A 24-year-old man comes to the office due to 3 days of urethral discharge and a burning sensation with urination. He had sexual intercourse with a new female partner a week ago and has had 4 female sexual partners over the past 6 years. The patient has no other medical conditions and takes no medication. He does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Examination shows no skin lesions or rash. The abdomen is soft and nontender. Genital examination shows copious, purulent discharge from the urethral orifice. Nucleic acid amplification testing (NAAT) result from the urine specimen is positive for Neisseria gonorrhoeae. HIV testing is negative. Antibiotic therapy is prescribed. Which additional test is indicated in this patient?
Sexually transmitted infection screening* | |
All patients |
|
Additional testing for certain populations |
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*For patients with active sexually transmitted infection or those who request screening. NAAT = nucleic acid amplification testing; RPR = rapid plasma reagin. | |
This patient with a new sexual partner and copious urethral discharge has Neisseria gonorrhoeae infection. N gonorrhoeae and Chlamydia trachomatis are the most commonly reported communicable diseases in the United States, and coinfection occurs in up to 40% of cases. Patients diagnosed with a sexually transmitted infection (STI) and those who ask for screening for an STI should undergo evaluation for the following:
Women who request STI screening should also be tested for Trichomonas vaginalis using microscopy with wet mount or NAAT (if suspicion is high and wet mount is negative); however, routine screening in men is not recommended because the infection is often asymptomatic and transient (<10 days) (Choice C). Herpes simplex virus screening is generally reserved for those who have recurrent vesicular, papular, or ulcerative genital lesions characteristic of the disease (Choice A).
Patients with an STI should be counseled on safe sexual practices and encouraged to inform recent partners of infection (with a recommendation to get tested).
(Choice B) Human papillomavirus screening is generally reserved for women (eg, cervical) or men who have sex with men (eg, anal). Screening is focused on identifying oncogenic strains or cytologic abnormalities associated with those strains to reduce patients' risk of cancer. Routine screening in heterosexual men is not recommended.
(Choice D) Additional screening is recommended to identify common coinfections to prevent progression (eg, neurosyphilis) and limit spread to others.
Educational objective:
Patients with Neisseria gonorrhoeae infection are at risk for coinfection with other sexually transmitted pathogens, including Chlamydia trachomatis, HIV, and Treponema pallidum (syphilis). Patients should be screened for these infections, counseled on safe sexual practices, and given appropriate antibiotics.