eMedicine Specialties > Emergency Medicine > Infectious Diseases
Gonorrhea: Differential Diagnoses & Workup
Updated: Oct 20, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
| Chlamydia | Testicular Torsion |
| Endometriosis | Urinary Tract Infection, Female |
| Pediatrics, Child Sexual Abuse | Urinary Tract Infection, Male |
| Pediatrics, Pharyngitis | Vaginitis |
| Pregnancy, Ectopic | |
| Sexual Assault |
Other Problems to Be Considered
Inflammatory arthritis
Septic arthritis
Herpes simplex urethritis
Mucopurulent cervicitis
Nongonococcal conjunctivitis
Nongonococcal endocarditis
Nongonococcal meningitis
Nongonococcal urethritis
Workup
Laboratory Studies
Laboratory studies for suspected gonorrhea may include the following:
- Gram stain
- Gram stain is a rapid and inexpensive test available in many EDs.
- Positive predictive value is high for urethral infection, but a negative Gram stain does not rule out infection in asymptomatic men.
- Sensitivity and specificity of the Gram stain are lower for endocervical specimens and rectal specimens. Gram stains from these sites are not recommended for routine use in the ED.
- The test is not useful for the diagnosis of pharyngeal infection because the oropharynx may be colonized by other Neisseria species that can lead to false-positive results.
- Culture
- Specific culture of a swab from the site of infection is a criterion standard for diagnosis at all potential sites of infection and can potentially guide treatment by determining antibiotic susceptibility.
- N gonorrhoeae is a fastidious organism that requires moist carbon dioxide-rich atmosphere and must be grown on enriched media, usually chocolate agar containing lysed blood.
- Empiric treatment is often necessary because culture results are not available for 24-48 hours.
- Cultures are particularly useful when the clinical diagnosis is unclear, when a failure of treatment has occurred, when contact tracing is problematic, and when legal questions arise.
- Nucleic acid amplification tests
- Nucleic acid amplification tests (NAATs) are designed to amplify sequences of DNA unique to a given pathogen, such as N gonorrhoeae. These tests are more sensitive and specific than nonamplification techniques.
- Several FDA-approved NAATs are available for the detection of N gonorrhoeae in urethral swab specimens obtained from males, endocervical swabs, and urine specimens obtained from men and women. These tests are more rapid than culture, more specific than immunoassays, and do not require viable organisms.3
- NAATs may be of particular use when examination and mucosal swab are difficult (in children or extremely apprehensive patients), and urine specimens are more easily obtained.
- NAATs can be used on eye secretions, but their performance is less well validated. NAATs are not all recommended for rectal and pharyngeal specimens at this time.
- Clinicians should be familiar with specimen collection guidelines and performance parameters of the test available at their own hospitals.
- Suspected DGI
- When DGI is suspected, blood and joint effusions should be sent for Gram stain and culture, although negative stain results and sterile cultures do not rule out disseminated disease. Cerebrospinal fluid should be stained and cultured if signs or symptoms of meningitis are present.
- Gram stains, cultures, and/or nucleic acid amplification tests (NAATs) of genital, rectal, conjunctival, and pharyngeal secretions should also be obtained when DGI is suspected, even if the patient has no localized symptoms at any of those sites.
- Tests to identify other STDs
- All patients with a likely diagnosis of gonorrheal infection should be tested for syphilis and C trachomatis.
- Testing for HIV may be indicated. Rapid HIV test technology makes ED testing and referral more practical than enzyme-linked immunosorbent assay (ELISA).
- Physical examination should always include scrutiny for signs of herpes simplex, syphilis, chancroid, lymphogranuloma venereum, and genital warts.
- Pregnancy test should always be obtained for women of childbearing age who present with gonorrhea or any other STD.
Imaging Studies
- Ultrasonography
- Pelvic ultrasonography or CT scan may demonstrate thick, dilated fallopian tubes or abscess formation.
- PID is uncommon in pregnancy when the cervical mucous plug may provide some protection to the upper tract. Ultrasonography should be used to rule out ectopic pregnancy whenever a pregnant patient has signs and symptoms of possible PID. See Pregnancy, Ectopic .
Procedures
- Collect specimens from the urethra, endocervix, pharynx, rectum, conjunctiva, urine, or blood; in addition, perform lumbar puncture and joint aspiration if indicated by clinical findings.
- Culdocentesis, although rarely indicated, may demonstrate free purulent exudate and provide material for Gram stain and culture.
More on Gonorrhea |
| Overview: Gonorrhea |
 Differential Diagnoses & Workup: Gonorrhea |
| Treatment & Medication: Gonorrhea |
| Follow-up: Gonorrhea |
| References |
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References
CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].
Goodyear-Smith F. What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review. J Forensic Leg Med. Nov 2007;14(8):489-502. [Medline].
Whiley DM, Tapsall JW, Sloots TP. Nucleic acid amplification testing for Neisseria gonorrhoeae: an ongoing challenge. J Mol Diagn. Feb 2006;8(1):3-15. [Medline].
Availability of cefixime 400 mg tablets--United States, April 2008. MMWR Morb Mortal Wkly Rep. Apr 25 2008;57(16):435. [Medline].
Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis. Jan 2006;33(1):36-51. [Medline].
Datta SD, Sternberg M, Johnson RE, et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med. Jul 17 2007;147(2):89-96. [Medline].
MacDonald N, Mailman T, Desai S. Gonococcal infections in newborns and in adolescents. Adv Exp Med Biol. 2008;609:108-30. [Medline].
Ness RB, Smith KJ, Chang CC, et al. Prediction of pelvic inflammatory disease among young, single, sexually active women. Sex Transm Dis. Mar 2006;33(3):137-42. [Medline].
Peeling RW, Holmes KK, Mabey D, et al. Rapid tests for sexually transmitted infections (STIs): the way forward. Sex Transm Infect. Dec 2006;82 Suppl 5:v1-6. [Medline].
Peter NG, Clark LR, Jaeger JR. Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain. Cleve Clin J Med. Mar 2004;71(3):233-9. [Medline].
Ross JD. Systemic gonococcal infection. Genitourin Med. Dec 1996;72(6):404-7. [Medline].
Spigarelli MG. Urine gonococcal/Chlamydia testing in adolescents. Curr Opin Obstet Gynecol. Oct 2006;18(5):498-502. [Medline].
Thompson EC, Brantley D. Gonoccocal endocarditis. J Natl Med Assoc. Jun 1996;88(6):353-6. [Medline].
Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55:1-94. [Medline]. [Full Text].
Workowski KA, Berman SM, Douglas JM Jr. Emerging antimicrobial resistance in Neisseria gonorrhoeae: urgent need to strengthen prevention strategies. Ann Intern Med. Apr 15 2008;148(8):606-13. [Medline].
Further Reading
Keywords
gonorrhea, STD, sexually transmitted disease, Neisseria gonorrhoeae infection, N gonorrhoeae infection, gonococcal cervicitis, pelvic inflammatory disease, PID, salpingitis, endometritis, tubo-ovarian abscess, abdominal peritonitis, Fitz-Hugh-Curtis syndrome, epididymitis, epididymo-orchitis, conjunctivitis, disseminated gonococcal infection, DGI, neonatal eye infection, gonococcal urethritis, endocervicitis, human immunodeficiency virus, HIV, genital infections, migratory polyarthritis, septic arthritis, gonococcal endocarditis, gonococcal meningitis, penicillinase-producing N gonorrhoeae, PPNG, chronic pelvic pain, septic abortion, chorioamnionitis in pregnancy, infertility, ectopic pregnancy, child sexual abuse, viral hepatitis, pharyngitis, secondary gonococcal bacterialconjunctivitis, bilateral conjunctivitis, purulent conjunctivitis, ophthalmia neonatorum, neonatal gonococcal infection, purulent gonococcal arthritis, tenosynovitis, , vulvovaginitis, hemorrhagic lesions, erythema nodosum, urticaria, erythema multiforme, intrauterine device, IUD
