that can be infected with gonorrhea. Moving to the upper right, you'll see some inflammation which is called ectopy. On the lower left you see cervical discharge covering the cervix. In the middle, slight amount of discharge. And on the right lower hand side you can see discharge cascading from within the cervix. Now some uncommon complications among males are Illustrated here. We see inguinal lymphadenitis, penile edema, periurethral abscess, which sometimes can form fistulas. Accessory gland infections, which is the Tyson gland Illustrated on the left lower picture, and this can cause balanitis, urethral stricture, and questionable proststitis. But the bottom line is that if left untreated it can cause some uncomplicated but significant complications. Women can also have accessory gland infections. Commonly the skin glands which are shown diagrammatically on the right diagram, and it's on the very top next to the clitoris and between the clitoris and the urethral meatus. Also the Bartholin's glands which are toward the lower section of the vaginal opening. Now, here's some illustrations of what this can look like, some clinical presentations. On the lower left-hand side You'll see a Bartholin gland abscess. Middle also Bartholin gland abscess. And on the right, you'll see a Skene's abscess. As with men, complications in women can occur, and the most severe is pelvic inflammatory disease in which the gonococcal infection ascends into the uterus and then down the fallopian tubes. Which can result in In scarring and consequently chronic pelvic pain or infertility or pelvic inflammatory disease. And here's a diagram of PID causing a lot of inflammation of, in this section, the right fallopian tube. And you can see that this can, if left to progress, can actually rupture and there's a significant mortality associated with that. Now the diagnosis of pelvic inflammatory disease is not so easy and we don't have a gold standard. So here's what the CDC suggests we as clinicians look for, for example on bimanual examinations cervical motion tenderness or uterine tenderness or adnexal tenderness. As you go down the list here, you can see there's more elaborate criteria. And then specific criteria such as endometrial biopsy all the way to laparoscopic evaluation to look for abnormalities consistent with PID. But the bottom line is pelvic inflammatory disease is hard to diagnose. So in summary PID is an ascending infection to the endometrium or fallopian tubes, and again pelvic inflammatory disease may present with symptoms or unfortunately, it can be silent or asymptomatic. Meaning that there's inflammation that slowly progresses, but the woman doesn't have any symptoms. And that also can cause this sequelae of chronic pelvic pain tubal infertility and/or ectopic pregnancy. As we said, symptoms may be lower abdominal pain, discharge, pain with intercourse, intramenstrual bleeding and fever. On examination a clinician on bimanual may find uterine adnexal or cervical motion tenderness, and may see evidence of cervicitis. As we discussed, the clinical diagnosis is imprecise, but the long-term sequelae, chronic pelvic pain, tubal infertility, and ectopic pregnancy are significant. Here are some pathological examples of the sequela. You can see on the top left a hysterectomy with bilateral tubal inflammation. On the upper right is a laparoscopic look at adhesions around the ovary. On the bottom left are fibrous formations, which is associated with fitzu curtis syndrome. In other words adhesion that can be seen on laparoscopy between the liver and the abdominal cavity, which is a consequence of ascending infection that dumps out of the Fallopian tubes into the abdominal cavity. And then on the bottom right hand corner is an example of a tubo-ovarian abscess on CT scan. So let me move to a hot topic which is the historical trends in drug resistance. This is a slide from the CDC which illustrates how gonorrhea has become resistant to whatever antibiotic we've thrown at it. In the 1930s we use sulfonamide, became resistant. In the 40s and we saw increasing resistance to sulfonamides and penicillin then became the drug of choice. In the 1980s, due to increasing resistance to penicillin and tetracycline, these were no longer recommended. In the 90s we were using fluoroquinolones, but by 2007 resistance became more and more prominent. So we had to move to cephalosporins and as we move now through 2012 to the present were seeing Cefixime which is an oral cephalosporin is no longer recommended as first-line treatment. Leaving us with injectable ceftriaxone. And we monitor this very closely so that ceftriaxone plus azithromycin is the only recommended treatment for gonorrhea as per the 2015 CDC STD treatment guidelines. So what does the CDC say? They tell us to take a sexual history to help us know which STDs to test our patients for and at which anatomical sites. So where did you have sex, we have to go to that place and test. So you want to ask what sites were exposed. For example, did you have oral, anal receptive, cervical, penile insertive sex? So that we know what anatomical site could be infected and what site needs to be tested. Adhere to the CDC recommendations by always treating gonorrhea promptly and with a combination of injectable ceftriaxone and oral azithromysin as per the 2015 treatment guidelines. And this includes post-treatment testing to confirm cure when it's recommended. So the CDC screening recommendations include all sexually active women who are younger than 25 years of age, older women with risk factors, such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. In sexually active men who have sex with men should be screened at anatomic sites of possible exposure at least annually, and honestly if they're on pre-exposure prophylaxis for HIV, it should be every 3 months if there's risk. What tests in women? Well right now nucleic acid amplification tests are the recommended test method. A self or clinician-collected vaginal swab is recommended, and self-collected vaginal swab specimens are an option for screening women when a pelvic exam is not otherwise indicated. An endocervical swab is acceptable again when a pelvic exam is indicated. A first-catch urine specimen is acceptable but might detect up to 10% fewer infections when compared with vaginal or endocervical swabs. And finally an endocervical swab specimen for neisseria gonorrhoeae culture should be obtained and evaluated for antibiotic susceptibility in patients that have received CDC-recommended antimicrobial regimens that are not first line. What tests we do in men? Currently again nucleic acid amplification tests are the recommended test method. A first-catch urine is the recommended sample, and it's equivalent to your urethral swab in detecting infection. A urethral swab specimen for neisseria gonorrhoeae culture should be obtained if the patient has received antibiotic therapy, that is not first-line reommended, or has persistent symptoms after a positive nucleic acid amplification test. And did not engage in sexual activity after treatment. What about extragenital testing, specifically from the rectum and the throat? Nucleic acid amplification test are the recommended test method for both rectal and oropharyngeal specimens. Laboratories must be in compliance with CLIA for test modifications since these tests have not been cleared by the FDA for these specimen types but FDA clearance, maybe so sooner than we think. Commensal neisseria species commonly found in the oropharynx might cause false positive reactions in some NAATs and further testing might be required for accuracy. A rectal or oropharyngeal swab specimen for GC culture should be obtained and evaluated for antibiotic susceptibility in patients who have received the recommended antimicrobial regimen as treatment. Had a subsequent positive gonorrhea test result, that means positive NAATs seven days or more after treatment, and did not engage in sexual activity after treatment. So what else does the CDC say? Evaluate and treat all patients' sex partners from the previous 60 days. Expedited partner therapy in which the infected individual is given pill packs to distribute to their sex partners, should be considered for heterosexual p artners unable or unwilling to access care. And many states allow this, you have to check with the state in which you're practicing to see what the rules and regulations are. Obtained cultures to test for decreased susceptibility from any patient with suspected or documented gonorrhea treatment failures. So we have to rely on the culture in that case. Report failures of infection to respond to treatment with CDC recommended therapies to your local Health Departments. This is the law. Visit CDC website for more current information on gonorrhea treatment. And I will say that the 2020 treatment guidelines are in review, so keep tuned. [MUSIC]
