218 PART II: PRIMARY CARE DISORDERS
may develop. Anorectal gonorrhea may present in men
or women who engage in unprotected receptive anal
intercourse. Symptomsinclude rectaldischarge,pain,or
tenesmus(spasmodiccontractionoftheanalsphincter).
Femalepatientsmaynothaveanysymptoms.Because
ofthis,screeningwomenwhoareatriskforinfectionor
presumptivetreatmentissometimeswarranted.Ifsymp-
toms are present, they may include vaginal discharge,
urogenitalitching,ordysuria.
Themajorcomplicationassociatedwithuntreatedgonor-
rheainwomenisPIDresultingfromtheascentofN. gonor-
rhoeae totheuppergenitaltract.SignsandsymptomsofPID
include fever, vaginal discharge, abdominal tenderness to
palpation,andadnexaltenderness.Infertilitymayalsobea
complication.
Menwithapeniledischargeareoftendiagnosedusing
a Gram stain examination of a urethral specimen that
reveals polymorphonuclear leukocytes with intracellular
gram-negativediplococci.Insuspectedcasesofendocervi-
cal,pharyngeal,orrectalinfection,Gramstainexamination
isnotrecommended.Inthesesituations,specimenculture
testing for N. gonorrhoeaeisrecommended.Aurinespeci-
menforculturetestingcanalsobeusedwhensymptoms
ofurethritisarepresent.Thereisnostandardizedserologi-
cal test available.
7
A patient with suspected or conrmed gonorrhea
shouldbepresumedtobecoinfectedwithchlamydiaand
treatedaccordingly(Table17–2).Patientswithgonorrhea
shouldalsobeevaluatedforundiagnosedHIVandsyphilis
infection.
Management
Thetreatmentof choice for uncomplicated gonorrheais
ceftriaxone, and unless coinfection with chlamydia has
beenruledout,doxycyclineorazithromycinisalsoadmin-
istered(Table17–2).Patientsshouldbeadvisedtoabstain
fromsexualintercoursefor7–10daysaftercompletionof
therapy,untilsymptomshaveresolved,andaftertheirsex
partnershavebeenadequatelytreated.
Although antibiotic-resistant cases of gonorrhea do
occur, the most common cause of treatment failure is
repeated exposure by the asymptomatic partner. There-
fore,sexualcontactswithina60-dayperiodoftheonset
ofsymptomsshouldbeevaluatedandtreatedforN. gonor-
rhoeae and C. trachomatis infections.
7
Urethritissymptomsthatpersistdespiteadequatetreat-
ment and abstinenceshould beevaluated forother pos-
siblepathogenssuchasMycoplasma genitalium, Trichomonas
vaginalis, and Ureaplasma urealyticum. Additionally, the
patientshouldbeevaluatedforchronicnonbacterialpros-
tatitisorchronicpelvicpainsyndrome,whichmaydevelop
asacomplication.
7
Syphilis
General Characteristics
Syphilis is an STI caused by Treponema pallidum. Left
untreated, it is capable of infecting virtually any organ
system in the body. The infection enters through minor
skinormucosalabrasionsandbecomesasystemicdisease
shortlyafterinfection.Asmallerosionatthesiteofinocu-
lationwilltypicallydevelop10to90daysafterexposure,
eventuallyresultinginapainlesssupercialulcer.
9
Syphilisisdividedintofourstagesofinfection:primary,
secondary,latent,andtertiarysyphilis.Leftuntreated,the
primarystageprogressestothetertiarystage.Theprimary
stageisdenedbythepresenceofanulcerorchancreat
the infection site. The secondary stage is dened by the
presenceofaskinrash,mucocutaneouslesions,andlymph-
adenopathy. Latent stages of syphilis begin when secondary
syphilissymptomsend,whichcanbefrom2yearstomore
than30yearsaftertheinitialinfection.Thelatentstageis
usuallydenedbytheabsenceofclinicalmanifestationbut
is detected through routine serological screening. The
latentstageisfurtherclassiedasearlylatent(usuallyno
symptoms,butitcanbeeasilytransmitted)andlatelatent
(almostalwaysnosymptoms,withalowriskoftransmis-
sion). Latent syphilis leads to the tertiary stage and is
denedbythepresenceofneurologic,cardiac,orophthal-
micmanifestations,auditoryabnormalities,orgummatous
lesions.
Signs, Symptoms, and Diagnosis
Primary syphilis usually presents with a painless ulcer-
ationknownasachancre(Figure 17–1).Thereisgenerally
lymphadenopathyassociatedwiththeprimarylesion.The
chancreismostoftenlocatedinthegenitalareabutmay
alsoappearontheoropharynxoranorectalarea.Itappears
asasupercialulcerationwithinduratedmargins.Healing
willoccurwithouttherapy,andthediseasethereforemay
goundetected.
Secondarysyphilisgenerallypresentsasadiffusemacu-
lopapular rash with constitutional symptoms weeks or
months after the primary lesion.
9
Classic presentation
involvesthesolesandpalms.Lesionsmayalsobepresent
on mucosal membranes, such as in the mouth, throat,
genitalia,andanus.Likethechancre,therashofsecond-
ary syphilis will eventually resolve on its own; thus the
infectionmaygoundetected.Latentsyphilismaydevelop
afterresolutionofthesecondarylesions.Inthisstagethere
Figure 17–1 Syphilitic chancre of the penis.
Source: Courtesy of CDC.

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