Original Study
Culture of Non-Genital Sites Increases the Detection of Gonorrhea in Women

https://doi.org/10.1016/j.jpag.2010.02.003Get rights and content

Abstract

Study Objectives

Although gonorrhea may infect the cervix, rectum, or pharynx of women, culturing non-cervical sites is rare outside of sexually transmitted disease (STD) clinics. This study aims to compare rectal and pharyngeal gonorrhea prevalence in adolescent and adult women and to calculate the percentage of cases that would be missed with cervical culture alone.

Design

Retrospective review of two laboratory databases.

Setting

STD clinic (2006–2007) and urban children's hospital (2003–2007).

Participants

Adolescent women (age 14–21, n = 16,039) in the hospital database; adolescent (n=525) and adult (age >21) women (n = 1424) in the STD database.

Main Outcome Measures

Prevalence of gonorrhea by group and culture source.

Results

Cervical plus additional culture was performed in 76% of adult STD, 52% of adolescent STD, and 2% of adolescent hospital samples. Pharyngeal gonorrhea prevalence in the adolescent hospital (3.5%) was similar to adolescent STD (6.8%, P = 0.1) and adult STD (2.5%, P = 0.4) samples. Rectal gonorrhea prevalence in adolescent hospital (2.9%) was lower than adolescent STD (13.4%, P = 0.01) but not adult STD (5.2%, P = 0.6) samples. Pharyngeal gonorrhea occurred in 0.6–3.4% and rectal gonorrhea in 0–2.7% of women with a negative cervical culture. Culturing only the cervix missed 20–40% of adult STD, 14–26% of adolescent STD, and 11% of adolescent hospital infected cases.

Conclusions

Pharyngeal gonorrhea is as high in adolescent women from a children's hospital as in adult women from an STD clinic. Without pharyngeal culture, 11–26% of infected adolescent women would be missed. Increased pharyngeal testing may impact the gonorrhea epidemic among adolescent women.

Introduction

Genital gonorrhea is a national public health concern because of its high prevalence and ability to cause serious sequelae among infected women. The national prevalence of 118 genital cases per 100,000 women in 2007 is much higher than the goal of 19 cases per 100,000 women set by Healthy People 2010.1, 2 Ominously, surveillance shows that between 2004 and 2007, the prevalence in Cincinnati has increased from 193 to 267 cases per 100,000 women. While over 95% of women with cervical gonorrhea are asymptomatic,3 women with gonorrhea are at risk for serious consequences such as pelvic inflammatory disease4, 5 and disseminated gonococcal infections.6, 7 The high proportion of asymptomatic infections makes screening of “at risk” women necessary because untreated cases present risks to the patient and can lead to transmission to others. Thus, current guidelines recommend screening all sexually active women under age 26 for genital gonorrhea.8

In addition to the urogenital tract (cervix and urethra), gonorrhea can also infect the rectum and pharynx. In most of these cases, concurrent cervical infection is present. For example, older studies have shown that while up to 60% of adult women with cervical gonorrhea also have a positive rectal culture, isolated rectal infections are reported in 2–10% of cases.9, 10 Untreated rectal infections can lead to symptomatic proctitis and are a significant source of disease transmission for men who have sex with men. However, the consequences for women are not well defined. The overall prevalence of pharyngeal gonorrhea in women in older studies ranges from 2–5%, and up to 20% of women with cervical gonorrhea were co-infected at the pharynx.11, 12, 13 However, isolated pharyngeal infection occurred in only 2–5% of infected women. The clinical importance of untreated pharyngeal infections in women is still unclear. Some studies have shown spontaneous resolution of pharyngeal infection.14, 15 However, other studies have shown that pharyngeal gonorrhea in women can be transmitted to a male partner during fellatio.12, 13 It is estimated that up to 2% of gonococcal urethritis cases result from fellatio.11 In a 1989 study of adolescent women, routine pharyngeal culturing showed no isolated pharyngeal infections in a low risk (3.5% prevalence) population, and only 1% of infected women had isolated pharyngeal infections in a high risk (33% prevalence) population.16 We could find no recent studies examining the benefit of screening for asymptomatic rectal and pharyngeal gonorrhea in adolescent women.

In Cincinnati's sexually transmitted disease (STD) clinic, providers obtain a comprehensive sexual history and routinely screen women for asymptomatic rectal and pharyngeal gonorrhea if a history of oral or anal sex is given. In other settings, providers vary in their ability to obtain a complete sexual history, and culture of non-genital sites is a matter of provider choice. In either setting, some patients may under-report oral or anal sexual practices. Therefore, it is possible that the pharynx or rectum could be a reservoir for gonorrhea that helps to maintain high rates of infection in young women in Cincinnati.

There are three main objectives for this study: First, we wish to update the estimates that are several decades old of oral and rectal gonorrhea prevalence in women. Second, in our city, with its known high prevalence of genital gonorrhea, we wish to compare the prevalence of cervical, pharyngeal, and rectal gonorrhea in three groups: adolescent women 14–21 years old and adult women over 21years old attending an STD clinic, and adolescent women 14–21 years old seen at a children's hospital. Finally, we wish to determine if culturing the rectum and pharynx increases detection of gonorrhea in any of these groups above culture of the cervix alone. These findings may inform clinical decisions to offer screening for non-genital gonorrhea infections and may allow a cost-benefit analysis of expanded testing in the future. Such information may direct efforts to control the epidemic of gonorrhea in high-prevalence areas such as Cincinnati.

Section snippets

Materials and Methods

This study was a retrospective review of de-identified data from two sources. We reviewed two years of data (2006–2007) from an electronic clinical database at the local health department's STD clinic. From this database, we exported de-identified data that was limited to age, source of gonorrhea culture, and culture result. During this time frame, all gonorrhea testing was performed using culture, and nucleic acid amplification was not available. We stratified this sample into those aged 14–21

Results

From the STD clinic there were 1949 visits that included a cervical culture. Gender and race were not indicated in the STD database, so cervical culture was used as a proxy for female gender. Twenty-seven percent of women at the STD clinic (n=525) were age 14–21, matching the children's hospital sample, and the remainder (n=1424) were over age 21. From the children's hospital there were 16,039 patient visits made by adolescent and young adult females aged 14–21 years that included at least one

Discussion

We were surprised to discover that the prevalence of cervical and pharyngeal gonorrhea among adolescents seen in a children's hospital setting matched the rates of infection among adolescent women at an STD clinic. These findings are in contrast to those reported by Brown et al in a 1989 study.16 Additionally, we showed that among women seen at an STD clinic, the prevalence of pharyngeal gonorrhea is higher in adolescent women (age 14–21) than in adult women (over age 21), even with a practice

Conclusions

Our data reflect current practices, where culturing of non-genital sites is routine in an STD clinic and rare in an adolescent population of women. In the STD clinic, culturing of the cervix, pharynx, and rectum increases the number of infected women detected over single cervical culture, and should be advocated. Because adolescent women may not report sexual behaviors as accurately as adult women, “routine” culturing of the pharynx and rectum may improve the detection of infected individuals.

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