5-27
Objective: Signs
Using Basic Tools:
Inspection: Acute (< 3 days): Purulent yellow to green discharge (both GC and chlamydia), mucoid /scant
discharge (more consistent with NGU), if oropharyngeal exposure, see red tonsils with exudate (GC), Sub
acute (3-10 days): Infection of periurethral glands, epididymitis, if disseminated GC: red, tender swollen
joints and tendon insertions, fever to 102ºF.
Palpation: Pelvic exam may show cervical movement tenderness
Using Advanced Tools: Lab: Gram stain: Urethral discharge shows gram-negative intracellular diplococci
(low diagnostic sensitivity in females), or many polymorphonuclear neutrophils but no organisms (NGU),
pregnancy test (drug selection).
Assessment:
Differential Diagnosis - other causes of dysuria include:
Trichomonas - malodorous discharge in females
Vaginal candidiasis - pruritus, white curd-like discharge
Herpes simplex - presence of mucoid discharge with skin ulcer
Urinary tract infection - usually frequency, urgency; sometimes hematuria
The arthritis-dermatitis syndrome of disseminated gonorrhea may resemble:
Meningococcemia - GC rash on extremities has distinctive bluish lesions surrounded by erythema
Lyme disease - E. migrans rash has larger, red lesions
Plan:
Treatment: Treatment for both GC and chlamydia is recommended in an operational setting
Primary: Ceftriaxone 125 mg IM single dose AND azithromycin 1 gram po single dose
Alternatives: Choose one from column A AND one from column B:
Column A Column B
cefixime 400 mg po single dose doxycycline 100 mg po bid x 7 days
ciprofloxacin 500 mg po azithromycin 1 gm po single dose
ceftriaxone 125 mg IM single dose erythromycin 500 mg qid x 7 days
Or use azithromycin 2 gm in single dose (poor gastrointestinal tolerance) alone.
Pregnant patient: Use ceftriaxone or cefixime in a single dose AND erythromycin 500 mg po qid for 14
days. Do not use doxycycline in pregnant or nursing females.
Patient Education
General: Evaluate and treat recent sexual contacts
No Improvement/Deterioration: Always treat patient as if co-infected with chlamydia
Medications: Avoid taking doxycycline with antacids, milk, iron pills or multivitamins. Avoid sun exposure. Do
not use doxycycline in children, or nursing or pregnant mothers.
Prevention and Hygiene: Use barrier protection (latex condoms) or abstinence for duration of treatment.
No Improvement/Deterioration: If relapse occurs, treat NGU/cervicitis for 21 days with doxycycline 100 mg
po bid. Also evaluate and treat partner. For recurrent urethritis after treatment of patient and partner, give
metronidazole 2 gm po in single dose and erythromycin 500 mg po qid for 7 days (discuss Antabuse effect of
metronidazole and do not use during pregnancy).
Follow-up Actions
Return evaluation: Consider evaluating for HIV antibody in 4-6 weeks
Evacuation/Consultation Criteria: Evacuation is not usually required. Consult urology, gynecology,
infectious disease or preventive medicine experts as needed.