Urethritis Gonorrhea

Definisi :
 Urethritis : inflamasi pada uretra yang paling sering disebabkan oleh infeksi yang
dikarakteristikan dengan keluhan urethral discharge dan dysuria
 Gonorrhea : infeksi menular seksual pada epitel yang bermanifestasi sebagai
urethritis, cervicitis, proctitis

Epidemiologi :
 Urethritis terjadi pada 4 juta orang Amerika
 Worldwide : 62 juta new case reported each year
 insidensi GU : 700.000 new case GU annually
 higher in developing countries than in industrialized nations
 affects young, non white, less educated members of urban population
 ethnicity : ↑ pada African American, ↓ Asian/pacific

Faktor Risiko :
 STI → transmitted male to female more efficiently
 Rate of transmission to female with unprotected sexual with infected male 40-60%
 Highest attack rate :
Female : 15-19 years old
Male : 20-24 years old
 Penularan GO : genito-genital , oro-genital, ano-genital
 Multipartner sexual, homoseksual (behavior)

Etiologi :
Nesseria Gonorrhea → gram (-), non motile, single/pairs (mono/diplococci)

Patgen, Patfis :
 faktor risiko

infeksi dan masuknya N. Gonorrhea ke urinary tract (mukosa)

faktor virulensi

outer membran LOS

protein

molecular release
mimicry
Pili OPA IgA
Por protein
protein protease

hindari endotoxic local

attachment pengenalan activity sitotoxic
ke sel proteksi inisiasi resisten lisis oleh sistem efek
adhesi & cegah
epitel dan dari IgA endositosis gabungan oleh serum imun
attachment & invasi
resistensi ke reseptor mukosa fagosom- host
terhadap sel host lisosom
fagosit

ikatan dengan
complement
inhibitory
molecul
(inflam < →
asimptomatik)
 penetrasi ke dalam sel epitel (24-48 jam)

multiplikasi

URETHRITIS GONORRHEA

reaksi inflamasi kerusakan mukosa urethra

release mediator inflamasi LUTS iritatif

edema & eritem (@orifice ↑permiabilitas IL 6,8 bradikinin, PG, histamin dysuria
urethral external)

vasodilatasi recruitment leukosit pruritus, burning

@ orifice urethral
external

WBC ↑

extravasasi leukosit ke site infection

tidak difagosit fagositosis leukosit terbawa urin

migrasi ke bagian sekitar urethra mucopurulent urethral discharge cloudy urin

epididimis prostat

epididimitis nyeri

nyeri scrotum bengkak

Manifestasi Klinis :
 Acute urethritis : inkubasi after exposure 2-7 days
 Bisa asimptomatik
 Urethral discharge :
- Awal : scant, mucoid
- Lama kelamaan : profuse, purulent (mulai hari ke 2 atau 3)
 Dysuria
 More severe than non GO
  Tanpa terapi : persisted ~8 weeks
 Edema penis (bisa karena lymphangitis/tromboplebitis, periurethral abses)
 95% male → asimptomatik setelah 3 bulan

Patogenesis Uretritis Non- Gonore

Dalam perkembangannya, Chlamydial trachomatis mengalami 2 fase. Dalam
perkembangannya Chlamydia trachomatis mengalami 2 fase: Fase I disebut fase
noninfeksiosa, terjadi keadaan laten yang dapat ditemukan pada genitalia maupun
konjungtiva. Pada saat ini kuman sifatnya intraselular dan berada di dalam vakuol yang
letaknya melekat pada inti sel hospes, disebut badan inklusi.
Fase II fase penularan, bila vakuol pecah kuman keluar dalam bentuk badan elementer
yang dapat menimbulkan infeksi pada sel hospes yang baru. (1) Siklus bifasik diawali dengan
menempelnya infeksius EB ke mikrofili sel host yang rentan.
EB secara aktif menembus sel host, EB didalam sel akan berdiam didalam
fagosom dan mulai bereplikasi. EB yang tidak aktif secara metabolik, menjadi aktif dan
membelah diri menjadi RB dimana RB tersebut dapat mensintesa DNA, RNA dan protein
namun masih tergantung pada sel hostnya untuk suplai energi (ATP), keadaan ini disebut
sebagai parasit energi.
Selanjutnya RB kemudian membelah diri secara berulang didalam fagosom. Fagosom
dengan RB didalamnya inilah disebut dengan badan inklusi. Setelah terjadi infeksi selam 18-
24 jam, RB kemudian kembali berorganisasi menjadi EB danantara 48-72 jam kemudian, sel
yang terinfeksi akan pecah dan kemudian dilepaskan oleh EB

Manifestasi Klinis
Penyakit yang paling umum terjadi pada infeksi C. trachomatis adalah uretritis,
ditandai dengan discharge encer atau mukoid pada uretra, dapat disertai dengan disuria. Pada
infeksi rectum menyebabkan proktitis pada wanita maupun pria. Infeksi juga dapat
termanifestasi sebagai Lymphogranuloma venerum.
(2) Gejala Klinis Tanda dan gejala Uretritis Gonococcal (UG) dan Uretritis Non-
Gonococcal (UNG) pada dasarnya adalah sama, namun berbeda pada derajat keparahan
gejala yang timbul. Kedua uretritis baik gonococcal maupun non-gonococcal
menyebabkan adanya lendir, dysuria, dan gatal pada uretra. Lendir yang sangat banyak,
dan purulen lebih sering pada gonorrhea, sedangkan pada kondisi UNG, lendir yang
dihasilkan lebih sedikit dan mukoid. Pada UNG, lendir sering hanya muncul pada pagi hari,
atau hanya terlihat seperti krusta yang melekat di meatus atau terlihat seperti bercak pada
pakaian dalam. frekuensi, hematuria, dan urgensi sering terjadi pada kedua jenis infeksi.
Masa inkubasi jauh lebih pendek pada infeksi gonorrhea, yaitu dalam 2-6 hari, sedangkan
pada UNG, gejala muncul dalam 1-5 minggu setelah infeksi, dengan masa inkubasi rata-rata
2-3 minggu.
(3) Pada penelitian yang dilakukan oleh Kreiger yang membandingkan manifestasi
klinis uretritis gonococcal, chlamydial, dan trichomonal. Hanya 55% pria dengan
trichomoniasis yang mengalami lendir uretra, dibandingkan pada infeksi Chlamydia 82%,
dan 93% pada gonorrhea. Lendir yang dihasilkan pada infeksi N. gonorrhea, 82% berjumlah
sangat banyak dan purulen. Berbeda dengan infeksi Chlamydia dan Trichomonal dengan
sedikit lendir berwarna jernih atau mukoid.

 Pria
Gejala baru mulai timbul biasanya setelah 1-3 minggu kontak seksual dan umumnya
tidak seberat gonore. Gejalanya berupa disuria ringan, perasaan tidak enak di uretra,
sering kencing dan keluarnya duh tubuh seropurulen. Dibandingkan dengan gonore,
perjalanan penyakit lebih lama karena masa inkubasi yang lebih lama dan ada
kecenderungan kambuh kembali. Pada beberapa keadaan tidak terlihat keluarnya cairan
duh tubuh, sehingga menyulitkan diagnosis. Dalam keadaan demikian sangat
diperlukan pemeriksaan laboratorium. Komplikasi yang dapat terjadi berupa prostatitis,
vesikulitis, epididimitis dan striktur uretra.

 Wanita
Infeksi lebih ringan terjadi di serviks bila dibandingkan dengan vagina, kelenjar
Bartholinatau uretra sendiri. Sama seperti pada gonore, umumnya wanita tidak
menunjukkan adanya gejala. Sebagian kecil dengan keluhan keluarnya duh tubuh vagina,
disuria ringan, sering kencing, nyeri daerah pelvis dan dispareunia. Pada pemeriksaan
serviks dapat dilihat tanda-tanda servisitis yang disertai adanya folikel-folikel kecil yang
mudah berdarah. Komplikasi dapat berupa bartholinitis, proktitis, salfingitis dan sistitis.
Peritonitis dan perihepatitis juga pernah dilaporkan.

 Diagnosis
Diagnosis ditegakkan berdasarkan gejala klinis dan pemeriksaan
laboratorium. Pada pemeriksaan laboratorium terlebih dahulu harus disingkirkan kuman-
kuman spesifik yakni gonokok, Trichomonas vaginalis, Candida albicans, dan
Gardnerella vaginalis. Diagnosis secara klinis sukar untuk membedakan infeksi karena
gonore atau non-gonore. Menegakkan diagnosis servisitis atau uretritis oleh klamidia,
perlu pemeriksaan khusus untuk menemukan atau menentukan adanya C. trachomatis.
Pemeriksaan laboratorium yang umum digunakan sejak lama adalah pemeriksaan
sediaan sitologi langsung dan biakan dari inokulum yang diambil dari
specimen urogenital. Baru pada tahun 1980an ditemukan tehnologi pemeriksaan
terhadap antigen dan asam nukleat C. trachomatis.
Pada meatus eksternus nampak tanda radang berupa edema dan kemarahan yang
biasanya ringan dan tidak sehebat gonore, atau tak ada kelainan. Sekret uretra dapat
berupa purelent (lebih sering pada gonore), mukos, seromukos atau cairan jernih. Pada
umumnya sekret uretra tidak sehebat sekret pada gonore. Saat ini pemeriksaan biakan
masih dianggap sebagai standar baku emas pemeriksaan klamidia namun pemeriksaannya
membutuhkan waktu 3-7 hari. Untuk teknik mendeteksi antigen ada beberapa cara Direct
fluorescent antibody (DFA), Enzyme immune assayenzyme linked immunosorbent assay
(EIA/ELISA). Metode yang terbaru adalah dengan cara mendeteksi asam nukleat
C.trachomatis dengan hibridisasi DNA Probe, dikenal dengan istilah gen probe dan
amplifikasi asam nukleat.
 Penatalaksanaan
Obat yang paling efektif adalah golongan tetrasiklin dan eritromisin. Indikasi
ertitromisin adalah untuk pasien yang tidak tahan tetrasiklin atau wanita hamil. Dosis
tetrasiklin HCL dan eritromisin adalah 4x500 mg sehari selama 1 minggu atau 4x250 mg
sehari selama 2 minggu, doksisiklin, dan minosiklin dosis pertama 200 mg, dilanjutkan
dengan 2 x 100 mg sehari selama 1-2 minggu. Kotrimoksasol, spiramisin, dan ofloksasin
juga dapat digunakan. Secara umum, manajemen obat yang paling efektif adalah
golongan tetrasiklin daneritromisin. Di samping itu dapat juga digunakan gabungan
sulfa-trimetoprim, spiramisin dankuinolon. Beberapa dosis obat yang dapat digunaka
adalah dosis Tetrasiklin HCl 4 x 500mg sehari selama 1 minggu atau 4 x 250mg sehari
selama 2 minggu, Oksitertrasiklin 4 x 250mg sehari selama 2 minggu, Doksisiklin 2 x
100mg sehari selama 1 minggu, Eritromisin 4 x 500mg sehari selama 1 minggu atau4 x
250mg sehari selama 2 minggu (untuk penderita tidak tahan tetrasiklin, hamil).

Diagnosis :
Anamnesis, pemeriksaan fisik, serta 5 tahap pemeriksaan penunjang :
- Pewarnaan gram : gonokokus gram negative intra dan ekstraseluler (Pria : fossa
navikularis , wanita : uretra, bartholin,serviks)
- Kultur
- Tes definitive
- Tes oksidasi : positif
- Tes fermentasi : glukosa positif.
- Tes betalaktamase : positif
- Tes Thomson : melihat sejauh mana infeksi

Management :
1. Non farmakologi
- Konseling : mengenai penyakit, cara penularan, komplikasi, pentingnya
mengobati pasangan seksual, resiko tertular penyakit lain ( hepatitis B, hepatitis C,
HIV, infeksi menular seksual lain)
- Periksa dan obati pasangan seksual pasien
- Abstinensia hingga terbukti sembuh dari pemeriksaan lab. Jika terpaksa, gunakan
kondom
- Kunjungan ulang pada hari ke-3 dan ke-8

2. Non Farmakologi
Komplikasi :
 Pada Pria (Urethritis)
Lokal : tysonitis, parauretitis, littritis, cowpernitis
Ascenden : prostatitis, vesikulitis, vas deferinitis, epididymitis, trigonitis.
 Pada wanita (urethritis/ cervicitis)
Lokal : pararuretritis, bartolinitis
Asenden : salpingitis, PID
 Komplikasi diseminata : Artitis, miokarditis, endocarditis, pericarditis, meningitis,
dermatitis.
Prognosis :
Treatment tepat, adekuat, dan tuntas : ad bonam

2.3.konseling HIV
Pengertian konseling adalah: hubungan kerjasama yang bersifat menolong antar dua
orang (konselor dan klien) yang bersepakat untuk :
1. Bekerja sama dalam upaya menolong klien agar dapat menguasai permasalahan dalam
hidupnya.
2. Berkomunikasi untuk membantu mengidentifkasi problem-problem klien
3. Terlibat dalam proses yang menyediakan pengetahuan keterampilan, dan akses
terhadap sumber- sumber
4. Membantu klien mengubah sikap/ presepsi yang negatif terhadap problemnya,
sehingga klien dapat mengatasi kekuatirannya dan memutuskan apa yang akan ia
lakukan dengan permasalahan yang dihadapinya.

Konseling HIV/AIDS (Voluntary Counseling Test) adalah konseling yang secara

khusus memberi perhatian terhadap permasalahan yang berkaitan dengan HIV/AIDS, seperti
menyediakan dukungan psikologis, informasi dan pengetahuan HIV dan AIDS, mencegah
penularan HIV, mempromosikan perubahan perilaku yang bertanggungjawab, pengobatan
dan memastikan pemecahan berbagai masalah terkait dengan HIV dan AIDS baik terhadap
orang yang terinfeksi maupun terhadap lingkungan yang terpengaruh.

Tujuan dari dilakukannya konseling HIV/AIDS agar tersedianya dukungan sosial dan
psikologik kepada odha dan keluarganya. Selain itu juga terjadinya perubahan perilaku yang
aman sehingga penurunan penularan infeksi HIV/AIDS.
Test VCT harus bersifat :
 Sukarela : artinya bahwa seseorang yang akan melakukan tes HIV haruslah
berdasarkan atas kesadarannya sendiri, bukan atas paksaan / tekanan orang lain. Ini
juga berarti bahwa dirinya setuju untuk dites setelah mengetahui hal-hal apa saja yang
tercakup dalam tes itu, apa keuntungan dan kerugian dari testing, serta apa saja
impilkasi dari hasil positif atau pun hasil negatif.
 Rahasia : artinya, apa pun hasil tes ini nantinya (baik positif maupun negatif) hasilnya
hanya boleh di beritahu langsung kepada orang yang bersangkutan. Tidak boleh
diwakilkan kepada siapa pun, baik orang tua, pasangan, atasan atau siapapun. Di
samping itu hasil tes HIV juga harus dijamin kerahasiaannya oleh pihak yang
 melakukan tes itu (dokter, rumah sakit, atau labratorium) dan tidak boleh
disebarluaskan.

VCT merupakan hal penting karena:

 Merupakan pintu masuk ke seluruh layanan HIV dan AIDS
 Menawarkan keuntungan, baik bagi yang hasil tesnya positif maupun negatif, dengan
fokus pada pemberian dukungan atas kebutuhan klien seperti perubahan perilaku,
dukungan mental, dukungan terapi ARV, pemahaman faktual dan terkini atas HIV
dan AIDS
 Mengurangi stigma masyarakat
 Merupakan pendekatan menyeluruh: kesehatan fisik dan mental
 Memudahkan akses ke berbagai pelayanan yang dibutuhkan klien baik kesehatan
maupun psikososial.

Konseling HIV/AIDS biasanya dilakukan dua kali, yaitu: sebelum tes (pra-test) atau sesudah
tes (Pasca test) HIV/AIDS.
1. Konseling pre-test : yaitu konseling yang dilakukan sebelum darah seseorang yang
menjalani tes itu diambil. Konseling ini sangat membantu seseorang untuk
mengetahui risiko dari perilakunya selama ini, dan bagaimana nantinya bersikap
setelah mengetahui hasil tes. Konseling pre-test juga bermanfaat untuk meyakinkan
orang terhadap keputusan untuk melakukan tes atau tidak, serta mempersiapkan
dirinya bila hasilnya nanti positif.
Tahapan:
 Alasan Test
 Pengetahuan tentang HIV & manfaat testing
 Perbaikan kesalahpahaman ttg HIV / AIDS
 Penilaian pribadi resiko penularan HIV
 Informasi tentang test HIV
 Diskusi tentang kemungkinan hasil yang keluar
 Kapasitas menghadapi hasil / dampak hasil
 Kebutuhan dan dukungan potensial - rencana pengurangan resiko pribadi
 Pemahaman tentang pentingnya test ulang.
 Memberi waktu untuk mempertimbangkan.
 Pengambilan keputusan setelah diberi informasi.
 Membuat rencana tindak lanjut.
 Memfasilitasi dan penandatanganan Informed Consent

2. Konseling post-test : yaitu konseling yang harus diberikan setelah hasil tes diketahui,
baik hasilnya positif mau pun negatif. Konseling post-test sangat penting untuk
membantu mereka yang hasilnya HIV positif agar dapat mengethui cara menghidnari
penularan pada orang lain, serta untuk bisa mengatasinya dan menjalin hidup secara
 positif. Bagi merek yang hasilnya HIV negatif, konseling post-test bermanfaat untuk
memberitahu tentang cara-cara mencegah infeksi HIV di masa datang.
Tahapan:
 Dokter & Konselor Mengetahui Hasil Untuk Membantu Diagnosa Dan
Dukungan Lebih Lanjut.
 Hasil diberikan dalam amplop tertutup .
 Hasil Disampaikan Dengan Jelas Dan Sederhana
 Beri Waktu Untuk Bereaksi
 Cek Pemahaman Hasil Test
 Diskusi Makna Hasil Test
 Dampak pribadi , keluarga , sosial terhadap odha , kepada siapa & bagaimana
memberitahu.
 Rencana pribadi penurunan resiko
 Menangani reaksi emosional.
 Apakah segera tersedia dukungan ?
 Tindak lanjut perawatan & dukungan ke layanan managemen kasus atau
layanan dukungan yang tersedia di wilayah.

Konselor HIV dilakukan oleh konselor terlatih yang memiliki keterampilan konseling dan
pemahaman akan seluk beluk HIV / AIDS:
 Full time counselor yang berlatar belakang psikologi&ilmuwan psikologi
(psychiatrists, family therapist, psikologi terapan) yang sudah mengikuti pelatihan
VCT dengan standart WHO.
 Profesional dari kalangan perawat, pekerja sosial, & dokter.
 Community-based dan PLWHA yang sudah terlatih (Peer).

Di dalam VCT ada 2 kegiatan utama yakni konseling dan tes HIV. Konseling
dilakukan oleh seorang konselor khusus yang telah dilatih untuk memberikan konseling VCT.
Tidak semua konselor bisa dan boleh memberikan konseling VCT. Oleh karena itu seorang
konselor VCT adalah orang yang telah mendapat pelatihan khusus dengan standar pelatihan
nasional ataupun internasional. Konselor harus memiliki sikap :
 Ramah
 Berempati
 Sopan
  Mampu berkomunikasi dg baik
 Dapat mengenali gangguan umum kejiwaan (depresi berat, cemas, ingin bunuh diri)
& gangguan otak organik
Konseling dalam rangka VCT utamanya dilakukan sebelum dan sesudah tes HIV.

Bila klien memutuskan untuk memeriksakan diri, ia perlu disiapkan untuk

menghadapi hasil yang akan diterimanya. Ada tiga kemungkinan hasil yang akan terjadi:
1. Hasil tes negatif dan bukan dalam periode jendela,
2. Jelaskan bahwa ini bukan berarti bebas HIV seumur hidup hingga boleh berperilaku
apapun.
3. Andaikata ada prilaku berisiko tinggi, perlu merubah perilaku tersebut, menjadi lebih
aman dan dipertahankan seumur hidup sesuai dengan pilihan A (abstinence), B (Be
Faithful), C (Condom) atau kombinasi demi pencegahan HIV.
4. Hasil tes negatif dalam periode jendela
5. Perlu mengulang tes untuk 3 bulan kemudian, untuk kepastian status HIV-nya.
6. Sudah harus merubah perilaku risiko tingginya, sesuai pilihan A,B, C atau kombinasi.
7. Hasil tes positif
8. Perhatikan reaksi klien saat menerima hasil tes, konselor perlu berempati
9. Jelaskan bawa positif bukan berarti mati.
10. Rujukan untuk dukungan dan pengobatan.
11. Jaminan kerahasiaan.
12. Kemungkinan memberitahu pasangan.
13. Merubah perilaku berisiko tingginya berdasarkan pilihan A, B, C, atau kombinasinya.
Gonorrhea
Updated: Dec 19, 2017

 Author: Brian Wong, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS,
MD more...

Practice Essentials
Gonorrhea is a purulent infection of the mucous membrane surfaces caused by Neisseria
gonorrhoeae. N gonorrhoeae is spread by sexual contact or through transmission during
childbirth. The Centers for Disease Control (CDC) recommends that all patients with
gonorrheal infection also be treated for presumed co-infection with Chlamydia trachomatis. [1]
See the image below.

This patient presented with

gonococcal urethritis, which became systemically disseminated, leading to gonococcal
conjunctivitis of the right eye. Courtesy of the CDC/Joe Miller, VD.
View Media Gallery

See 20 Signs of Sexually Transmitted Infections, a Critical Images slideshow, to help make
an accurate diagnosis.

Signs and symptoms

History

In women, the major genitourinary symptoms of gonorrhea include the following:

 Vaginal discharge: The most common presenting symptom of gonorrhea, vaginal

discharge from endocervicitis is usually described as thin, purulent, and mildly
odorous; however, many patients have minimal or no symptoms from gonococcal
cervicitis
  Dysuria
 Intermenstrual bleeding
 Dyspareunia (painful intercourse)
 Mild lower abdominal pain

If the infection progresses to pelvic inflammatory disease (PID), symptoms may include the
following:

 Lower abdominal pain: Most consistent symptom of PID

 Increased vaginal discharge or mucopurulent urethral discharge
 Dysuria: Usually without urgency or frequency
 Cervical motion tenderness
 Adnexal tenderness (usually bilateral) or adnexal mass
 Intermenstrual bleeding
 Fever, chills, nausea, and vomiting (less common)

In males, the major genitourinary symptoms of gonorrhea include the following:

 Urethritis: The major manifestation of gonococcal infection in men; initial

characteristics include burning upon urination and a serous discharge; a few days
later, the discharge usually becomes more profuse, purulent, and, at times, tinged with
blood
 Acute epididymitis: Usually unilateral and often occurs in conjunction with a urethral
exudate
 Urethral strictures: Have become uncommon in the antibiotic era, but they can present
with a decreased and abnormal urine stream, as well as with the secondary
complications of prostatitis and cystitis
 Rectal infection: May present with pain, pruritus, discharge, or tenesmus

In males and females, the classic presentation of disseminated gonococcal infection (DGI) is
an arthritis-dermatitis syndrome. Joint or tendon pain is the most common presenting
complaint in the early stage of infection. The second stage of DGI is characterized by septic
arthritis. The knee is the most common site of purulent gonococcal arthritis.

In neonates, in whom bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal

delivery from an untreated mother with a gonococcal infection, symptoms of gonococcal
conjunctivitis include the following:

 Eye pain
 Redness
 Purulent discharge

Physical examination

Look for the following genitourinary symptoms during physical examination in females:

 Mucopurulent or purulent vaginal, urethral, or cervical discharge

 Vaginal bleeding; vulvovaginitis in children
 Cervical friability - Tendency to bleed upon manipulation
 Cervical motion tenderness during bimanual pelvic examination
  Fullness and/or tenderness of the adnexa, unilateral or bilateral (eg, ovaries, fallopian
tubes)
 Lower abdominal pain/tenderness, with or without rebound tenderness
 Possible low back pain - More common in progression to PID
 Upper right abdominal tenderness (with perihepatitis)

Look for the following genitourinary symptoms during physical examination in males:

 Mucopurulent or purulent urethral discharge: Obtained by milking the urethra along

the shaft of the penis
 Possible epididymitis: Unilateral epididymal tenderness and edema, with or without
penile discharge or dysuria
 Penile edema without other overt inflammatory signs
 Urethral stricture: Uncommon; more often seen in the preantibiotic era with urethral
irrigation using caustic liquids

See Clinical Presentation for more detail.

Diagnosis

Culture is the most common diagnostic test for gonorrhea, followed by the deoxyribonucleic
acid (DNA) probe and then the polymerase chain reaction (PCR) assay and ligand chain
reaction (LCR). The DNA probe is an antigen detection test that uses a probe to detect
gonorrhea DNA in specimens.

Specific culture of a swab from the site of infection is a criterion standard for diagnosis at all
potential sites of gonococcal infection. 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.

In patients who may have DGI, all possible mucosal sites should be cultured (eg, pharynx,
cervix, urethra, rectum), as should blood and synovial fluid (in cases of septic arthritis). Three
sets of blood cultures should also be obtained.

See Workup for more detail.

Management

For uncomplicated urogenital, anorectal, and pharyngeal gonococcal infection, a drug

regimen using ceftriaxone plus either azithromycin or doxycycline may be used.
Antimicrobial drugs used alone or in various combinations in other gonococcal infections
include the following:

 Gonococcal arthritis: Ceftriaxone

 Gonococcal conjunctivitis: Ceftriaxone
 Gonorrhea contributing to PID: Cefoxitin, ceftriaxone, doxycycline, metronidazole,
cefotetan, clindamycin, gentamicin
 Gonococcal epididymitis: Ceftriaxone, doxycycline
 DGI: Ceftriaxone, cefotaxime, ceftizoxime
 Gonococcal meningitis and endocarditis: Ceftriaxone
See Treatment and Medication for more detail.

Background
Gonorrhea, an important public health problem and the second most common notifiable
disease in the United States, is a purulent infection of mucous membrane surfaces caused by
the gram-negative diplococcus Neisseria gonorrhoeae. Although gonorrhea (known
colloquially as the clap and the drip) is most frequently spread during sexual contact, it can
also be transmitted from the mother's genital tract to the newborn during birth, causing
ophthalmia neonatorum and systemic neonatal infection. (See Etiology.)

In women, the cervix is the most common site of gonorrhea, resulting in endocervicitis and
urethritis, which can be complicated by pelvic inflammatory disease (PID). In men,
gonorrhea causes anterior urethritis. Gonorrhea can also spread throughout the body to cause
localized and disseminated disease. Complications also include ectopic pregnancy and
increased susceptibility to human immunodeficiency virus (HIV) infection. Most commonly,
the term gonorrhea refers to urethritis and/or cervicitis in a sexually active person. (See
Pathophysiology, Prognosis, Presentation, and Workup.)

Gonococcal infections following sexual and perinatal transmission are a major source of
morbidity worldwide. In the developed world, where prophylaxis for neonatal eye infection is
standard, the vast majority of infections follow genitourinary mucosal exposure. (See
Pathophysiology, Etiology, and Prognosis, and Treatment.)

In the pediatric population, the importance of gonorrhea is 3-fold, as follows:

 As a common and preventable sexually transmitted disease (STD) in the sexually

active teenage population
 As a perinatal infection at childbirth
 As a forensic aid in investigating sexual abuse

Gonococcemia

Gonococcemia is defined as the presence of N gonorrhoeae in the bloodstream, which can

lead to the development of disseminated gonococcal infection (DGI). Gonococcemia occurs
in about 0.5-3% of patients with gonorrhea (see the image below). (See Pathophysiology and
Prognosis.)
 This patient presented with
gonococcal urethritis, which became systemically disseminated, leading to gonococcal
conjunctivitis of the right eye. Courtesy of the CDC/Joe Miller, VD.
View Media Gallery

The clinical manifestations of this process are biphasic, with an early bacteremic phase
consisting of tenosynovitis, arthralgias, [2] and dermatitis, followed by a localized phase
consisting of localized septic arthritis. Other potentially severe clinical complications include
osteomyelitis, meningitis, endocarditis, adult respiratory distress syndrome (ARDS), [3, 4] and
fatal septic shock. [5] Polymyositis is also a rare complication of gonococcemia. (See
Pathophysiology, Prognosis, and Presentation.)

Patients who are pregnant or menstruating may be particularly prone to gonococcemia. Other
populations at risk of infection include women and individuals with complement deficiencies,
HIV disease, or systemic lupus erythematosus (SLE). DGI is an important, potentially life-
threatening, and easily treatable clinical entity that remains the most common cause of acute
septic arthritis in young, sexually active adults.

Pathophysiology
The pathophysiology of N gonorrhoeae and the relative virulence of different subtypes
depend on the antigenic characteristics of the respective surface proteins. Certain subtypes
are able to evade serum immune responses and are more likely to lead to disseminated
(systemic) infection.

Well-characterized plasmids commonly carry antibiotic-resistance genes, most notably

penicillinase. Plasmid and nonplasmid genes are transmitted freely between different
subtypes. The ensuing exchange of surface protein genes results in high host susceptibility to
reinfection. The exchange of antibiotic resistance genes has led to extremely high levels of
resistance to beta-lactam antibiotics. Fluoroquinolone resistance has also been documented
on multiple continents and in widespread populations within the United States. [6]

Infection of the lower genital tract, the most common clinical presentation, primarily
manifests as male urethritis and female endocervicitis. Infection of the pharynx, rectum, and
female urethra occur frequently but are more likely to be asymptomatic or minimally
symptomatic. Retrograde spread of the organisms occurs in as many as 20% of women with
cervicitis, often resulting in pelvic inflammatory disease (PID), with salpingitis, endometritis,
and/or tubo-ovarian abscess. Retrograde spread can lead to frank abdominal peritonitis and to
a perihepatitis known as Fitz-Hugh-Curtis syndrome.

Long-term sequelae of PID, such as tubal factor infertility, ectopic pregnancy, and chronic
pain, may occur in up to 25% of affected patients. Epididymitis or epididymo-orchitis may
occur in men after gonococcal urethritis. Lower genital infection is a risk factor for the
presence of other sexually transmitted diseases (STDs), including human immunodeficiency
virus (HIV).

Conjunctivitis can occur in adults, as well as children, following direct inoculation of

organisms (usually as a result of hand-eye inoculation in adults) and can lead to blindness.

Disseminated gonococcal infection

Disseminated gonococcal infection (DGI) occurs following approximately 1% of genital

infections. Patients with DGI may present with symptoms of rash, fever, arthralgias,
migratory polyarthritis, septic arthritis, tendonitis, tenosynovitis, endocarditis, or meningitis.

N gonorrhoeae organisms spread from a primary site, such as the endocervix, the urethra, the
pharynx, or the rectum, and disseminate to the blood to infect other end organs. Usually,
multiple sites, such as the skin and the joints, are infected. Neisserial organisms disseminate
to the blood due to a variety of predisposing factors, such as host physiologic changes,
virulence factors of the organism itself, and failures of the host's immune defenses. [7]

For example, changes in the vaginal pH that occur during menses and pregnancy and the
puerperium period make the vaginal environment more suitable for the growth of the
organism and provide increased access to the bloodstream. (Three fourths of the cases of DGI
occur in women; susceptibility is increased if the primary mucosal infection occurs during
menstruation or pregnancy.) [8, 9]

Defects in the host's immune defenses are also involved in the pathophysiology, with certain
patients more likely to develop bacteremia. Specifically, patients with deficiency in terminal
complement components are less able to combat infection, as complement plays an important
role in the killing of neisserial organisms. As many as 13% of patients with DGI have a
complement deficiency.

A study of 22 patients with DGI revealed that total serum complement activity was greater
than 25% below the normal mean. Other causes of immunocompromise (eg, HIV, SLE) also
predispose to dissemination of infection.

In addition, certain strains of gonorrhea causing asymptomatic genital infections are seen in
association with DGI. [10]

Etiology
N gonorrhoeae is a gram-negative, intracellular, aerobic diplococcus; more specifically, it is
a form of diplococcus known as the gonococcus. N gonorrhoeae is spread by sexual contact
or through vertical transmission during childbirth. It mainly affects the host’s columnar or
cuboidal epithelium. Virtually any mucous membrane can be infected by this microorganism.
The physiologic ectopy of the squamocolumnar junction onto the ectocervix in the adolescent
female is one factor that causes particular susceptibility to this infection.

Many factors influence the manner in which gonococci mediate their virulence and
pathogenicity. Pili help in attachment of gonococci to mucosal surfaces and contribute to
resistance by preventing ingestion and destruction by neutrophils. Opacity-associated (Opa)
proteins increase adherence between gonococci and phagocytes, promote invasion into host
cells, and possibly down-regulate the immune response.

Porin channels (porA, porB) in the outer membrane play key roles in virulence. Gonococcal
strains with porA may have inherent resistance to normal human serum and an increased
ability to invade epithelial cells, explaining their association with bacteremia.

Certain acquired plasmids and genetic mutations enhance virulence. TEM-1–type beta-
lactamase (penicillinase) affects penicillin binding and efflux pumps and confers resistance to
penicillin. [11, 12] TetM protects the ribosome and confers resistance to tetracycline. Alterations
in gyrA and parC genes result in fluoroquinolone resistance by efflux activation and
decreased antibiotic cell permeation. [11]

Gonococci attach to the host mucosal cell (pili and Opa proteins play major roles) and, within
24-48 hours, penetrate through and between cells into the subepithelial space. A typical host
response is characterized by invasion with neutrophils, followed by epithelial sloughing,
formation of submucosal microabscesses, and purulent discharge. If left untreated,
macrophage and lymphocyte infiltration replaces the neutrophils. Some gonococcal strains
cause an asymptomatic infection, leading to an asymptomatic carrier state in persons of either
sex.

The ability to grow anaerobically allows gonococci, when mixed with refluxed menstrual
blood or attached to sperm, to secondarily invade lower genital structures (vagina and cervix)
and progress to upper genital organs (endometrium, salpinx, ovaries).

Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual
contact or perinatally.

Sexually transmitted infection

Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual
contact. It also may be caused by inoculation of mucosa by contaminated fingers or other
objects. Transmission through penile-rectal contact is fairly efficient.

The risk of transmission of N gonorrhoeae from an infected woman to the urethra of her male
partner is approximately 20% per episode of vaginal intercourse and rises to 60-80% after 4
or more exposures. In contrast, the risk of male-to-female transmission approximates 50-70%
per contact, with little evidence of increased risk with more sexual exposures.

Persons who have unprotected intercourse with new partners frequently enough to sustain the
infection in a community are defined as core transmitters.

Neonatal and pediatric gonococcal infection

Neonatal gonococcal infection may follow conjunctival infection, which is obtained during
passage through the birth canal. In addition, direct infection may occur through the scalp at
the sites of fetal monitoring electrodes.

In children, infection may occur from sexual abuse by an infected individual or possibly
nonsexual contact in the child's household or in institutional settings.

Autoinoculation

Autoinoculation can occur when a person touches an infected site (genital organ) and
contacts skin or mucosa.

Risk factors

Risk factors for gonorrhea include the following:

 Sexual exposure to an infected partner without barrier protection (eg, failure to use a
condom or condom failure) [13]
 Multiple sex partners
 Male homosexuality
 Low socioeconomic status
 Minority status - Blacks, Hispanics, and Native Americans have the highest rates in
the United States
 History of concurrent or past STDs
 Exchange of sex for drugs or money
 Use of crack cocaine
 Early age of onset of sexual activity
 Pelvic inflammatory disease (PID) - Use of an intrauterine device (IUD)

Epidemiology
Occurrence in the United States

An estimated 820,000 new gonococcal infections occur annually in the United States, with a
significant number of cases likely unreported. [14] Per the CDC, gonorrhea is the second most
commonly reported communicable disease. [15] The national average in 2009 was 99.1 cases
per 100,000 population, a 10.5% decrease from 2008, with considerable state-to-state
variation (see the figure below). [16, 17] Men were apparently less likely than women to be
tested for gonorrhea, 20.7% vs 50.9%, respectively. [18] However, the infection rates between
men and women were similar (105.8 vs 108.7 cases per 100,000). [19]
 Gonorrhea rates, United States,
1941-2016. Courtesy of the Centers for Disease Control and Prevention (CDC).
View Media Gallery

One report estimated the annual cost of gonorrhea and its complications to be $162.1 million
(range, $81.1 million to $243.2 million). [20]

In the United States, the number of gonococcal infections peaked in the 1970s, the era of the
sexual revolution. With the onset of the HIV epidemic and the practicing of safe sex
techniques, the incidence dramatically decreased from 468 cases per 100,000 population in
1975 to 100-150 cases per 100,000 population at the turn of the century. The rate of reported
gonorrhea cases was at its lowest in 2009 but has been increasing overall since then. [21] Since
2016, more than 450,000 cases have been reported to the CDC, with a rate of 145.8 cases per
100,000 people, an increase of 18.5% from 2015. [22] The increased numbers have been
attributed to increased cases in males and persistently high rates in adolescents, young adults,
and certain racial/ethnic groups in defined geographic areas. [22]

Within the United States, carriage rates highly depend on the geographic area, the racial and
ethnic group, and sexual preferences. The rate of gonorrhea is much higher in African
Americans than in other racial groups [23] and is much higher in the rural southeastern United
States and in inner cities, presumably because of an association with socioeconomic and
behavioral factors, as well as with social networks.

In 2016, rates of infection ranged from about 479.9 cases per 100,000 population in the
District of Columbia to 20.1 cases per 100,000 population in Vermont. [24] The CDC supports
a campaign (Healthy People 2020) that targets a decreased incidence rate of 251.9 cases per
100,000 population among females aged 15-44 years and 194.8 per 100,000 population
among males of the same age by the year 2020.
 Rates of gonococcal infection per
100,000 by state and outlying regions (2016). Courtesy of the Centers for Disease Control
and Prevention (CDC).
View Media Gallery

In children who have been sexually abused, rates of recovery of gonorrhea range from 1% to
30%. In female adolescents who are sexually active, asymptomatic carriage of gonorrhea
occurs in 1-5%.

Resistant gonorrhea

The incidence of antibiotic-resistant strains of N gonorrhoeae has been rising since the late
1940s. Of greatest concern is the rise in the percentage of cases due to N gonorrhoeae with
higher minimum inhibitory concentrations (MICs) to ceftriaxone, the current treatment of
choice. In 2016, the Gonococcal Isolate Surveillance Project (GISP) found 0.3% of the tested
isolates had elevated ceftriaxone MICs. [25]

In May 2016, the first cluster of highly resistant gonorrhea infections in the United States was
identified in Hawaii. Most of the isolates showed decreased susceptibility to ceftriaxone, and
all cases had very high-level resistance to azithromycin. [26]

International occurrence

An estimated 98 million new cases of gonorrhea occur annually, according to World Health
Organization estimates. In comparison, an estimated 62 million new cases occurred in 1999
and 88 million in 2005. In 1999, the number of new cases of gonococcal infection diagnosed
in North America was 1.56 million; in Western Europe, 1.11 million; in South and Southeast
Asia, 27.2 million; and in Latin America and the Caribbean, 7.27 million.

Gonorrhea was the most common STD worldwide for at least most of the 20th century,
although since the mid-1970s, public health initiatives in the industrialized world have
resulted in declining incidence of the disease. As noted earlier, however, gonococcal
infection is still the second most common notifiable disease in the United States, and Western
European rates approximate those in the United States. [27, 28, 29]

Although the frequency data are unknown in most developing nations, these countries are
considered to have the highest rates of gonorrhea and its complications. Gonococcal infection
rates in pregnant women in the Central African Republic and South Africa were found to be
3.1% and 7.8%, respectively.
Resistant gonorrhea

The incidence of antibiotic-resistant strains has been rising since the late 1940s. Of greatest
concern historically has been the high percentage of cases due to penicillinase-producing N
gonorrhoeae. However, fluoroquinolone resistance has increased rapidly over the past decade
on most continents and within the United States. The CDC reported fluoroquinolone
resistance in 6.8% of 2004 isolates, 9.4% of 2005 isolates, and 13.3% of 2006 isolates. [6]

Race-related demographics

All sexually active populations are at risk for gonococcal infection, and the level of risk rises
with the number of sexual partners and the presence of other STDs.

Although race has no intrinsic effect on susceptibility to gonorrhea, the frequency of

gonorrhea in the United States is increased among urban dwellers, individuals of lower
socioeconomic status, and minorities of any population. This may be due to decreased access
to diagnosis and treatment; lack of adequate care (ie, education, diagnosis, and treatment),
leading to increased transmission rates; and/or reflection bias due to data collection site
preference (eg, urban emergency departments [EDs] and STD clinics), as well as true
differences in prevalence.

Overall, the African American–to–white ratio of gonococcal infections declined from 23:1 in
2002 to 18:1 in 2006. Infection rates have been trending downward since 1998. However,
between 2005 and 2006, the CDC noted a 6.3% increase in the rate of gonococcal infections
in African Americans. Subsequently, rates have begun to downtrend once again. (See the
figure below.)

Gonorrhea rates by race/ethnicity,

United States, 2012-2016. Courtesy of the Centers for Disease Control and Prevention
(CDC).
View Media Gallery

Compared with reported incidence in whites, the rate of reported cases was 8.6 times higher
in blacks, 3 times higher in native Hawaiians/Pacific Islanders, 1.7 times higher in Hispanics,
and 0.5 times higher in Asians. [21] From 2012-2016, the rate of gonorrhea increased among
all races and ethnic groups.

Sex-related demographics

The male-to-female ratio for gonorrhea is approximately 1:1.4; however, females may be
asymptomatic, whereas males are rarely asymptomatic. From 2015 to 2016, rates among
males increased approximately 22%, while rates in females increased 13.8%. The large
increase in diagnosis in males has been attributed to either increased transmission or
increased case documentation (increased extra-genital screening) among men who have sex
with men (MSM). [21]

Serious sequelae are much more common in women, in whom pelvic inflammatory disease
(PID) may lead to ectopic pregnancy or infertility and in whom DGI is more likely, owing to
menstruation, pregnancy, and a higher incidence in occult infection.

Age-related demographics

The highest incidence of gonococcal infection in the United States in 2016 was among adults
aged 20-24 years, in both men and women. [16, 17] This is likely due to the following (see the
figure below):

 Increased numbers of sexual partners

 Decreased access to or use of health care
 Physiologic ectopy of the squamocolumnar junction in females
 Decreased use of barrier contraceptives

Rates of reported gonorrhea cases

by age group and sex, United States, 2016. Courtesy of the Centers for Disease Control and
Prevention (CDC).
View Media Gallery

Infection in children is a marker for child sexual abuse and should be reported as such,
although a 2007 review provided some support for nonsexual transmission between children
and for transmission from adults to children related to poor hand hygiene. [30, 31]

Gonococcemia remains an important disease in the adolescent and young adult population,
with a peak incidence in males aged 20-24 years and in females aged 15-19 years.

Prognosis
With adequate early therapy, complete cure and return to normal function are the rule. Most
gonococcal infections respond quickly to cephalosporin therapy. Late, delayed, or
inappropriate therapy may lead to significant morbidity or, on rare occasions, death.

Complications in males
Urethral strictures secondary to gonococcal infection in men are less common than previously
thought. Some strictures in the preantibiotic era likely resulted from treatment by urethral
irrigation using caustic compounds rather than from the gonorrhea itself.

Other complications, such as penile lymphangitis, periurethral abscess, acute prostatitis,

seminal vesiculitis, and infection of the Tyson and Cowper glands, are now rare.

Complications in females

Tubal scarring and infertility are the major complications of gonococcal infection in females.
The incidence of involuntary infertility is estimated at 15% after one attack of pelvic
inflammatory disease (PID) and approximately 50%-80% after 3 attacks. (However,
infertility may be more common after chlamydial PID than after gonococcal PID, presumably
because the more acute inflammatory signs associated with gonorrhea prompt women to seek
diagnosis and treatment sooner.) Despite clinical and microbiological cure of infection, one
study showed 13% infertility rates in females with PID due to N gonorrhoeae infection. [32]

Failure to diagnose PID can result in acute morbidity, including tuboovarian abscess,
endometritis, Fitz-Hugh-Curtis syndrome (perihepatitis), and other chronic sequelae.
Perihepatitis secondary to gonorrhea presents as right upper quadrant pain and nausea.

The incidence of ectopic pregnancy is increased from 7-fold to 10-fold in women with
previous salpingitis, with resultant increased fetal and maternal mortality rates.

Gonococcal infections in women may also manifest as gonococcal urethritis or infection of

periurethral (Skene) or Bartholin glands.

Pelvic inflammatory disease

PID is generally the most feared complication of gonococcal infection, because it is one of
the leading causes of female infertility and often leads to hospitalization. This can be
devastating to any woman, especially an adolescent who potentially has many years of
childbearing ahead of her. In a 2011 study, female adolescents with PID were more likely
than older women to have a rapid recurrence of PID or to become pregnant despite reporting
more consistent condom use. [33] Ten to twenty percent of patients diagnosed with cervical
gonorrhea may develop PID.

Tubo-ovarian abscess and, rarely, tubal perforation with peritonitis and death, can occur,
especially if the tubo-ovarian abscess was recurrent. Females with recurrent PID have high
rates of ectopic pregnancy and infertility.

Epididymitis and orchitis

Epididymitis and orchitis occur infrequently in males who go untreated. These conditions
usually respond well to the same antibiotics used for uncomplicated urethritis, but the drugs
are administered for a longer course.

Arthritis
Gonorrhea is the most common cause of arthritis in the adolescent. However, arthritis (septic
or reactive) is a rare complication of this disease.

Because it mimics septic arthritis, excluding the possibility of gonococcal infection in any
adolescent with acute onset of pyogenic arthritis is important. Adequate diagnosis may
require culturing extraarticular sites for N gonorrhoeae.

Endocarditis

Endocarditis is a rare but serious complication of disseminated gonococcal infection,

affecting 1%-2% of cases. Prior to the era in which antibiotics were the primary treatment,
median survival was 6-8 weeks.

Additional complications

Complications of gonococcal infections also include the following [34] :

 Corneal scarring after ocular gonococcal infections

 Destruction of cardiac valves in gonococcal endocarditis
 Death from congestive heart failure related to endocarditis
 Central nervous system (CNS) complications of gonococcal meningitis

It has been suggested that a person with a gonococcal infection may be at a 3- to 5-fold
increased risk of acquiring HIV infection, if exposed to the virus.

DGI is an acute illness that causes fever, asymmetrical polyarthralgias, and skin pustules
overlying small joints in patients with gonorrhea. Disseminated infection may also lead to
meningitis or endocarditis.

In newborns, vertical transmission can cause conjunctivitis, known as ophthalmia

neonatorum, and permanent damage and blindness, if untreated.

Oral sex with an infected partner can result in pharyngitis, and, similarly, anal infection can
arise from anal sex or local spread from a vaginal source.

Patient Education
Discuss safe sexual practices with all individuals in whom gonorrhea is suspected. Proper
education to prevent gonorrhea may be more effective than simplistic instructions to avoid
sex, especially in the teenaged population. Teenagers involved with abstinence-only
campaigns have unchanged STD rates and disproportionately acquire anal and oral infections,
rather than vaginal infections (the perception being that if an activity is not vaginal sex, it is
not sex). Stress that oral or anal sex can also transmit disease.

Patients should know the method of disease transmission and the adverse impact of recurrent
infections on future fertility, they should be counseled about the risks of complications
following gonococcal infection and the risk of other STDs, and they should always be
instructed to refer any sex partners for prompt evaluation and treatment.
In addition, these individuals should be aware that they should avoid sexual contact until
medication is finished and until their partners are fully evaluated and treated. Thereafter, they
should avoid unprotected contact.

The discussion of responsible sexual behavior should not be limited or withheld because of
personal religious or moral views, because these may not be shared by the patient, and
teenagers are notorious for sexual experimentation; evidence suggests that offering only
limited discussion does the teenage population a huge disservice. This advice is especially
pertinent in states where sexual education is almost nonexistent in the school system because
of abstinence-only teaching, which is misleading and factually inaccurate.

In one study in Peru, a bundle of interventions that included extensive public health efforts,
including training of local medical personnel, specific and presumptive treatment, outreach to
female sex workers, and supply of barrier contraception, may have been effective at reducing
the prevalence of several STDs, although the effect did not reach statistical significance
overall.

The effects were more greatly pronounced (and significant) among female sex workers and
young adult women. The study was hampered by several methodologic limitations, such as
comparing different cities as controls, which made drawing conclusions from the data
difficult. [35]

Abstinence education

Although the most effective STD prevention is abstinence from sex, this is oftentimes an
unrealistic expectation, especially in the teenaged population. In fact, 88% of teenagers who
pledged abstinence in middle and high school still engaged in premarital sex. Moreover, they
tend to have riskier, unprotected sex because of their lack of education. Those who pledge
before having sex have been found to have a 33% higher prevalence rate of STDs than have
those who had sex and then retrospectively pledged, with nonpledgers falling in between.
This is despite a lower number of partners and an older age at first intercourse in pledgers.

Moreover, pledgers are less likely to be aware of their STD status and are less likely to seek
testing, even if their STD rates are similar overall (again, highlighting a lack of appropriate
sexual education).

Of course, abstinence should be explained to be the best option, but a more practical
expectation is abstinence from sex with someone known or suspected of having an STD until
treatment is obtained and completed. In light of the difficulty of knowing a potential partner's
sexual history (or honesty), strongly recommend the use of condoms as a reasonable
alternative to abstinence. [13]

Risks of unprotected sex

Patients should also be counseled about the additional risks of unprotected sex, including the
acquisition of more serious or lifelong infections such as herpes, hepatitis B, and HIV, and, of
course, about the risks of pregnancy. The emotional aspect of sexual relationships may also
need to be addressed, especially in teenage girls. Teenagers are vulnerable in that they are
sexually mature but not yet emotionally mature.
For patient education information, see the Sexual Health Center, as well as Sexually
Transmitted Diseases, Gonorrhea, and Chlamydia.

Patient education materials are also available at The Centers for Disease Control and
Prevention (CDC) Website (Sexually Transmitted Diseases – Gonorrhea) and from many
local public health departments