Setting: ambulatory clinic
CC: “It burns when I urinate.”
VS: T: 98°F
HPI: A 24-year-old man comes to the clinic complaining of burning on urination for the past 3 days. He feels “when I have to go, I really have to go in a hurry” happens 10 times a day. He is sexually active with both men and women. He has a creamy yellow discharge coming from his penis.
PMHX:
Herpes genital infection three times in past
Human immunodeficiency virus (HIV) test negative 6 months ago
Medications: none
PE:
Genital: discharge from urethra visible on slight pressure to glans of penis; no vesicular lesions
Joints: normal
Skin: normal
Initial Orders:
Urethral swab for Gram stain
Voided urine for nucleic acid amplification test (NAAT)
Chlamydia and gonorrhea testing
Urethral discharge tells you it is urethritis, not cystitis.
Dysuria + Urethral Discharge = Urethritis
What is the main difference between urethritis in men and cervicitis in women?
a. A urethral swab is used for Gram stain testing.
b. NAAT is required.
c. Chlamydia is the most common cause.
d. Ceftriaxone and azithromycin are used.
e. Cefixime is used.
Answer a. A urethral swab is used for Gram stain testing.
The management of urethritis in men and cervicitis in women is the same except for two points:
1. Gram stain testing for Neisseria gonorrhoeae is only used in men.
2. Women can do a self-administered swab into the vagina.
Otherwise, both cervicitis and urethritis are treated with ceftriaxone and azithromycin and both are most commonly caused by chlamydia. Neither should be treated with cefixime.
Neisseria gonorrhoeae
• Gram-negative diplococcus
• Chocolate agar growth medium
• CO2 needed
• Oxidase positive
On CCS, add HIV testing for every person with an sexually transmitted disease (STD). You will never lose points for hepatitis B testing and Venereal Disease Research Laboratory (VDRL) rapid plasma reagin (RPR) for syphilis.
The patient agrees to HIV testing.
Report:
Gram stain of urethral discharge: gram-negative diplococci inside multiple neutrophils (Figure 10-5)
Figure 10-5. Gram stain of urethral discharge from a male patient with gonorrhea shows gram-negative intracellular monococci and diplococci. (Reproduced with permission from the Public Health Agency of Canada.)
Additional written consent is not needed for HIV testing.
Neisseria grows on Thayer-Martin medium
• Antibiotics in media
• Vancomycin, colistin, and nystatin
• Kills off potentially competitive bacteria
Orders:
Ceftriaxone intramuscularly (IM)
Azithromycin orally
HIV test
VDRL-RPR
Treat both chlamydia and gonorrhea at the same time.
Chlamydia trachomatis
• It is an intracellular parasite.
• NAAT is the best test.
• Use doxycycline, azithromycin, or erythromycin.
Chlamydia is present in 50% of patients with gonorrhea.
Do not forget to “counsel,” “educate,” or “advise” on safe sex practices for any patient with an STD, as well as to do screening and treatment of the patient’s sexual partners. Without treating the partner, the patient will likely become reinfected.
The patient can leave to go home after the ceftriaxone and azithromycin are given. Directly observed therapy in the clinic for oral azithromycin is preferred. Cefixime orally is not as effective as ceftriaxone orally. The patient and his partner should return to discuss the HIV, hepatitis, and syphilis test in a week. A routine test of cure is not needed if the patient’s symptoms resolve.