GONORRHEA
Essentials of diagnosis
Most affected women are asymptomatic carriers.
Purulent vaginal discharge.
Frequency and dysuria.
Recovery of organism in selective media.
May progress to pelvic infection or disseminated infection.
General Considerations
Sites of infection include the cervix, urethra, rectum, and pharynx.
In addition, gonorrhea is a cause of PID.
Humans are the natural reservoir.
Gonococci are present in the exudate and secretions of infected mucus
membranes.
Neisseria gonorrhoeae is a gram-negative diplococcus that forms
oxidase-positive colonies and ferments glucose.
The columnar and transitional epithelium of the genitourinary tract is the
principal site of invasion.
The organism may enter the upper reproductive tract, causing salpingitis
with its attendant complications.
It has been estimated that after exposure to an infected partner, 20-50%
of men and 60-90% of women become infected.
Without therapy, 10-17% of women with gonorrhea develop pelvic
infection.
N gonorrhoeae is often present with other sexually transmitted diseases.
Traditionally, women with gonorrhea are considered to be at risk for
incubating syphilis.
It has been shown that 20-40% also has Chlamydia infection.
Symptoms and Signs
1. Early symptoms
Most women with gonorrhea are asymptomatic.
When symptoms occur, they are localized to the lower genitourinary tract
and include vaginal discharge, urinary frequency or dysuria, and rectal
discomfort.
The incubation period is only 3-5 days
Ninety-five percent of males with gonorrhea are symptomatic, with a
yellowish-green urethral discharge and burning on urination.
Both males and females can develop gonococcal proctitis and pharyngitis
after exposure.
2. Discharge
The vulva, vagina, cervix, and urethra may be inflamed and may itch or
burn.
Specimens of discharge from the cervix, urethra, and anus should be
taken for culture in the symptomatic patient.
3. Bartholinitis
Unilateral swelling in the inferior lateral portion of the introitus suggests
involvement of Bartholin's duct and gland.
Enlargement, tenderness, and fluctuation may develop, signifying abscess
formation
4. Anorectal inflammation
Anal itching, pain, discharge, or bleeding occurs rarely
5. Pharyngitis
Acute pharyngitis and tonsillitis rarely occur; most infections are
asymptomatic.
6. Disseminated infection
Asymptomatic carriers can develop systemic infection.
Commonly, a triad of polyarthralgia, tenosynovitis, and dermatitis is seen
or purulent arthritis without dermatitis.
7. Conjunctivitis
In adults, ophthalmic infection is usually due to autoinoculation.
Ophthalmia neonatorum may result from delivery through an infected
birth canal.
Complications
The major complication in the female is salpingitis and the complications
that may arise from salpingitis
It is important to note that asymptomatic carriers can also develop tubal
scarring, infertility, and increased risk of ectopic gestations.
Gonorrhea is complicated occasionally by perihepatitis and rarely by
endocarditis or meningitis.
Treatment
Any patient with gonorrhea must be suspected of also having other
sexually transmitted diseases (e.g. syphilis, HIV, and chlamydial
infection) and managed accordingly.
Treatment should cover N gonorrhoeae, Chlamydia trachomatis, and
incubating syphilis.
Dual therapy has contributed greatly to the declining prevalence of
chlamydial infections.
Therefore, if chlamydial infection is not ruled out, the regimens below
should be given with doxycycline (for nonpregnant patients) or
azithromycin.
A. Uncomplicated Infections
Guidelines issued by the Centers for Disease Control (CDC) for therapy
of uncomplicated infection in adults are as follows:
(1) Recommended regimens:
a) Ceftriaxone, 125 mg intramuscularly once, plus doxycycline, 100 mg
orally twice daily for 7 days (for nonpregnant patients), or azithromycin 1
g orally in a single dose if chlamydial infection is not ruled out;
b) Cefixime 400 mg orally once, plus doxycycline or azithromycin as
above; and
c) Ofloxacin 400 mg, levofloxacin 250 mg, or ciprofloxacin 500 mg, orally
once in nonpregnant, nonlactating patients over 17 years of age, plus
doxycycline or azithromycin as above.
(2) Alternative regimens:
a) Spectinomycin, 2 g intramuscularly once, followed by doxycycline or
azithromycin as above, for patients who cannot take cephalosporins or
quinolones (not reliable for pharyngeal infection);
b) Ceftizoxime, 500 mg, cefotaxime 500 mg, or cefoxitin 500 mg,
intramuscularly once with probenecid 1 g orally, plus doxycycline or
azithromycin as above; and
c) Gatifloxacin 400 mg, norfloxacin 800 mg, or lomefloxacin 400 mg orally
once in nonpregnant, nonlactating patients over 17, plus doxycycline or
azithromycin as above.
Precaution:
Pregnant women should not be treated with quinolones or tetracyclines.
They should be treated with a recommended or alternate cephalosporin.
If cephalosporins are not tolerated, spectinomycin 2 g IM should be given
along with treatment for diagnosed or presumptive C. trachomatis.
