Snapshot A 19-year-old female presents in the clinic with a 3-day history of low grade fever and abdominal pain. There is no nausea, diarrhea, or vomitting. Last menstrual period was a week ago. She is sexually active with one partner but uses condoms infrequently. Temperature is 100.9°F (38.3°C). On pelvic exam there is a mucopurulent exudate and bilateral cervical motion tenderness. Serum β-hCG is negative. Urinalysis is positive for leucocyte esterase and cultures are pending. Her leukocyte count is 16,000/mm3. Cervical and urethral swabs were sent out for culture. A Gram stain of the exudate revealed intracellular diplococci within the polymorphonuclear neutrophils. Introduction STDs are one of the most common gynecologic ER presentations All sexually active partners should be screened for STDs Risk factors include multiple sexual partners unprotected sexual intercourse young age at first intercourse 25-50% have multiple genital tract infections Gonorrhea often has co-infection with chlamydia Presentation Symptoms dysuria urinary frequency purulent yellow-green discharge may progress to PID Physical exam solitary erythematous nodule on the penile shaft Disseminated gonococcal infections can present with either bacteremic or suppurative form bacteremic form: fever, chills, asymmetric arthralgias, tenosynovitis, and dermatitis suppurative form: septic arthritis Evaluation Cervical and urethral cultures chlamydia and gonorrhea Clean-catch urine culture to rule out UTI Saline/KOH/Gram stain of vaginal discharge Gram stain shows characteristic intracellular diplococci (kissing kidneys) Nucleic acid amplification testing if disseminated gonorrhea suspected Differential Chlamydial infections UTI Genital herpes simplex Syphilis Treatment Single dose of IM ceftriaxone or oral cefixime covers Neisseria gonorrhea Single dose of oral azithromycin (macrolide) covers coinfections (chlamydia) Oral single doses are best in STD patients because compliance is often an issue Prognosis, Prevention, and Complications Prognosis complete cure if treated early contact tracing essential, especially in females Prevention avoid sex use condoms screening at-risk patients sexual contacts of infected patients commercial sex workers Complications men prostatitis epididymitis orchitis women infertility chronic PID ectopic pregnancy both sexes disseminated infection leads to arthritis endocarditis meningitis