eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Gonorrhea: Differential Diagnoses & Workup
Updated: Aug 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Bacterial Vaginosis
Ectopic Pregnancy
Epididymitis
Hepatitis
Orchitis
Pregnancy
Rat-bite Fever
Tubo-ovarian Abscess
Vaginitis
Workup
Laboratory Studies
- Culture is the most common diagnostic test for gonorrhea, followed by the DNA probe, and then polymerase chain reaction (PCR) and ligand chain reaction (LCR).
- The DNA probe is an antigen detection test that uses a probe to detect gonorrhea DNA in specimens.
- PCR and LCR are gene amplification techniques that markedly increase the sensitivity of specimen testing. Both techniques amplify the genetic fingerprint of specimens with very few organisms present in order to more easily detect and identify the organisms. Although the sensitivity is significantly increased, these methods of diagnosis are many times more expensive than culture or DNA probe. In many settings, PCR and LCR are not readily available because they may require a specialized lab facility. False positives are generally due to laboratory error (inadvertent contamination).
- Perform a culture or nonculture detection test for N gonorrhoeae on endocervical, urethral, pharyngeal, or rectal discharge. Because organisms are intracellular, attempt to obtain specimen in a manner that will contain mucosal cells and not merely discharge (similar to a Papanicolaou smear).
- Nonculture tests are less accurate in the presence of blood or during menses. Use culture instead at these times.
- Culture is performed on Thayer-Martin plates that must be stored refrigerated but warmed to room temperature before obtaining sample. The plate is then incubated in a carbon dioxide atmosphere. Poor technique drastically reduces test sensitivity.
- Medicolegal cases (eg, child abuse, rape) require culture due to the possibility of false-positive results with nonculture methods. However, performing the more sensitive PCR-based tests to raise the likelihood of detecting an infection, and then following up with culture to produce admissible evidence, is appropriate.
Imaging Studies
- Ultrasonography may be indicated in women to investigate suspected pelvic inflammatory disease (PID) and to visualize the appendix and ovaries as other possible causes of the symptoms.
Other Tests
- Other tests that might be indicated are those for concurrent sexually transmitted diseases (STDs), such as chlamydia (especially because of the high rate of asymptomatic carriage), herpes, hepatitis B, syphilis, and HIV (with counseling). The need for additional testing depends on the situation; they are often performed as a battery of tests in suspected rape and child abuse cases.
- HIV testing in cases of rape or new-onset abuse does not acutely diagnose a new infection but does establish a baseline status of the patient such that subsequent seroconversion might be linked back to the event in question.
Procedures
- In women with symptoms and signs suggestive of PID who are difficult to diagnose clinically, laparoscopy may be indicated to rule out (and, if need be, treat) appendicitis, ovarian torsion, ectopic pregnancy, or other surgical emergencies.
- Imaging studies such as ultrasonography are obviously a less invasive means of obtaining diagnostic information, but potentially emergent cases may require a more definitive examination, which permits rapid intervention if required.
Histologic Findings
- A Gram stain of urethral or cervical discharge may show gram-negative intracellular diplococci (diagnostic in the male) and polymorphonuclear cells.
- This is very useful if the physician has easy access to a microscope because the diagnosis may be made without waiting for culture results.
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References
CDC. STD Surveillance 2007, Gonorrhea. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/STD/stats07/gonorrhea.htm. Accessed 3/28/09.
Mulye TP, Park MJ, Nelson CD, Adams SH, Irwin CE Jr, Brindis CD. Trends in adolescent and young adult health in the United States. J Adolesc Health. Jul 2009;45(1):8-24. [Medline].
[Guideline] 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].
Gonococcal Isolate Surveillance Project (GISP) Annual Report 2005. Sexually Transmitted Disease Surveillance 2005 Supplement. CDC; January 2007. [Full Text].
American Academy of Pediatrics. 2006 Red book: Report of the committee on infectious diseases. 27th ed. 2006:301-9.
Behrman RE. Nelson's Textbook of Pediatrics. 14th ed. Philadelphia, PA: WB Saunders Co; 1992:536-7.
Blake D, Woods E. The future is here: Noninvasive diagnosis of STDs. Contemp Pediatr. Feb 2001;71-87.
Bruckner H, Bearman PS. After the promise: the STD consequences of adolescent virginity pledges. J Adolesc Health. 2005;4:271-8. [Medline]. [Full Text].
CDC. Increases in gonorrhea--eight western states, 2000--2005. MMWR Morb Mortal Wkly Rep. Mar 16 2007;56(10):222-5. [Medline].
[Guideline] CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
Kerr-Layton JA, Stamm CA, Peterson LS. Chronic plasma cell endometritis in hysterectomy specimens of HIV- infected women: a retrospective analysis. Infect Dis Obstet Gynecol. 1998;6(4):186-90. [Medline].
McCormack WM. Pelvic inflammatory disease. N Engl J Med. Jan 13 1994;330(2):115-9. [Medline].
Palusci VJ, Reeves MJ. Testing for genital gonorrhea infections in prepubertal girls withsuspected sexual abuse. Pediatr Infect Dis J. Jul 2003;22(7):618-23. [Medline].
Further Reading
Keywords
gonorrhea, GC, neisserial infections, the clap, sexually transmitted diseases, STD, Neisseria gonorrhoeae, gonococcal urethritis, pelvic inflammatory disease, PIC, urethritis, cervicitis, epididymitis, pharyngitis, proctitis, sexual abuse, septic arthritis, perihepatitis, Fitz-Hugh-Curtis syndrome, disseminated gonococcal infection, DGI, conjunctivitis, ophthalmia neonatorum, peritonitis, tuboovarian abscess, tubal perforation, ectopic pregnancy, urethral discharge, dysuria, dyspareunia, chlamydia, herpes, hepatitis B, syphilis, human immunodeficiency virus, HIV
