Introduction to gonorrhea.
Gonorrhea is a purulent infection of the mucosal surface caused by Neisseria gonorrhoeae. It is transmitted through sexual contact or the birth canal. The CDC recommends that all patients with gonorrhea should be treated for possible chlamydial infection.
Clinical presentation.
(1) In women, the major genitourinary tract symptoms include
Vaginal discharge: Most commonly, the cervical discharge is thin, purulent, and mildly odorous. Many patients present with mild or no signs of cervicitis.
Difficulty urinating; bleeding between menstrual periods; painful intercourse; mild lower abdominal pain; if the infection progresses to pelvic inflammatory disease, symptoms include
Lower abdominal pain: mostly associated with pelvic inflammatory disease; increased vaginal discharge or purulent discharge of urethral mucus; dyspareunia: usually without urgency or frequency; active cervical tenderness; adnexal tenderness (usually bilateral) or adnexal masses; intermenstrual bleeding; fever, chills, nausea, vomiting (less common).
(2) In men, the main genitourinary tract symptoms include
Urethritis: the most common manifestation; early manifestations are burning sensation and plasmatic exudate; after a few days, the discharge increases, purulent, sometimes with blood.
Acute epididymitis: often unilateral, often occurring simultaneously with urethral discharge.
Urethral stricture: rare in the antibiotic era, but may present with reduced and abnormal urine flow, as well as secondary prostatitis and cystitis.
Rectal infection: may present with pain, itching, discharge, or urgency.
The classic presentation in men and women presenting with disseminated gonococcal infection is the arthritis-dermatitis syndrome. Joint or Achilles tendon pain is the most common manifestation in the early stages of infection. Septic arthritis appears in the later stages. The knee joint is the most frequently involved site.
(3) In newborns, bilateral conjunctivitis (neonatal ophthalmia) may develop, often occurring in mothers with untreated gonorrhea infection who deliver vaginally, and manifestations include
Ocular pain, redness, and purulent discharge.
Physical examination.
Females include.
Purulent or purulent vaginal, urethral, and cervical mucus discharge; vaginal bleeding; vulvovaginitis in children; increased cervical fragility – bleeds easily to palpation; tenderness with cervical movement on bimanual examination; adnexal fullness and/or tenderness, unilateral or bilateral (e.g., ovaries, hatching oviducts); lower abdominal pain/tenderness with or without rebound pain; may have lower back pain – more common with development of pelvic inflammatory disease; right upper abdominal tenderness (perihepatitis inflammation).
In men this includes.
Purulent or pus-like discharge of urethral mucus: cheese like urethra along the penis.
Possible epididymitis: unilateral epididymal tenderness and edema, with or without urethral discharge or dyspareunia.
Penile edema without other inflammatory manifestations Urethral stricture: uncommon: caused by irritation of the urethra with caustic fluids in the days when antibiotics were not available.
Diagnosis.
Culture is the most commonly used, followed by DNA probes and PCR tests and light chain reaction (LCR). DNA probes are detecting antigens and are used for the detection of gonococcal DNA in the specimen.
Test cultures are the standard for diagnosing gonococcal infection. It is more important in cases of unclear diagnosis, treatment failure, difficulties in follow-up, and legal implications.
Treatment.
For gonococcal infections of the genitourinary tract, anorectum, and pharynx without complications, treatment with ceftriaxone + azithromycin or doxycycline is indicated. In other cases, antibacterial drugs can be used alone or in combination with multiple drugs, as follows.
Gonococcal arthritis: ceftriaxone.
Gonococcal conjunctivitis: ceftriaxone.
Gonococcal pelvic inflammatory disease: ceftesidine, ceftriaxone, doxycycline, metronidazole, cefotetan, clindamycin, gentamicin.
Gonococcal epididymitis: ceftriaxone, doxycycline.
Disseminated streptococcal infection: ceftriaxone, cefotaxime, ceftizoxime.
Gonococcal meningitis and endocarditis: ceftriaxone.