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18 Dermatology andPruritus Ani
253
• Scrapings can also be examined for hyphae
with KOH prep, but this test is rarely available
because of the lack of trained and experienced
personnel.
• It is essential to have discussed the proper
arrangements with the laboratory and nursing
personnel (clinic and operating room) to
assure adequate specimen handling and testing well before obtaining a specimen.
• In patients with diarrhea, bacterial stool cultures as well as ova and parasites on three different stool samples can be useful.
• In patients with suspected or conrmed streptococcal or staphylococcal perianal infections,
nasal or throat swabs rarely detect the offending bacteria and therefore are unnecessary.
• If pinworms are suspected, a cellophane or
scotch tape test in the early morning identies
adult worms and their eggs and conrms the
diagnosis.
Patch Testing
• Patients with an extensive list of allergies,
both dietary and drug-related, are good candidates for patch testing.
• This usually involves a dermatologic consultation, which can be very helpful when the
staff has a particular interest in perianal dermatology (Table18.4).
• It is important to also test the patient’s own
products as these have been shown to be a signicant etiology in pruritus ani.
Table 18.4 Patch test ndings in 58 consecutive patients
suspected of having allergic contact anal eczema (26)
Contact allergen N (%)
Thimerosal 11 (19)
Patients’ own products 6 (10)
Balsam of Peru (Myroxylon pereirae) 5 (9)
Amerchol 3 (5)
Lanolin alcohol 3 (5)
Nickel sulfate 3 (5)
Fragrances/perfumes 3 (5)
Lidocaine, benzocaine 2 (3)
Propolis 1 (2)
Neomycin 1 (2)
Anoscopy: Proctoscopy
• All patients with pruritus ani should undergo
anoscopy and exible sigmoidoscopy.
• Full colonoscopy is indicated for patients who
are age-appropriate for colorectal cancer
screening and those with hematochezia, irondeciency anemia, and positive family history
of colorectal cancer.
Biopsy
• Skin lesions not responding to treatment or
suspicious for malignancy require biopsy.
• This is the single most valuable test in patients
with primary pruritus ani and should include
an area of the lesion with adjacent normal
skin.
• Specic query should be made to a pathologist
with expertise in dermatologic pathology with
clinically suspected diagnoses.
• Biopsy may conveniently be done with either
an 11 blade or skin punch blades (Keyes dermal punches).
Evidence-Based Management
• The management of dermatologic diseases of
the anus in practice is particularly challenging
for several reasons.
– These conditions are hidden on a part of the
body often associated with embarrassment,
and therefore patients may have advanced
disease before they present to a doctor for
help.
– Additionally, there is limited class A data
regarding the management of pruritus
ani.
Aims ofTreatment
• The aims of treatment for any form of anal
dermatitis are rapid relief of symptoms, healing of dermatitis, and prevention of
recurrence.
254
W. B. Gaertner and G. B. Melton
• Long-term recurrence can be prevented in
many patients by avoiding contact with allergens and irritants, as well as curing the underlying anorectal disease or condition.
Primary Prutitis Ani
• Because primary or idiopathic pruritus ani is
more common, a therapeutic trial of generic
management is recommended.
• This will be effective in more than 90% of
patients.
• This management strategy focuses on reestablishing ideal anal hygiene and providing
reassurance that there is no underlying condition causing the symptoms.
– Treatment begins with avoiding known
irritants such as soaps, lotions, creams, perfumed powders, medicated baby wipes,
and any product with witch hazel.
– The patient must also know to avoid further
trauma to the perianal skin, which may be
caused by scratching, dry toilet paper, and
vigorous scrubbing with bathing.
• Gently blotting the skin clean with
moist toilet paper, a cotton ball, or a
soft, unscented, and non-medicated
baby wipe is recommended.
– An important part of the initial manage-
ment of primary pruritus ani is to avoid
moisture and keep the perianal area dry.
– Patients should avoid tight-tting, syn-
thetic undergarments and may also use a
small piece of cotton or makeup removal
pad to help soak up any excess moisture.
– The brief use of a hair dryer with cool air is
an excellent way to keep the perianal skin
dry after cleansing.
– Unscented Dove® (Unilever, London, UK)
is free of conventional soap and is the preferred bathing agent.
– It is also important for patients to maintain
regular bowel movements of normal
consistency.
• This is especially useful to avoid seepage and fecal contamination of the perianal skin.
• A high-ber diet without excessive uid
intake and the judicious use of loperamide or cholestyramine is recommended, as needed.
• As mentioned earlier in this chapter, an
elimination diet excluding “high-risk”
dietary components such as coffee, tea,
chocolate, soda, and alcohol for 2weeks
can be strongly considered in most
patients with primary pruritus ani.
• In those patients in whom the initial management strategy is not effective after 4–6weeks,
attention is directed toward excluding the
multiple potential causes of secondary pruritus ani.
– If no secondary cause can be found, topical
therapy is recommended (Table18.5).
– Topical steroids are an effective and safe
treatment option.
• First-line topical treatment includes
preparations with a low-potency topical
steroid such as 1% hydrocortisone,
which should not be given for more than
8weeks.
• Potent or extended use of topical steroids should be avoided as they can lead
to skin atrophy, infections, and worsened pruritus ani (Fig.18.10).
– Capsaicin has also been studied in a ran-
domized fashion in 44 patients with primary pruritus ani.
• This topical agent decreases levels of
substance P, a neuropeptide that triggers
itching and burning pain.
• Topical capsaicin (0.006%) showed
relief of symptoms in 70% of patients as
compared to 2% patients who received
placebo (1% menthol).
• The majority of patients with moderate symptoms and minimal skin changes will respond
well to low-dose topical steroids or topical
capsaicin.
• These preparations are applied at night and in
the morning after bathing.
• If topical steroids are used, a tapering regimen
should be set in place ending with substitution
of a barrier cream such as Calmoseptine®
(Calmoseptine, Inc., Huntington Beach, CA).
18 Dermatology andPruritus Ani
Table 18.5 Marketed topical products most commonly prescribed for the treatment of perianal dermatitis (66)
Active ingredients Brand name(s)
Single active agents
Hydrocortisone Procto-Kit, DermoPosterisan
Tribenoside Borraza G
Cinchocaine Dolapostern
Glyceryl trinitrate Rectogesic
Corticosteroids+local anesthetics
Hydrocortisone + pramocaine or cinchocaine or lidocaine or
benzocaine + amylocaine + aesculin
Prednisolone + cinchocaine or+desonide + lidocaine + heparin +
vitamins A and E
Diucortolone + lidocaine Neriproct
Fluocinonide + lidocaine Jelliproct
Fluocortolone + lidocaine or cinchocaine Doloproct, Ultraproct
Fluocinolone + lidocaine (+ menthol + bismuth) Synalar Rectal
Corticosteroids+antimicrobials/antiseptics
Hydrocortisone + benzyl benzoate + Peru balsam + bismuth + zinc
with or without resorcinol
Corticosteroids+local anesthetics+antimicrobials/antiseptics
Hydrocortisone + cinchocaine with neomycin + aesculin or
framycetin
Local anesthetics+antimicrobials/antiseptics
Cinchocaine + polycresulin Faktu
Other combinations
Trimebutine + ruscogenin Proctolog
Peru balsam + bismuth + zinc Anusol
Hydrocortisone + Escherichia coli suspension Posterisan
Hydrocortisone + phenylephrine + parafn oil + sh oil Preparation H
Lidocaine + carraginates + zinc Titanoreine
Products with >10,000 prescriptions in 2011 according to IMS data for Brazil, France, Germany, Japan, the UK, and the
USA
Pramosone, Proctofoam, Proctocreme HC,
Porctosedyl, Xyloproct
Scheriproct, Cirkan
Anusol HC
Proctosedyl
255
• Patients with chronic perianal skin changes
should be managed with a medium- or highpotency steroid (Table18.6).
– It is important to emphasize to patients that
a high-potency steroid should be used for a
limited period of time, generally 4–8weeks.
– Once normalization of the skin has
occurred, patients are switched to a mild
steroid that can be further tapered down to
bi-weekly applications until total
elimination.
• Nonirritating cleansers are highly recommended during the initial therapeutic trial.
– Dilute white vinegar (one tablespoon in an
8-ounce glass of water) on a cotton ball is a
cheap and effective non-soapy cleanser.
– Tea tree oil, a volatile oil with antibacterial
and antifungal properties, works well for
patients with moist perianal skin and
pruritus.
• Patients who come to the ofce with acute
moderate-to-severe changes of the perianal
skin may be treated with Berwick’s dye (crystal violet 1%+brilliant green 1%+95% ethanol 50%+distilled H2O q.s.ad. 100%).
– Dried with a hair dryer and subsequently
covered with benzoin tincture as a barrier
and dried similarly.
– This topical treatment will stay in place for
several days if only water is used to cleanse,
relieves symptoms rapidly, and allows for
reepithelialization of broken-down skin.
256
Fig. 18.10 Chronic skin changes of atrophy and ulcerations secondary to pruritus ani with associated left buttock infection in a patient who had been taking steroids
for 8years
W. B. Gaertner and G. B. Melton
Table 18.6 Relative potency of topical steroids
Group 1 (most potent)
Betamethasone dipropionate 0.05% (Diprolene®)
Clobetasol propionate 0.05% (Temovate®)
Group 2
Desoximetasone 0.25% (Topicort®)
Fluocinonide 0.05% (Lidex®)
Group 3
Betamethasone valerate ointment 0.1% (Valisone®)
Triamcinolone acetonide 0.5% (Aristocort®)
Group 4
Desoximetasone 0.05% (TopicortLP®)
Flurandrenolide 0.05% (Cordran®)
Group 5
Betamethasone valerate cream 0.1% (Valisone®)
Hydrocortisone butyrate 0.1% (Locoid®)
Triamcinolone acetonide 0.1% (Kenalog®)
Group 6 (least potent)
Alclometasone dipropionate 0.05% (Aclovate®)
Hydrocortisone 1%
Finne CO, Fenyk JR.Dermatology and pruritus ani. In:
Fleshman JW, Wolff BG, editors. The ASCRS textbook of
colon and rectal surgery. New York: Springer; 2007.
p.277–294. ©Springer
• Skin breakdown or maceration caused by
scratching or over-vigorous cleansing efforts
must be avoided.
• A combination of topical and systemic medications has shown the best results compared to
either alone.
– Doxepin (both topical and oral) and
hydroxyzine are effective adjuncts to
reduce or eliminate itching.
• Doxepin, a tricyclic antidepressant, possesses both anti-H1 and anti-H2
activities.
• Hydroxyzine, a potent H1 receptor
inverse agonist, has shown to have equal
antipruritic efcacy compared to oral
doxepin but with higher sedation effects.
– Patients may not be aware of nocturnal
scratching, and this can be a serious contributing factor in many cases of primary
pruritus ani.
• For intractable cases or primary pruritus ani,
intradermal injection of methylene blue has
been described with some efcacy (Fig.18.11).
– The presumed mechanism of symptomatic
improvement is through the destruction of
nerve endings.
– Intracutaneous and subcutaneous injec-
tion of 30mL of 0.25% bupivacaine with
1:200,000 epinephrine mixed with equal
volumes of 0.5% lidocaine at the anoderm and perianal areas in the operating
room.
– After this, 20 to 30mL of 0.5% methylene
blue was injected at the same sites using a
25-gauge spinal needle.
– Risk of full-thickness skin necrosis.
– Mentes et al. used a slightly different
technique.
• Intradermal and subcutaneous injection
of a mixture of 7–8mL of 2% methylene blue with equal volumes of 0.5%
lidocaine without previous local anesthesia or sedation.
• No major complications or cases of skin
necrosis were reported, likely due to a
smaller injected volume.
18 Dermatology andPruritus Ani
Fig. 18.11 Tattooing with methylene blue for severe
refractory idiopathic pruritus ani. (Courtesy of C.O Finne,
St Paul, MN)
Secondary Prutitis Ani
Infectious
• Bacterial infections of the perianal region
should be treated with systemic antibiotics.
• If a specic agent has not been identied, antibiotic coverage should include Gram-positive
and Gram-negative cocci.
• Parenteral antibiotics have been reported to be
especially useful with Staphylococcus aureus
infection.
• When refractory pruritus ani is associated
with cultures that show growth of Candida
albicans, antifungals should be given, especially in patients who are immunosuppressed
and diabetic or who were recently treated with
systemic steroids or antibiotics.
– We have seen good results with a combina-
tion of oral uconazole and topical luliconazole 1%, given for 2–3weeks.
257
– When dermatophytes are found in the set-
ting of pruritus ani, this associated fungal
infection should also be treated
appropriately.
• The treatment of erythrasma involves systemic antibiotics, typically erythromycin
250mg qid for 10days, or tetracycline may be
used as a second alternative.
• Silver sulfadiazine is an effective topical
adjunct in patients with bacterial perianal dermatitis, especially in patients with ulcerations
and ssuring skin as it sooths and promotes
reepithelialization.
Dermatologic
• With regard to anal eczema, both the European
and American Academy of Allergy, Asthma,
and Immunology guidelines recommend starting treatment with basic skin care.
• Keys to success include avoiding allergens,
irritants and tight constricting undergarments,
liberal use of warm sitz baths for comfort, and
keeping the affected area dry at all other
times.
• As mentioned above, gentle but thorough
cleansing of the perianal area with soap substitutes (i.e., Dove) is recommended during
bathing.
• When these methods fail, mild-to-moderately
potent topical corticosteroids for 2–3 weeks
periods are recommended.
• Topical calcineurin inhibitors such as tacrolimus and pimecrolimus are also effective for
reducing inammation and itch in patients
with anal eczema and also avoid skin atrophy.
• Although systemic gamma interferon and narrowband UVB therapy has shown promising
results in patients with atopic dermatitis as
well as cholestatic and uremic pruritus, no evidence in patients with pruritus ani exists.
• Treatment of atopic dermatitis begins with
providing a barrier such as Vaseline® (white
petrolatum USP) or Calmoseptine®
(Calmoseptine, Inc., Huntington Beach, CA)
and the use of anti-inammatory agents (systemic and topical) and antipruritic agents.
• Psoriasis is not a curable condition, but symptoms can be well controlled with mild topical
258
W. B. Gaertner and G. B. Melton
steroid preparations (i.e., 1% hydrocortisone
cream).
• Seborrheic dermatitis responds well to 2%
sulfur with 1% hydrocortisone or miconazole
lotion.
• Lichen sclerosus is initially managed with
topical steroids.
– Potent topical steroid creams, such as clo-
betasol 0.05%, for a short course
(4–6weeks) followed by less potent hydrocortisone cream are the mainstay of
treatment.
– Systemic steroids are given only for very
severe cases.
– Topical calcineurin inhibitors are effective
alternatives in patients who have failed
therapy with potent corticosteroids or who
have a contraindication for the use of
corticosteroids.
– Treatment with retinoid and testosterone
creams may be useful in selective cases.
• The treatment of lichen simplex chronicus or
neurodermatitis
– Begins with topical steroids to decrease the
inammation and break the itch-scratchitch cycle.
– Antihistamines, doxepin, or capsaicin
creams are effective adjuncts to topical
steroids.
– For patients who have a poor response to
topical steroids, topical acetylsalicylic
acid/dichloromethane or immunomodula-
tors, such as tacrolimus, have shown positive results.
• Treatment of perianal Paget’s disease requires
wide local excision.
– Soft tissue and skin reconstruction fre-
quently requires V-Y gluteal aps or skin
grafting, with the assistance of plastic
surgery.
– Recurrence of disease is common and may
occur up to a decade after initial excision;
therefore, regular and long-term follow-up
is imperative.
Systemic Diseases
• Effective treatment of pruritus ani in patients
with poorly controlled or exacerbated systemic disease involves appropriate management of the underlying disease.
• Appropriate skin cleansing, application of a
topical barrier, and antipruritic agents are the
mainstay of treatment.
• Cimetidine has been reported to eliminate
itching induced by lymphoma and polycythemia vera.
• In our experience, doxepin and gabapentin are
also effective antipruritic agents in patients
with systemically induced pruritus ani.
• Chronic itching in these patients may also lead
to lichenication and secondary infections;
appropriate systemic antibiotic or antifungal
therapy is warranted.
Sexually Transmitted Infections
CindyJ.Kin andMarkL.Welton
19
Key Concepts
• Nucleic acid amplication tests are superior to
culture to screen for Chlamydia trachomatis
and Neisseria gonorrhea infections. The best
specimens are vaginal or endocervical swabs
from women and rst catch urine samples
from men.
• Nucleic acid amplication tests for Chlamydia
trachomatis and Neisseria gonorrhea can be
used for rectal and oropharyngeal specimens
in addition to genital sites to increase the sensitivity of testing.
• If one suspects failure of standard antibiotic
treatment for gonococcal infection, then culture needs to be performed to evaluate antibiotic susceptibility.
• Infections causing rectal or genital ulcerations
increase the risk for infection with HIV in
both men and women, compared to patients
with non-ulcerative STIs.
• Patients diagnosed with syphilis should be
tested for HIV. Patients with HIV should be
regularly screened for syphilis.
• Empiric treatment for proctitis in populations
at high risk for STIs should be given at the
C. J. Kin (*)
Department of Surgery, Stanford University School
of Medicine, Stanford, CA, USA
e-mail: cindykin@stanford.edu
M. L. Welton
Corporate Department, Fairview Health Services,
Minneapolis, MN, USA
time of evaluation rather than waiting for test
results and should consist of treatment for
gonorrhea, chlamydia/lymphogranuloma
venereum, and genital herpes.
• Herpes simplex virus is a common cause of
proctitis in men who have sex with men and
may often present without visible external
ulcerations.
Introduction
• “Sexually transmitted diseases” (STD) and
“sexually transmitted infections” (STI) are
interchangeably used terms, but the latter has
been increasingly adopted to emphasize that
infections may not cause symptoms of disease
nor may they result in development of disease.
• Clinicians must maintain a high level of suspicion for STIs to avoid delays or errors in
diagnosis.
• A frank discussion of the patient’s sexual history should direct STI testing and empiric
therapy.
• A substantial proportion of patients with STIs
are completely asymptomatic.
– 7% of men who have sex with men (MSM)
undergoing screening for STI test will be
positive for at least one infection.
– HIV-positive MSM with an STI are twice
as likely to be being asymptomatic from
the STI than HIV-negative MSM with an
STI.
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_19
259
260
C. J. Kin and M. L. Welton
Screening Guidelines
forAsymptomatic High-Risk
Patients
• The predominant risk factor for contracting
STIs is high-risk sexual behavior.
• Other risk factors include current infection
with ulcerative STIs and HIV
seropositivity.
• MSM, especially those who engage in unprotected receptive anal intercourse, represent the
demographic group at greatest risk for STIs
and should undergo regular universal testing
for STIs.
• People in high-risk sexual networks such as
swingers are also at very high risk for STIs
and should also undergo universal testing for
STIs.
• A policy of universal testing can help to stop
the cycle of ongoing transmission of STIs
within these networks.
• MSM and other high-risk populations including prostitutes and swingers should undergo
testing for STIs (mainly, chlamydia and gonorrhea) at anorectal, oropharyngeal, and urogenital sites.
– Isolated non-urogenital infections repre-
sented the majority of infections in both
MSM and high-risk women.
Screening Guidelines
forSymptomatic Patients
• Symptoms of STIs may include painful or
painless perianal or genital lesions; rectal,
vaginal, or urethral discharge; or proctitis.
• Table 19.1 details the suspected etiologies,
recommended testing, and empiric therapy by
symptom class.
Perianal or Genital Lesions
• Lesions or other symptoms involving the anus
and perianal skin may be easily mistaken for
other diagnoses so physical exam of the perianal skin and anal canal is crucial.
• Genital lesions in young sexually active
patients are most likely to be genital herpes or
syphilis.
• Less commonly, chancroid and donovanosis
may also be the cause of genital ulcers.
• The genital lesions of molluscum contagiosum may cause pruritus.
• Painless lesions may be condyloma or other
HPV-related dysplasia.
• Empiric treatment of the most likely pathogen
should be started.
Table 19.1 Initial sexually transmitted infections (STI) testing and empiric therapy by symptom
Symptom Suspected etiology Testing Empiric therapy
Genital, anal,
perianal ulcers
Proctitis Gonorrhea
Proctocolitis Campylobacter, Shigella,
Enteritis Giardia Stool studies
HSV herpes simplex virus, LGV lymphogranuloma venerum, PCR polymerase chain reaction, NAAT nucleic acid amplication tests
Herpes
Syphilis
Chancroid
Donovanosis
Chlamydia
Syphilis
Herpes
and Entamoeba histolytica
LGV
Syphilis serology
HSV culture or PCR
HIV
H. ducreyi testing in settings
where chancroid is prevalent
Intra-anal swabs for chlamydia
and gonorrhea and HSV culture
or PCR
Stool studies
NAAT for chlamydia
Treatment for HSV or
syphilis depending on
clinical suspicion
19 Sexually Transmitted Infections
261
Proctitis
• Proctitis is inammation of the rectum, causing symptoms of anorectal pain, tenesmus,
and discharge (Fig.19.1).
• The suspected etiologic agents are N. gon-
orrhea, C. trachomatis, T. pallidum, and
HSV.
• Patient discomfort may preclude a proctoscopic examination, but intra-anal swabs for
chlamydia and gonorrhea and HSV can and
should be performed.
– Swabs should be taken before doing a rec-
tal exam with lubricant given its bacteriostatic properties.
• Infectious proctitis is often misdiagnosed as
inammatory bowel disease so it is important
to elicit a clear sexual history to help distinguish between the two.
• Anorectal pain and bleeding may also signal
the presence of a malignancy such as anal or
rectal cancer.
• Patients who present with both symptoms of
proctitis and an anal ulceration are very likely
to have HSV (83%) or gonorrhea.
• HIV-positive MSM presenting with proctitis
are:
– More likely than their HIV-negative
counterparts with proctitis to be infected
with HSV-1 (14% vs. 7%) or HSV-2 (22%
vs. 12%), lymphogranuloma venereum
(8% vs. 0.7%), or multiple STIs (18% vs.
9%)
– Equally likely to have chlamydia or
gonorrhea
• Empiric treatment for proctitis should be
given at the time of evaluation rather than
waiting for test results and should consist of
treatment for gonorrhea (ceftriaxone 250mg
intramuscular × 1), chlamydia/LGV (doxycycline 100mg bid×21 days), and HSV (valacyclovir 1g bid × 10days).
• Symptom management with topical anesthetics and stool softeners will also be helpful.
• When test results come back, the medication
regimen can be adjusted.
Proctocolitis
• Proctocolitis causes symptoms of proctitis
(anorectal pain, tenesmus, and discharge)
along with diarrhea and abdominal cramps.
• Lower endoscopy reveals inammation of the
rectal and distal colonic mucosa.
• Stool studies may reveal fecal leukocytes.
• The suspected etiologic agents include
Campylobacter, Shigella, and Entamoeba histolytica. LGV serovars of C. trachomatis may
also cause proctocolitis.
• The route of transmission may be oral or
oral-anal.
Fig. 19.1 Patients with STIs may present with proctitis,
characterized by anorectal pain, tenesmus, and mucopurulent discharge. Proctoscopy may not be possible due to
pain
Enteritis
• Symptoms of enteritis include diarrhea and
abdominal cramping; since the rectum is not
involved, patients will not present with proctitis symptoms.
• Enteritis acquired as an STI can be attributed
to oral-anal contact.
• The most common etiologic agent is Giardia
lamblia.
262
C. J. Kin and M. L. Welton
Diagnosis andManagement
ofSexually Transmitted Bacterial
Infections
Testing forChlamydia andGonorrhea
• Nucleic acid amplication tests (NAATs) are
86% sensitive and 97% specic for detecting
gonorrhea and chlamydia.
• NAATs can be used in all circumstances to
detect chlamydia and gonorrhea, except for
special circumstances involving prepubescent
boys and girls, and potential treatment failures
in which cultures are indicated.
Gonorrhea
Epidemiology
• Neisseria gonorrhea is the causative agent in
gonococcal infections.
– Second most common notiable communi-
cable disease in the USA
– Over 300,000 cases reported annually,
likely a gross underestimation of the actual
disease burden due to underdiagnosis and
underreporting
• Groups suffering from particularly high rates
include MSM, HIV-positive patients, African
Americans, adolescents, and young adults.
Clinical Presentation
• Men
– Urethritis manifesting as painful
urination.
– Epididymitis.
– Proctitis, in those who engage in anal
receptive intercourse.
– Disseminated infection can also occur.
• Women
– Tend to be asymptomatic although they can
cause cervicitis, urethritis, proctitis, and,
later, pelvic inammatory disease
Screening andTesting forN.
gonorrhoeae
• CDC recommends routine screening of oro-
pharyngeal, anorectal, and urogenital sites for
all MSM who are sexually active and at risk
for STI.
– Nucleic acid amplication tests (NAATs),
with at least 86% sensitivity and 97% specicity for detecting gonorrhea and chlamydia, are the recommended testing
method.
• First catch urine and urethral swab are
the recommended sample types for
men.
• In women, the recommended sample
types are vaginal swabs that can be
either self- or clinician-collected or
endocervical swab if a pelvic examination is also indicated.
• First catch urine in women may miss
10% of infections compared to the other
sample types.
• Rectal and oropharyngeal specimens
can also be tested with NAATs.
Treatment andManagement
ofGonorrhea
• For uncomplicated gonococcal infections, the
CDC recommends combination therapy with
ceftriaxone 250 mg intramuscular injection,
plus a single dose of oral azithromycin 1g or
a 7-day course of oral doxycycline 100 mg
twice daily.
• Azithromycin is preferred due to the high
prevalence of tetracycline resistance.
• Patients with allergies to cephalosporins can
be treated with a single oral dose of azithromycin 2 g, but N. gonorrhea isolates have
demonstrated resistance to azithromycin
(Fig.19.2).
• N. gonorrhea culture testing to evaluate for
antibiotic susceptibility should be performed
if treatment failure is clinically suspected, or
NAAT positivity persists.
• Patients who have undergone treatment for
gonorrhea should be referred to programs to
reduce STI risk and also undergo retesting for
gonorrhea at 3months.
• Sexual partners of infected patients in the
preceding 2 months should also undergo
treatment with ceftriaxone and
azithromycin.