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Gonococcal urethritis

What's new

Added 2024 EAU, 2022 AAFP, 2021 CDC, 2021 USPSTF, and 2020 IUSTI/WHO guidelines for the diagnosis and management of gonococcal urethritis.

Background

Overview

Definition
Gonococcal urethritis is a STI of the urethra caused by N. gonorrhoeae.
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Pathophysiology
The pathophysiology of gonococcal urethritis involves N. gonorrhoeae invading the urethral epithelium, adhering to epithelial cells, multiplying, and initiating an inflammatory response. The infection is transmitted by direct inoculation of infected secretions from one mucosal surface to another. Antibiotic resistance is associated with specific gene mutations, including penA, penB, and mtrR for penicillin resistance, rpsJ, penB, and mtrR for tetracycline resistance, and gyrA and parC for fluoroquinolone resistance.
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Epidemiology
Gonococcal infection is the second most common STI in US, with a reported incidence of 1,264 per 100,000 in men and 1,611 per 100,000 in women.
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Disease course
The clinical course of gonococcal urethritis typically involves symptoms such as mucopurulent urethral discharge, dysuria, and erythema of the urethral meatus. However, asymptomatic cases can occur, especially in men.
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Prognosis and risk of recurrence
The prognosis of gonococcal urethritis is generally good with appropriate antibiotic treatment. Untreated cases can lead to complications such as epididymitis, prostatitis, and disseminated gonococcal infection.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of gonococcal urethritis are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2024,2021), the European Association of Urology (EAU 2024), the American Academy of Family Physicians (AAFP 2022), the U.S. Preventive Services Task Force (USPSTF 2021,2019), the International Union Against Sexually Transmitted Infections (IUSTI/WHO ...
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Screening and diagnosis

Indications for screening: as per AAFP 2022 guidelines, obtain annual screening for gonococcal infections in sexually active females aged ≤ 24 years who have a cervix.
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Diagnostic investigations

Indication for testing: as per IUSTI/WHO 2020 guidelines, obtain testing for gonococcal infection in male patients with symptoms or signs of urethral discharge, as well as in any patient with newly diagnosed other STIs or sexual contacts with patients diagnosed with a STI or pelvic inflammatory disease.
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  • Laboratory tests

  • Screening for other STIs

Medical management

General principles: as per EAU 2024 guidelines, delay treatment until the results of the NAATs are available to guide treatment choice in patients with mild symptoms.
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  • Indications for treatment

  • Antibiotic therapy

Specific circumstances

Infants
As per CDC 2021 guidelines:
Administer erythromycin 0.5% ophthalmic ointment in each eye in a single application at birth for the prevention of gonococcal ophthalmia neonatorum.
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Administer a single dose of ceftriaxone IM or IV 20-50 mg/kg (not to exceed 250 mg) in neonates without signs of gonococcal infection born to mothers with gonococcal infection.
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Patient education

General counseling: as per AAFP 2022 guidelines, offer behavioral counseling to sexually active adolescents and adults at increased risk of acquiring STIs to reduce their risk.
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Preventative measures

Post-exposure prophylaxis: as per CDC 2024 guidelines, counsel MSM and transgender women who have had a bacterial STI (specifically syphilis, Chlamydia, or gonorrhea) in the past 12 months that doxycycline can be used as post-exposure prophylaxis to prevent these infections. Offer persons in this group a prescription for doxycycline post-exposure prophylaxis (200 mg, not to exceed 200 mg every 24 hours) after shared decision-making, to be self-administered within 72 hours after having oral, vaginal, or anal sex.
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Follow-up and surveillance

Assessment of treatment response: as per AAFP 2022 guidelines, obtain testing for reinfection at 3 months in nonpregnant patients treated for gonococcal infection.
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  • Management of treatment failure