Gonococcal Urethritis Case (Gonorrhea, หนองในแท้): Diagnosis and Outpatient Management

👤 Patient Scenario

A 24-year-old male presents to the OPD with purulent urethral discharge and burning micturition for 2 days. He reports recent unprotected sexual intercourse with a new partner.

🌡️ Clinical Presentation:

1. Gonorrhea (หนองในแท้)

Purulent urethral discharge (thick, yellow-green)
Dysuria (burning sensation during urination)
Incubation: 2–7 days
May be asymptomatic in some men

2. Nongonococcal Urethritis (NGU; หนองในเทียม)

Mucoid or watery urethral discharge
Mild dysuria
Incubation: ~1–3 weeks
Common organisms: Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum

🔍 Investigations

1. Urinalysis (UA):

Detects pyuria and bacteriuria
Helps exclude urinary tract infection (UTI)

2. Urine Gram Stain (UGram):

May show Gram-negative diplococci (N. gonorrhoeae)
Presence of >5 WBC/HPF supports urethritis

3. Urethral Swab for Gram Stain:

If shows Gram-negative intracellular diplococci, confirms gonorrhea in symptomatic males

4. NAAT (Nucleic Acid Amplification Test):

Most sensitive test for both N. gonorrhoeae and C. trachomatis

5. Additional STI Panel:

HIV, Syphilis, Hepatitis B/C serologies

🧩 Patient Problem List

Urethritis with mucopurulent discharge
Dysuria with inflammatory urine findings
Positive Gram stain: Gram-negative intracellular diplococci
Unprotected recent sexual intercourse
Risk for coinfection with Chlamydia trachomatis

📌 Final Diagnosis

Urethritis caused by Neisseria gonorrhoeae

Likely coinfection with Chlamydia trachomatis

🏥 Management Plan

Setting: Outpatient Department (OPD)

Patient is stable and has no systemic signs → manage in OPD.

💊 Treatment Plan

Problem 1: Gonococcal Urethritis

Definitive Treatment:

Ceftriaxone 500 mg IM single dose
- If weight >150 kg → 1 g IM single dose
Doxycycline 100 mg PO bid × 7 days

Supportive Treatment:

Paracetamol (500 mg) PO q6h PRN for dysuria or fever
Hydration, rest, and abstain from sexual contact for 7 days

🧠 Patient Education

Importance of partner notification and treatment
Condom use in future sexual activity
Risks of untreated gonorrhea: epididymitis, infertility, or DGI (disseminated gonococcal infection)