Case: Painful Urination

CASE STUDY: Man with Painful Urination

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Case: Sam Marx is a 46-year-old insurance agent who presents to your office with a chief complaint of dysuria and purulent urethral discharge for the past 3 days.

He is a divorced insurance agent living in Dallas.  He is engaged to a 46-year-old woman with whom he has unprotected sexual intercourse 2-3 times per week for the past 8 months—most recently as 2 nights ago.   Neither of them had an intimate partner for at least 6 months prior to their engagement.

Family History:  Father is alive with a history of hypertension and heart disease.  Mother is alive and well.  He has two grown sons who are both healthy.

Past Medical History:  Nonsmoker.  Drinks wine socially.  Diet is mostly vegetarian; he and fiancée enjoy cooking at home and shopping for fresh fruits and vegetables.  He runs four miles a day, 3 days/week with minimal joint pain.  Goes to the gym on the days he doesn’t run.  He takes an occasional NSAID for ‘aches and pains’ as well as antihistamines for seasonal allergies.

Physical Exam:

  • Vital signs: blood pressure 98/72, pulse 68, respiration 14, temperature 37.2°C.
  • Chest, heart, musculoskeletal, and abdominal exams within normal limits.
  • No flank pain on percussion, normal rectal exam, no sores or rashes.
  • The genital exam reveals a reddened urethral meatus, with a purulent discharge. No lesions or lymphadenopathy

Further questioning reveals that his fiancée is asymptomatic.  He mentions that 2 weeks ago he had three sexual encounters with a woman he met on a business trip.  They had unprotected vaginal sex and he has no information about her past sexual history.

 

What is wrong with Sam, and what might you do next?

Based on Sam’s symptoms alone, he might have either gonorrhea or chlamydia.  You decide to run some lab tests, which come back as follows:

  • Gram stain shows WBCs containing intracellular Gram-negative diplococci.
  • Urethral culture showed growth of oxidase-positive Gram-negative diplococci.
  • Nucleic acid amplification test (NAAT)  for chlamydia was negative.
  • RPR was nonreactive.
  • HIV antibody test was negative.

Based on his symptoms, behavior and confirmed by his lab tests, Sam has gonorrhea—one in a family of sexually transmitted diseases (STDs).  It is caused by Neisseria gonorrhoeae, an oxidase-positive, gram negative diplococcus that is typically spread by sexual contact.   Symptoms of gonorrhea usually appear 2 – 5 days after infection, however, in men, symptoms may take up to a month to appear.  It’s important to treat gonorrhea as soon as possible, as epididymitis or epididymo-orchitis may occur in men who are left untreated.  Although women with gonorrhea may be asymptomatic at first, it may be asymptomatic at first, untreated gonorrhea can lead to longer-tem health consequences, including chronic pelvic pain, ectopic pregnancy and infertility.  The presence of gonorrhea in the lower genital area can also increase the risk of contracting and transmitting HIV.[1]

Gonorrhea, considered one in a family of sexually transmitted diseases (STDs), is a very common infectious disease. In 2010, more than 300,000 cases of gonorrhea were reported to the Centers for Disease Control and Prevention (CDC).[2] However, CDC estimates that more than 700,000 people in the United States acquire new gonorrhea infections each year.[2]

While antibiotics have long been successfully used to treat gonorrhea, the bacteria has eventually grown resistant to every drug ever used to treat it, including sulfonamides, penicillin, tetracycline, and most recently fluoroquinolones. In 2007, due to widespread drug resistance, CDC revised its gonorrhea treatment guidelines to no longer recommend fluoroquinolones. This left only one class of antibiotics, cephalosporins — which includes the oral antibiotic cefixime and the injectable antibiotic ceftriaxone — to effectively treat the disease.[3]

Now, evidence from CDC suggests that cefixime is becoming less effective in treating gonorrhea.  To date, no patients have failed treatment with either cefixime or ceftriaxone in the United States. However, a small but growing number of cefixime treatment failures have been observed in other countries. This information, coupled with past experience and the latest U.S. surveillance data, suggest that it is only a matter of time before gonorrhea becomes resistant to the only remaining treatments currently available.[3]

For this reason, CDC updated its gonorrhea treatment guidelines in August 2012 and no longer recommends the routine use of cefixime.[3]

For patients with uncomplicated genital, rectal, and pharyngeal gonorrhea, CDC now recommends combination therapy with ceftriaxone 250 mg as a single intramuscular dose, plus either azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days.  In instances where ceftriaxone is not available, CDC recommends cefixime 400 mg orally, plus either a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days.  The use of azithromycin as the second antibiotic may be preferable to doxycycline because the dosage is easier and more convenient and because data suggest that there is a higher prevalence of gonococcal resistance to doxycycline than to azithromycin.

For patients with a severe allergy to cephalosporins, CDC recommends a single 2-gram dose of azithromycin orally.

According to the new recommendations, patients who have persistent symptoms should be retested with a culture-based gonorrhea test, which can identify antibiotic-resistant infections. The patient should return one week after retreatment for another culture test (‘test of cure’) to ensure the infection is fully cured.  No test of cure is required if the symptoms have abated following a single course of treatment.[4]

Every effort should be made to ensure that the sex partners of all patients with gonorrhea from the past 60 days—in this case both his fiancée and the woman from Las Vegas—are  evaluated and treated for gonorrhea with ceftriaxone and either azithromycin or doxycycline, if possible. If a partner cannot be brought in for treatment and you’re located in one of the states where it is permitted,  you might consider ‘expedited partner therapy’—having Sam deliver an oral combination regimen consisting of cefixime with azithromycin to both women without an intervening medical evaluation.[5]

Remind Sam to avoid all sexual contact while he is being treated for an STD.  He should have no sexual contact for 7 days after treatment so the medicine will have time to work.  Also reinforce the concept that having a cured gonorrhea infection does not protect him from becoming reinfected.

Sam returns to the office in 2 weeks and reports that he is completely asymptomatic.  According to the new guidelines, no test of cure is required and he can resume sexual relations with his fiancée.

Depending on what state you live in, your job may not yet be complete.  Gonorrhea is a reportable STD in all U.S. states and territories.  In most parts of the country, both the provider and the laboratory are required to report gonorrhea cases to the local health department.  Check here for links to your state health department for details about reporting requirements in your area.

Jill Shuman, MS, ELS
Published on October 2, 2012
Updated on October 9, 2012

 

References

  1. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. 1999;75:3–17.
  2. Centers for Disease Control and Prevention (CDC). 2010 Sexually transmitted diseases surveillance: gonorrhea. http://www.cdc.gov/std/stats10/gonorrhea.htm  Accessed August 24, 2012
  3. Centers for Disease Control and Prevention (CDC).  Gonorrhea treatment guidelines.  Revised guidelines to preserve last effective treatment option.  August 2012.  http://www.cdc.gov/nchhstp/Newsroom/docs/2012/GonorrheaTreatmentGuidelinesFactSheet8-9-2012.pdf
  4. Centers for Disease Control and Prevention.  Update to CDCs sexually transmitted disease treatment guidelines 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections.  MMWR Morb Mortal Wkly Rep. 2012;61(31):590-594.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w
  5. Hogben M, Kidd S, Burstein GR. Expedited partner therapy for sexually transmitted infections.  Curr Opin Obstet Gynecol 2012;Aug 17. Epub ahead of print.