Gonorrhoea and Non gonorrhoccocal urethratis

Gonorrhoea
• Gonorrhea: An acute or chronic purulent infection of the urogenital tract often
abbreviated as GC.
o Gonorrhea is by far the commonest of so called ‘classical STIs’ known before the emergence of HIV and AIDS all over the world.
• HIV infection and AIDS may have taken over this dubious honour in developing
countries, especially in sub-Saharan Africa.
• Gonorrhea can cause sterility in both males and females and accounts for a serious decline in birth rate in some communities.

Epidemiology of Gonorrhoea
• Gonorrhea is caused by the gonococcus, a gram negative kidney – shaped diplococcus, which can only grow intracellularly.
• This type of gonococcus is known as Neisseria gonorrhoeae.
• The Gonococcus is not able to penetrate intact skin or squamous epithelium but prefers columnar epithelium such as in the urethra, endocervix, rectum and conjunctiva.
• Gonorrhoea is mainly transmitted through sexual intercourse, however, there are exceptions e.g. gonorrheal ophthalmia neonatorum is an acute inflammation of the conjunctiva of the new born, contacted during passage through the birth canal of an infected mother.

Clinical Features and Complications of Gonorrhoea
Clinical Features of Gonorrhoea
• The risk of infection after a single exposure to an infected partner ranges from 20 to 35% in male and from 60 to 90% in females
• After an incubation period of 2 – 10 days, symptoms of urethritis develop in majority of infected men
• In males
o The earliest symptom is irritation at the urinary meatus
o A burning sensation when passing urine
o A purulent yellow and profuse discharge soon follow
o Dysuria (difficult in passing urine) may be slight or very severe
o Severe dysuria is often accompanied by urgency and frequency and occasionally
terminal haematuria (blood in urine)

o In untreated cases, the discharge which was purulent and profuse gradually become scant and less purulent and may be present only in the mornings
o Some cases may recover spontaneously, but most develop one or more complications.
• In females
o About 50 -80% of infected women have no symptoms and the urethritis and discharge often go unnoticed
o Cervicitis may cause a discharge
o Most of symptoms in females are due to complications

Complications of Gonorrhoea
• In males - urethritis periurethral abscess, urethral stricture and consequently urine
retention and infertility
• In female
o Bartholin’s abscess or cyst.
o Endometritis, cervicitis, salpingitis and oophoritis.
o These are collectively representing a syndrome called Pelvic Inflammatory Disease (PID).
o This syndrome presents with onset of lower abdomen pains with or without vaginal discharge.
o Note that PID may be transmitted by other means apart from sexual intercourse for example endogenous and iatrogenic.

o The management of PID will be well covered in syndromic approach.
o Ectopic pregnancy due to blockage of uterine tubes leading to infertility.
o Disseminated gonococcal disease such as joint disease and systemic infection can occur in both sexes.

Management of Gonorrhoea
Investigation
• The diagnosis can be confirmed by examination of a urethral smear in males and endocervical smear in female.
• Gram stain will show Gram negative diplococci lying inside pus cells (intracellular), though some may escape and lie outside the cells, but diagnosis should not be made unless intracellular diplococci are definitely seen.
• If there are facilities for culture, this should be done to confirm the diagnosis.

Treatment
• The recommended first line drugs for treatment of gonorrhoea include the following:
o Ceftriaxone 250mg intramuscularly in a single dose or
o Norfloxacin 800mg orally in a single dose or
o Ciprofloxacin 500mg orally in a single dose or
o Ofloxacin 400mg orally in a single dose or
o Levofloxacin 250mg orally, single dose or
o Enoxacin 400mg orally in a single dose
• The recommended alternative or second line drugs for treatment of gonorrhoea include the following:
o Cefixime 400mg orally in a single dose or
o Ceftriaxone 250mg intramuscularly in a single dose or
o Cefoxitin 2g intramuscularly in a single dose with 1g of probenecid orally or

Cefotaxime 2g intramuscularly in a single dose or
o Spectinomycin (Togamycin) 2g intramuscularly in a single dose
o Azithromycin 1g orally in a single dose
• Note that: the cephalosporins and Spectinomycin have the advantage that they can even be used in pregnant women while Azithromycin should not be used in pregnant patients.
• There is increase quinolone resistance in the world so care needs to be taken with using those medications.
• All these drugs are expensive and are unlikely to be available at health centres and dispensaries.
• Many other drugs (Antibiotics) are used for the treatment of GC and have the advantages that they are cheaper and widely available.
• These drugs are useful in areas where GC is still sensitive and they include the following:
o Kanamycin 2g intramuscularly or
o Thiamphenicol 2.5g orally or
o Cotrimoxazole four tablets orally twice daily for 2 days or
o Gentamycin 80mg twice daily for 3 days or
o Erythromycin 500mg four times a day for 7 days

• There are five important causes of treatment failure in gonorrhea:
o Wrong diagnosis e.g. Non-gonococcal urethritis (NGU), chemical urethritis
o Drug resistance
o Use of low dose of antibiotics
o No treatment given to sexual partner, resulting in re-infection
o Post gonococcal urethritis

• Treatment of Ophthalmia neonatorum include:
o Penicillins and the tretracyclines are no longer recommended because the Gonococcus is resistant to them.
o Gentamycin and Kanamycin are still effective against the gonococcus at a dosage of 1 mg/kg and 15-30mg/kg (check dosing) respectively 8 hourly for at least 3 days.
o Gentamicin can be available in form of eye drops.
o Zinnat syrup (oral cephalosporin-cefuroxime) at a dosage of 125mg orally 12 hourly for 5 days.
o The eyes should be washed with saline 2 hourly for the first 12 hours and
subsequently every 4 hours.

Prevention and Control Measures of Gonorrhoea
• Abstinence
• Avoid multiple partners and stick to one uninfected partner
• Proper and consistent use of condom
• Early diagnosis and treatment is important to reduce/prevent complications and further spread of infection among the community
• Partners must be treated regardless of their symptoms or test results
• Health education on public awareness and specific knowledge of STIs in the target groups

Overview of Non-gonococcal Urethritis
• Non-gonococcal urethritis is also known as non-specific urethritis as it is usually caused by other organisms.
• Chlamydia trachomatis is responsible for 50% of infections.
• Other organisms include Cefotaxime 2g intramuscularly in a single dose or
o Spectinomycin (Togamycin) 2g intramuscularly in a single dose
o Azithromycin 1g orally in a single dose
• Note that: the cephalosporins and Spectinomycin have the advantage that they can even
be used in pregnant women while Azithromycin should not be used in pregnant patients.
• There is increase quinolone resistance in the world so care needs to be taken with using
those medications.
• All these drugs are expensive and are unlikely to be available at health centres and
dispensaries.
• Many other drugs (Antibiotics) are used for the treatment of GC and have the advantages
that they are cheaper and widely available.
• These drugs are useful in areas where GC is still sensitive and they include the following:
o Kanamycin 2g intramuscularly or
o Thiamphenicol 2.5g orally or
o Cotrimoxazole four tablets orally twice daily for 2 days or
o Gentamycin 80mg twice daily for 3 days or
o Erythromycin 500mg four times a day for 7 days
• There are five important causes of treatment failure in gonorrhea:
o Wrong diagnosis e.g. Non-gonococcal urethritis (NGU), chemical urethritis
o Drug resistance
o Use of low dose of antibiotics
o No treatment given to sexual partner, resulting in re-infection
o Post gonococcal urethritis
• Treatment of Ophthalmia neonatorum include:
o Penicillins and the tretracyclines are no longer recommended because the Gonococcus
is resistant to them.
o Gentamycin and Kanamycin are still effective against the gonococcus at a dosage of 1
mg/kg and 15-30mg/kg (check dosing) respectively 8 hourly for at least 3 days.
o Gentamicin can be available in form of eye drops.
o Zinnat syrup (oral cephalosporin-cefuroxime) at a dosage of 125mg orally 12 hourly
for 5 days.
o The eyes should be washed with saline 2 hourly for the first 12 hours and
subsequently every 4 hours.
Prevention and Control Measures of Gonorrhoea
• Abstinence
• Avoid multiple partners and stick to one uninfected partner
• Proper and consistent use of condom
• Early diagnosis and treatment is important to reduce/prevent complications and further
spread of infection among the community
• Partners must be treated regardless of their symptoms or test results
• Health education on public awareness and specific knowledge of STIs in the target groups
Overview of Non-gonococcal Urethritis
• Non-gonococcal urethritis is also known as non-specific urethritis as it is usually caused
by other organisms.
• Chlamydia trachomatis is responsible for 50% of infections.
• Other organisms include mycoplasma, anaerobic and various viruses like herpes simplex., anaerobic and various viruses like herpes simplex.

Clinical Features of Non-gonococcal Urethritis
• The disease present with urethral discharge which is thinner and whiter than of gonorrhoea, this is noticed mostly in the morning.

• Other symptoms include:
o Vaginal discharge in women
o Feeling of discomfort in the urethra
o Pain on micturition
o Tickling sensation
o Wanting to massage the shaft of the penis all the time
o Painful urination
o Lower abdominal pain
o Painful sexual intercourse in women
o Testicular pain in men
• Note that prevention for this condition is same as gonorrhoea and other STIs

Management of Non-gonococcal Urethritis
• Since presentation is similar to gonorrhoea a wet smear to exclude trichomoniasis and gram stain can be done at primary level facility.
• If Chlamydia is suspected at primary level it is advised to treat by syndromicapproach or refer to district hospital for field’s stain.
• Field’s stain show blue-staining intracellular inclusion bodies lying inside monocytes or polymorph.
• Chlamydiae are sensitive to tetracyclines.
o Doxycycline is very effective in a dose of 100 mg morning and evening for 5-7
o Tetracycline at a dosage of 500 mg 6-hourly for 7 days
o Erythromycin 500 mg 6-hourly for 1 week
o Note that doxycycline and tetracycline cannot be used in pregnancy

Non gonorrhoccocal urenthratis

Urethritis is inflammation of the urethra – the tube that carries urine from the bladder out of the body. It is usually caused by an infection.

The term non-gonococcal urethritis (NGU) is used when the condition is not caused by gonorrhoea – a sexually transmitted infection (STI).

NGU is sometimes referred to as non-specific urethritis (NSU) when no cause can be found.
Although sexually transmitted infections (STIs) can cause NGU, it does not result from a gonorrhoeainfection. Urethritis caused by gonorrhoea is called gonococcal urethritis.

Chlamydia

In men, chlamydia is thought to be responsible for up to 43 out of 100 cases of NGU. In women, about 4 in 10 cases of NGU may be caused by chlamydia.

Chlamydia is caused by Chlamydia trachomatis bacteria. It is an STI and is spread during unprotected sex (sex without a condom), including anal and oral sex.

Other infections

A number of other infections can cause NGU.

These include other bacteria that usually live harmlessly in the throat, mouth or rectum. They can cause NGU if they get into the urethra, which is the tube that carries urine from the bladder to the outside of the body. This can occur during oral or anal sex.

Infections that can cause NGU include:
Trichomonas vaginalis – which is an STI caused by a tiny parasite other bacteria – such as Mycoplasmaa, urinary tract infection the herpes simplex virus – which can also cause cold sores and genital herpes an adenovirus – which usually causes a sore throat or an eye infection

Non-infectious causes
It is possible for NGU to have a non-infectious cause. This is when something else leads to the urethra becoming inflamed. 

Non-infectious causes of NGU include:
Irritation from a product used in the genital area – such as soap, deodorant or spermicided amage to the urethra caused by vigorous sex or masturbation, or by frequently squeezing the urethra – some men may do this if they are worried they have an infection damage to the urethra caused by inserting an object into it, such as a catheter – this can be done during an operation in hospital

Sexually transmitted infections (STIs)
     Urethritis can be caused by an STI, and is therefore more common among people who are at risk of STIs. This includes people who:
are sexually active have had unprotected sec have recently had a new sexual partner

In women, NGU rarely has any symptoms. Symptoms in men include:

A painful or burning sensation when urinating the tip of the penis feeling irritated and sore a white or cloudy discharge from the tip of the penis

Non-gonococcal urethritis (NGU) can cause different symptoms in men and women. In some cases, NGU does not cause any symptoms at all.

Symptoms of NGU in men

The symptoms of NGU in men can include:
~A white or cloudy discharge from the tip of the penis a burning or painful sensation when you urinate (pee)the tip of your penis feeling irritated and sore a frequent need to urinate

Depending on the cause of NGU, symptoms may begin a few weeks or several months after an infection.

If NGU has a non-infectious cause, such as irritation to the urethra, symptoms may begin after a couple of days. Symptoms that start a day or two after sex are usually not caused by an STI, but testing for STIs is still recommended.

If you think you have NGU, you should visit your local genitourinary medicine (GUM) clinic or sexual health clinic. These clinics have access to specialist diagnostic equipment that your GP may not have.

It is easy to find sexual health services in your area. Sexual health services are free and available to everyone, regardless of age, sex, ethnic origin and sexual orientation.

Symptoms of NGU in women

NGU tends to cause no noticeable symptoms in women unless the infection spreads to other parts of the female reproductive system, such as the womb or fallopian tubes (which connect the ovaries to the womb).

If the infection does spread, a woman may develop pelvic inflammatory disease (PID). PID is a serious health condition that can cause persistent pain. Repeated episodes of PID are associated with an increased risk of infertility.

Some women with PID don't have symptoms. If there are symptoms, they include: 

~Pain around the pelvis or lower part of your stomach (abdomen) 
~Discomfort or pain during sexual intercourse that is felt deep inside the pelvis bleeding between periods and after sexpain when you urinateheavy or painful periodsunusual vaginal discharge – especially if it is yellow or green

A few women with PID become very ill with:

~Severe lower abdominal pain
~A fever (high temperature) of 38C (100.4F) or
~Above nausea and vomiting

• Other symptoms include:
o Vaginal discharge in women
o Feeling of discomfort in the urethra
o Pain on micturition
o Tickling sensation
o Wanting to massage the shaft of the penis all the time
o Painful urination
o Lower abdominal pain
o Painful sexual intercourse in women
o Testicular pain in men

Why does NGU happen?

NGU can have a number of possible causes, including irritation to the urethra and STIs. Chlamydia causes up to 43 out of 100 cases of NGU.

There are many cases of NGU where no infection is found. If no cause is found, you will still be offered treatment for possible infection. This is also the case if inflammation is caused by an object such as a catheter in the urethra, or by using creams and soaps around the genitals.

Who is affected?

Urethritis is the most common condition diagnosed and treated among men in GUM clinics or sexual health clinics in the UK.

There are around 80,000 men diagnosed with urethritis every year. It is more difficult to diagnose urethritis in women because it may not cause as many symptoms.

NGU is usually diagnosed after urine and swab tests.

Read more about diagnosing NGU.

Treating NGU

Antibiotics are usually prescribed to treat NGU. You may be given them before you get your test results.

Antibiotics are also used in cases where NGU is thought to have been caused by an object, cream or soap.

In most cases, only a short course of treatment is needed and symptoms clear up after about two weeks.

The most common antibiotics used or
Recommended Regimens
Azithromycin 1 g orally in a single dose
OR
Doxycycline  (Vibramycin-D).100 mg orally twice a day for 7 days
Alternative Regimens
Erythromycin base 500 mg orally four times a day for 7 days.    OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days.   OR
Levofloxacin 500 mg orally once daily for 7 days.  OR
Ofloxacin 300 mg orally twice a day for 7 days
Tetracycline at a dosage of 500 mg 6-hourly for 7 days

It is important that past and current sexual partners are also treated, to prevent any infection spreading to others.

After treatment has been completed, and symptoms have disappeared, it should be safe to start having sex again.

Preventing NGU

As NGU is usually caused by an STI, practising safer sex is the best way to reduce the chances of it developing.

Safer sex involves using barrier contraception, such as condoms, and having regular checks at sexual health clinics or GUMs.

Complications

NGU can have some complications – for example, the condition can keep coming back.

Other complications include:

Reactive arthritis – when the immune system starts attacking healthy tissue, which can lead to joint pain and conjunctivitis epididymo-orchitis – inflammation of the testicles

Women often have no symptoms of NGU. However, if it's caused by chlamydia and left untreated, it can lead to pelvic inflammatory disease (PID). Repeated episodes of PID are associated with an increased risk of infertility.

Persistent urethritis

The most common complication of NGU is persistent or recurrent urethritis. This is when you still have urethritis 1 to 3 months after being treated for NGU. This affects 1 or 2 men in every 10 who are treated for NGU, and can affect women too.

If you still have symptoms two weeks after starting a course of antibiotics, you should return to the genitourinary medicine (GUM) clinic or sexual health clinic. 

Reactive arthritis

Reactive arthritis is an uncommon complication of NGU, estimated to affect less than 1 in 100 people with the condition.

Reactive arthritis is caused by the immune system attacking healthy tissue for an unknown reason, rather than the bacteria responsible for NGU.

This can cause:
Joint pain conjunctivitis (inflammation of the eyes)recurring urethritis

Epididymo-orchitis

Epididymo-orchitis is a possible complication of NGU in men. It is a combination of epididymitis and orchitis:
Epididymitis is inflammation of the Epididymis – a long coiled tube in the testicles that helps store and transport spermorchitis is inflammation of the testicles

Epididymo-orchitis affects fewer than 1 in 100 men with NGU.

Pelvic inflammatory disease (PID)

In women, pelvic inflammatory disease (PID) can be a result of NSU if left untreated. PID is a serious condition that can increase the risk of infertilityand ectopic pregnancy.

The disease present with urethral discharge which is thinner and whiter than of
gonorrhoea, this is noticed mostly in the morning.