Gonorrhea (gonorrhea) is a classical sexually transmitted disease caused by infection with Neisseria gonorrhoeae (gonococcus) and manifests mainly as purulent inflammation of the mucous membranes of the genitourinary system. The most common manifestation in men is urethritis, while in women it is cervicitis. Local complications are mainly epididymitis and prostatitis in men, and endometritis and pelvic inflammatory disease in women. The pharynx, rectum and conjunctiva may also be the primary sites of infection. Blood-borne transmission of gonococci can lead to disseminated gonococcal infection (DGI), but it is rare clinically.
1. Epidemiological history.
History of unsafe sex, multiple sexual partners or sexual partner infection, history of close contact with gonorrhea patients, history of sexual abuse in children, history of gonorrhea in mothers of newborns.
2. Clinical manifestations.
(1) Uncomplicated gonorrhea.
(1) Uncomplicated gonorrhea in men: gonococcal urethritis is the most common manifestation in men, and about 10% of infected patients are asymptomatic. The incubation period is 2-10 d, often 3-5 d. Patients often have painful urination, stinging urethra or urinary urgency and frequency. The patient’s urethral discharge starts as mucus and is small in volume, and after a few days a large amount of purulent or purulent blood discharge appears. The urethral orifice is flushed and edematous. In severe cases, glans glabris may appear, manifesting as redness and swelling of the glans and inner plate of the foreskin, with exudate or erosion, and edema of the foreskin, which may be complicated by foreskin impaction; the inguinal lymph nodes are red and painful. Occasionally, urethral fistulas and sinus tracts are seen. A small number of patients may present with posterior urethritis, marked urinary frequency, perineal swelling, and painful penile erection at night. Patients with obvious signs and symptoms, even if untreated, usually have a gradual reduction of symptoms in 10-14 d. Symptoms largely disappear after 1 month, but are not cured and may continue to spread to the posterior urethra or upper genital tract and even develop complications.
② uncomplicated gonorrhea in women: about 50% of women infected have no obvious symptoms. It is often difficult to determine the incubation period because of the insidious nature of the disease.
a. Cervicitis: increased, purulent vaginal discharge, congestion, redness and swelling of the cervix, mucopurulent discharge from the cervical orifice, and itching and burning sensation of the vulva may be present.
b. Urethritis: painful urination, urgency, frequency or hematuria, congestion at the urethral orifice with tenderness and a small amount of purulent discharge, or purulent discharge after squeezing the urethra.
c. Vestibular adenitis: usually unilateral, with limited elevation of the labia majora area, redness, swelling, heat and pain. Abscesses may form, with fluctuating sensation on palpation and significant local pain, which may be accompanied by systemic symptoms and fever.
d. Perianal inflammation: perianal flushing, mild edema, purulent exudate on the surface, with itching.
③Gonorrhea in children.
a. Male children mostly have urethritis and prepuce glansitis with painful urination and urethral discharge. Examination reveals redness and swelling of the foreskin, flushing of the glans and urethral orifice, and purulent urethral discharge.
b. Young girls present with vulvovaginitis, with painful urination, frequent and urgent urination, and purulent vaginal discharge. Examination reveals redness and swelling of vulva, vagina and urethral orifice, and purulent discharge from vagina and urethra.
(2) Complicated gonorrhea:
(1) Men with complicated gonorrhea.
a. Epididymitis: often unilateral, with swollen and painful epididymis and reflex throbbing pain in the groin and lower abdomen on the same side. Examination reveals enlargement of the scrotum on one side, edema, redness and fever of the scrotal skin, swollen and painful epididymis on palpation, and purulent discharge visible at the urethra.
b. Seminal vesiculitis: fever, frequent urination, urgent urination, painful urination, terminal hematuria, hematospermia, and pain in the lower abdomen in the acute phase. Rectal examination may palpate enlarged seminal vesicles with severe tenderness.
c. Prostatitis: in the acute stage, there are chills and fever, frequent urination, urgent urination, painful urination or difficulty in urination, terminal hematuria or purulent discharge from the urethra, discomfort in the perineum or suprapubic area, rectal distention, and a feeling of defecation. Rectal examination shows an enlarged prostate with tenderness. Severe cases may be complicated by acute urinary retention and prostate abscesses.
d. Paracolic gland (Tyson’s gland) or paraurethral gland inflammation and abscess: rare (<1%), painful swelling on one or both sides of the tether with pus draining through the glandular ducts.
e. Urethral bulbous gland (Cowper’s gland) inflammation and abscess: rare, with throbbing pain in the perineum, painful defecation, acute urinary retention, and a palpable mass on rectal finger examination.
f. periurethral cellulitis and abscess: rare, painful and swollen on the side of the abscess, rupture producing a fistula. Fluctuating masses with tenderness may be palpable on physical examination. Commonly in the navicular fossa and bulb.
g. Urethral stricture: rare, narrowing of the urethra due to periurethral cellulitis, abscess or fistula formation. Presence of urinary tract obstruction (weakness, difficulty in urination, gonorrhea) and urinary frequency and retention.
②Women with complications of gonorrhea: Upstream infection with gonococcal cervicitis can lead to gonococcal pelvic inflammatory disease, including endometritis, tubal inflammation, tubal ovarian cysts, pelvic peritonitis, pelvic abscesses, and perihepatitis. Gonococcal pelvic inflammatory disease can lead to infertility, ectopic pregnancy, chronic pelvic pain, and other adverse consequences.
a. Pelvic inflammatory disease: clinical manifestations are non-specific and may include systemic symptoms such as chills, fever (>38°C), loss of appetite, nausea, vomiting, etc. Lower abdominal pain, irregular vaginal bleeding, abnormal vaginal discharge. Abdominal and pelvic examinations may include lower abdominal pressure, cervical lifting pain, adnexal pressure pain or palpable masses, and purulent discharge from the cervical opening.
b. Perihepatitis: manifests as sudden pain in the upper abdomen, which increases with deep breathing and coughing, accompanied by systemic symptoms such as fever, nausea and vomiting. There is obvious pressure pain in the right upper abdomen on palpation, and a small amount of pleural effusion on the right side is seen on X-ray chest X-ray.
(3) Other sites of gonorrhea.
(1) Ocular conjunctivitis: It is often acute purulent conjunctivitis, with symptoms appearing 2-21 d after infection. Gonococcal conjunctivitis is often bilateral in newborns, and may be unilateral or bilateral in adults. The conjunctiva is congested and edematous with more purulent discharge; the sclera has patches of congestive erythema; the cornea is cloudy and hazy, and in severe cases corneal ulceration or perforation may occur.
② pharyngitis: seen in those who have oral sex. more than 90% of infected patients have no obvious symptoms, a few patients have dry throat, pharyngeal discomfort, burning or painful feeling. Examination reveals congestion of the pharyngeal mucosa and mucus or purulent secretions from the posterior pharyngeal wall.
(iii) Proctitis: It is mainly seen in those who have anal sex and can be caused by contamination of vaginal secretions in women. Usually there are no obvious symptoms. In mild cases, there may be anal itching and burning sensation, mucus or mucopurulent discharge from the anal opening, or a small amount of rectal bleeding. In severe cases, there are obvious symptoms of proctitis, including rectal pain, urgency, and pus and blood stools. Examination reveals congestion, edema, and erosion of the anal canal and rectal mucosa.
(4) Disseminated gonorrhea:
It is rare clinically.
(1) Disseminated gonorrhea in adults: Patients often have fever, chills, and general malaise. The most common is arthritis-dermatitis syndrome with a hemorrhagic or pustular rash at the extremity sites. Small joints of the fingers, wrists and ankles are often involved, with arthralgia, tenosynovitis or septic arthritis. A few patients may develop gonorrheal meningitis, endocarditis, pericarditis, myocarditis, etc.
(2) Neonatal disseminated gonorrhea: rare, gonorrheal sepsis, arthritis, meningitis, etc. may occur.
3. Laboratory tests.
①Microscopic examination: take a smear of male urethral secretion for Gram staining, and microscopic examination of polymorphonuclear cells is positive for Gram-negative diplococci. It is suitable for the diagnosis of gonorrhea in men without comorbidities and is not recommended for the diagnosis of pharyngeal, rectal and female cervical infections.
②Gonococcal culture: for the confirmatory test of gonorrhea. It is suitable for gonococcal examination in men, women and all clinical specimens.
③Nucleic acid test: detects positive gonococcal nucleic acid in all types of clinical specimens by PCR and other techniques. Nucleic acid testing should be carried out in laboratories accredited by relevant institutions.
4. Diagnostic classification.
Diagnosis should be made carefully based on comprehensive analysis of epidemiological history, clinical manifestations and laboratory test results.
① suspected cases: meet the epidemiological history and clinical manifestations of any one of them.
②Confirmed cases: those who meet both the requirements of suspected cases and any of the laboratory tests.