346

Practical Urology: EssEntial PrinciPlEs and PracticE

refrain from sexual intercourse until all parties’

acid hybridization test can be performed on an

treatmentiscompletedor7daysafter single-dose

intraurethral or endocervical specimen, or on

therapy. Reculture for cure is not needed for

urine.Urine NAATs for N. gonorrhoeae have been

patients treated with doxycycline or a quinolone,

shown to be less sensitive than endocervical and

but is recommended 3 weeks after treatment

intraurethral swabs in asymptomatic men.22

with erythromycin, in pregnant women, or for

persistent symptoms. Patients with chlamydia

Treatment

are at high risk for reinfection and should be

The recommended treatment for gonorrhea is

rescreened 3–4 months after treatment.

ceftriaxone 250 mg intramuscularly as a single

Gonorrhea

dose. It results in cure in approximately 99% of

uncomplicated urogenital, anorectal and pha-

Diagnosis

ryngeal cases. An oral alternative is a single oral

dose of cefixime 400 mg. Alternative single-dose

Gonorrhea is caused by a gram-negative diplo-

parenteral agents for uncomplicated urogenital

coccus, Neisseria gonorrhoeae. Men will usually

and anorectal gonorrhea are listed in Table 25.4.

experience lower urinary-tract symptoms

These agents may not be as effective for pharyn-

attributed to urethritis, epididymitis, proctitis,

geal infection which often goes undiagnosed. A

or prostatitis, with associated mucopurulent

single 2 g dose of azithromycin is effective in

urethral discharge. Women are most often

uncomplicated infections, but is not recom-

asymptomatic, but may have symptoms of vagi-

mended by the CDC because of increasing resis-

nal and pelvic discomfort, dysuria, or abnormal

tance. It may be an option for uncomplicated

vaginal discharge. Both symptomatic and

infections in patients with a documented severe

asymptomatic infections can lead to PID and its

allergy to penicillins or cephalosporins. Due to

subsequent complications. Manifestations of

emerging resistance, the CDC no longer recom-

gonococcal dissemination are rare today and

mends quinolones for the treatment of GC in

include arthritis, dermatitis, meningitis, and

any population.23 Patients infected with gonor-

endocarditis.

rhea are often coinfected with C. trachomatis

The United States Preventive Services Task

and should be treated simultaneously for both

Force recommends screenings for gonorrhea to

infections, unless chlamydial infection has been

those at increased risk for infection, including

ruled out.

women with previous gonorrhea infection, or

Recent sexual partner (past 60 days) should

other STIs, new or multiple sex partners, incon-

be evaluated and treated. Sexual activity should

sistent condom use, sex, and drug use; and for

be avoided until both partners complete treat-

women in certain demographic groups and those

ment and are symptom free. Persons with per-

living in high prevalence areas. Screening may be

sistent symptoms or recurrence shortly after

done by endocervical culture, or can be per-

treatment should be re-evaluated by culture for

formed with newer screening tests,including NAAT

N. gonorrhoeae and positive isolates should

and nucleic acid hybridization tests using vaginal,

undergo antimicrobial-susceptibility testing.

urethral(men only), or urine specimens.33, 34 The

Clinicians and laboratories should report treat-

CDC recommends screening by culture on an

ment failures or resistant gonococcal isolates to

endocervical swab specimen in women or an

CDC at 404-639-8373 through state and local

intraurethral swab in men. Culture and sensitiv-

public health authorities.

ity are important to monitor antibiotic suscepti-

bility and resistance. A positive Gram stain of

Trichomoniasis

diplococci on a male urethral swab is highly

specific (99%) and sensitive (95%); however, a

Diagnosis

negative Gram stain does not rule out GC. Gram

Trichomoniasis is caused by Trichomonas vag-

stain of secretions from the pharynx, cervix, or

rectum is insufficient for diagnosis of GC and

inalis, a flagellated protozoan which can

not recommended. If transport and storage con-

inhabit the vagina, urethra, Bartholian glands,

ditions are not conducive to maintaining the

Skene’s glands, and prostate. It cannot infect

viability of N. gonorrhoeae, a NAAT or nucleic

the rectum or mouth. Nearly half of women,