1. Scientific Presentation
on
Gonorrhoea
Speaker:
Dr. Md. Shahidul Islam
Assistant Professor of Dermatology & VD,
CBMC’B
Chairperson:
Professor. Hasibur Rahman
Head of the Department of Dermatology & VD, CBMC’B

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

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

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

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

6. 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. Microbiology

Etiologic agent: Neisseria
gonorrhoeae

Gram-negative intracellular
diplococcus

Infects mucus-secreting epithelial cells

9. Gonorrhea: Gram’s Stain
of
Urethral Discharge

10. Genital Infection in Men

Urethritis – Inflammation of urethra

Epididymitis – Inflammation of the
epididymis

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

12. Gonococcal Urethritis:
Purulent Discharge

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

20. Swollen or Tender
Testicles (Epididymitis)

22. LOCAL







COMPLICATIONS in Male
Urethral stricture
Periurethral abscess
Prostatitis
Prostatic abscess
Seminal vasiculitis
Epidedymitis
Orchitis

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

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

25. Gonococcal Cervicitis

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

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

28. Bartholin’s Abscess

29. Gonococcal complications in
Pregnancy



Postpartum endometritis
Septic abortions
Post-abortal PID
Possible role in:
 Gestational bleeding
 Preterm labor and delivery
 Premature rupture of membranes

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

31. Gonococcal Ophthalmia

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

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

34. Disseminated Gonorrhea—
Skin Lesion

35. Diagnostic Methods
1. Gram’s stain for microscopic
examination
–
P/S or urethral discharge
(male)
–
Cervical swab (female)
2. Culture tests
3. Others
Polymerase chain reaction (PCR)
 DNA probe
 NAATs


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

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

38. 
Specific diagnosis of infection with N.
gonorrhoeae can be performed by testing
endocervical, vaginal, urethral (men only), or
urine specimens. Culture, nucleic acid
hybridization tests, and NAATs are available
for the detection of genitourinary infection
with N. gonorrhoeae.

Culture and nucleic acid hybridization tests
require female endocervical or male urethral
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 FDAcleared 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:
Urethral Smear


Numerous
PMNs
Gram
negative
intracellular
diplococci

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

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

43. GC Culture Candle Jar

44. GC Culture Specimen
Streaking
Cervical and Urethral

45. GC Culture After 24
Hours

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

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

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

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

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

51. Co-treatment for
Chlamydia

If chlamydial infection is not ruled out:
Tab.Azithromycin 1 gm (Tab.Zimax-500mg) Orally
Once
or
Doxycycline (Cap.Doxacil-100 mg)
Orally Twice a day for 7 days

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

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

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

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

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

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

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

59. Acknowledgements

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Prof. Hasibur Rahman
Dr.Hadiuzzaman
Dr.Nahida Islam Nipa
Dr.Sabrina Alam Mumu
Dr. Atia Afrose Jecy.
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