Alexander McMillan1, 2
(1)
Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk
(2)
University of Edinburgh, Edinburgh, Uk
Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer
Email: a.amcmm@btinternet.com
Abstract
Richard’s partner, Maria, attends the clinic the next day (see Case 7). She is symptomless and was shocked when Richard told her that he had gonorrhoea and that she must have infected him. Her most recent sexual contact had been with Richard, and she had no other sexual partners for 4 months. Her last menstrual period had ended 1 week previously.
Richard’s partner, Maria, attends the clinic the next day (see Case 7). She is symptomless and was shocked when Richard told her that he had gonorrhoea and that she must have infected him. Her most recent sexual contact had been with Richard, and she had no other sexual partners for 4 months. Her last menstrual period had ended 1 week previously.
8.1 What Tests Would You Undertake to Diagnose or Exclude Infection With Neisseria Gonorrhoeae?
Table 8.1 indicates the anatomical sites that may be infected by N. gonorrhoeae in a woman.
Table 8.1.
Anatomical sites that may be infected by Neisseria gonorrhoeae in a woman.
|
Site affected |
Frequency of infection at that site (%) |
|
Endocervix Urethraa Anorectuma Oropharynxa |
85–90 65–75 25–50 5–15 |
aSole site of infection in ≤5% of women.
Maria is examined as described in Case 2. Material is collected from the urethra and endocervical canal for Gram-smear microscopy and culture. Specimens for culture are also collected from the anorectum and pharynx 1 (see Case 3).
There is no apparent urethral discharge and the cervix appears normal. Gram-smear microscopy of urethral and endocervical material fails to identify Gram-negative diplococci.
8.2 What Do You Do?
Many women with gonorrhoea have a mucopurulent discharge from the endocervical canal. As the cervix appears normal in other infected women, absence of infection in this case cannot be inferred from lack of abnormal signs. Although Gram-smear microscopy is helpful in making a presumptive diagnosis of gonorrhoea if Gram-negative diplococci are seen in endocervical or urethral material, the sensitivity of direct microscopy is relatively low: about 50% for endocervical samples and about 20% for female urethral specimens. The negative result in this case therefore does not exclude infection. Culture is more sensitive than direct microscopy, and nucleic acid amplification assays are the most sensitive tests, but, of course, results are not immediately available.
The risk of transmission of N. gonorrhoeae from an infected male to a female is estimated to be between 60 and 90%2. It is therefore common clinical practice to offer treatment to known sexual contacts of individuals with gonorrhoea before the results of culture or nucleic acid amplification methods are available. If a woman opts to await the results of the microbiological tests before treatment, she is advised to avoid any sexual contact, including oral sex, until negative results are obtained. As the proportion of infected women detected by culture at their first attendance may be 90% or lower, two sets of investigations need to be taken to diagnose or exclude infection.
As Maria was to return to the Philippines the following day, empirical treatment for gonorrhoea and chlamydial infection3 was offered and accepted, and she was given oral cefixime as specific treatment for gonorrhoea, and azithromycin for possible chlamydial infection.
Having considered the implications of not informing his wife, Rosemary, that she may have an STI, Richard tells her that his GP thinks that he may have a urinary tract infection and that she should be tested for “infections” and possibly treated with antibiotics. Although Richard tells her that it is best that she should attend the Sexual Health clinic “where they have special facilities to diagnose such urinary infections,” he does not divulge the fact that he has already attended.
Several days later, she consults you at the Sexual Health clinic.
8.3 How Would You Manage Her Case?
The preservation of a patient’s confidentiality is essential, and although you know that Richard probably has gonorrhoea, you must not divulge this fact to his wife without his express consent. In this case, no such consent has been given. A useful opening question is “What has your husband told you?” This allows you to gauge how much he may have told her in the interval between his consultation at the clinic and her attendance.
Rosemary tells you that he has a urinary infection and that the GP has advised that she should attend a specialist clinic. She has had an increased vaginal discharge for about 3 weeks, but had attributed this to stress at work – she is an architect, and has been working long hours at the office to complete an important project. Her most recent menstrual period had begun 10 days before her clinic attendance and had been normal. She uses a combined oral contraceptive agent and has not missed any pills. When you examine her you note a mucopurulent discharge from the endocervical canal. There are no other abnormal findings.
You undertake the tests for the STIs as outlined in Case 2. Microscopical examination of a Gram-stained smear of endocervical material shows many polymorphonuclear leucocytes and intracellular Gram-negative diplococci.
8.4 What Would You Do Next?
The presumptive diagnosis is gonorrhoea. However, it would be unwise to tell her your suspicions at this stage – other Neisseria species can colonize the genital tract and these are indistinguishable microscopically from N. gonorrhoeae. You tell her that she may have an infection but that the nature of this can only be confirmed in the laboratory. You offer and she accepts empirical treatment before the results of the laboratory tests are available. She is given cefixime and azithromycin. She is invited to re-attend the clinic in 7 days.
Rosemary attends the clinic as arranged. Neisseria gonorrhoeae was cultured from the endocervical canal, urethra, anorectum, and pharynx. Tests for C. trachomatis and the other STIs yielded negative results.
8.5 What Do You Do Next?
It would be improper to withhold the diagnosis from her, and you tell Rosemary that she has gonorrhoea.
She becomes very agitated and tearful, and asks how and when she could have acquired this infection. You explain that the causative organism is sexually transmitted, but it is difficult to determine its duration. You explore her sexual history further. She tells you that she had had unprotected sexual intercourse with a fellow architect, James, about 1 month previously when her husband had been abroad. Following treatment she has become symptomless.
As Rosemary had developed symptoms about a week after sex with her colleague, it is possible that he may have been the source of her infection. She is seen by a clinic Health Adviser who persuades her to contact James and suggest that he attend for screening for STIs. She telephones him from the Health Adviser’s office. James is angry at the suggestion that he may have an STI and is adamant that he could not have gonorrhoea as neither he nor his wife has symptoms.
Up to about 5% of men with urethral gonorrhoea and the majority of men with pharyngeal infection are symptomless. Although women become infected most commonly from unprotected peno-vaginal intercourse, infection may be acquired through cunnilingus.
As cure of pharyngeal gonorrhoea is less predictable that that of anogenital infection, Rosemary should be offered a test of cure at the follow-up attendance.
8.6 What Are the Complications of Untreated Gonorrhoea in a Woman?
· Local complications include inflammation and abscess formation of
· paraurethral (Skene’s) glands;
· greater vestibular (Bartholin’s) glands.
· Pelvic inflammatory disease (see Case 14).
· Disseminated infection and reactive arthritis (see Case 24).
· Acute conjunctivitis from auto-inoculation from the genital tract.
This Case shows how important partner notification is in the control of gonorrhoea and other STIs. It also illustrates that one must not jump to conclusions about the source of these infections.
Footnotes
1
Cure of pharyngeal gonorrhoea is less certain than anogenital infection, and inadequately treated infection at this site may be the source of re-infection of a sexual partner. It is therefore important to recognize pharyngeal gonorrhoea, and undertake at least one test of cure after treatment. Disseminated infection from the pharynx is a recognized complication.
2
The risk of a male acquiring gonorrhoea from an infected female is somewhat lower, being estimated to be between 20 and 50%. Studies suggest that inoculum size is important in establishing infection.
3
About 40% of women with gonorrhoea have concurrent chlamydial infection.