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Gonorrhea

By Sheldon R. Morris, MD, MPH, Assistant Professor of Family Medicine and Public Health, University of California San Diego

Gonorrhea is a sexually transmitted disease caused by the bacteria Neisseria gonorrhoeae, which infect the lining of the urethra, cervix, rectum, and throat or the membranes that cover the front part of the eye (conjunctiva and cornea).

  • Gonorrhea is usually spread through sexual contact.

  • People usually have a discharge from the penis or vagina and may need to urinate more frequently and urgently.

  • Rarely, gonorrhea infects the joints, skin, or heart.

  • Microscopic examination, culture, or DNA tests of a sample of the discharge or DNA tests of urine can detect the infection.

  • Antibiotics can cure the infection, but resistance to the antibiotics used to treat gonorrhea is becoming more common.

In the United States, the number of new cases peaked at 464 per 100,000 people in 1975. In 2009, the number of new cases decreased to 98.1 per 100,000—the lowest number since recording of this information began. However, the number of cases gradually increased in subsequent years and, in 2014, reached 110.7 per 100,000. Most of this increase is due to an increase in the number of men who are diagnosed with gonorrhea. Part of the explanation may be that gonorrhea is becoming more common among men who have sex with men, but other factors may also be involved.

Gonorrhea is almost always spread through sexual contact. After one episode of vaginal intercourse without a condom, the chance of spread from an infected woman to a man is about 20%. The chance of spread from an infected man to a woman may be higher.

If pregnant women are infected, the bacteria can spread to the eyes of the fetus during birth, causing conjunctivitis in the newborn. However, in most developed countries, infection is prevented because all newborns are routinely treated after delivery with medicated eye ointment.

Many people with gonorrhea have other sexually transmitted diseases (STDs), such as chlamydial infection, syphilis, or human immunodeficiency virus (HIV) infection.

Did You Know...

  • If pregnant women have gonorrhea, the eyes of the fetus may become infected during birth, so newborns are routinely treated to prevent this infection.

Symptoms of Gonorrhea

Usually, gonorrhea causes symptoms only at the sites of initial infection. In some people, infection spreads through the bloodstream to other parts of the body, especially to the skin, joints, or both.

In men, symptoms begin within about 2 to 14 days after infection. Men feel mild discomfort in the urethra (the tube that carries urine from the bladder out of the body). This discomfort is followed a few hours later by mild to severe pain during urination, a yellow-green discharge of pus from the penis, and a frequent urge to urinate. The opening at the tip of the penis may become red and swollen. The bacteria sometimes spread to the epididymis (the coiled tube on top of each testis), causing the scrotum to swell and feel tender to the touch.

Some women (about 10 to 20%) have minimal or no symptoms. Thus, the infection may be detected only during routine screening or after diagnosis of the infection in their male partner. Symptoms typically do not begin until at least 10 days after infection. Some women feel only mild discomfort in the genital area and have a puslike discharge from the vagina. However, other women have more severe symptoms, such as a frequent urge to urinate and pain during urination. These symptoms develop when the urethra is also infected.

Bacteria commonly spread up the genital tract and infect the tubes that connect the ovaries to the uterus (fallopian tubes). This infection, called salpingitis, causes severe lower abdominal pain, especially during intercourse. In some women, the infection spreads to the lining of the abdominal cavity (peritoneum), causing peritonitis or pelvic inflammatory disease, which may cause severe pain in the lower abdomen. Women who have had pelvic inflammatory disease have an increased risk of infertility and mislocated (ectopic) pregnancies, which can cause dangerous internal bleeding.

Occasionally, infection in the abdomen concentrates around the liver. This infection, called perihepatitis or Fitz-Hugh-Curtis syndrome, causes pain in the upper right part of the abdomen.

Anal sex with an infected partner may result in gonorrhea of the rectum. This infection usually causes no symptoms, but it may make bowel movements painful. Other symptoms include constipation, itching, bleeding, and a discharge from the rectum. The area around the anus may become red and raw, and stool may be coated with mucus and pus. When a doctor examines the rectum with a viewing tube (anoscope), mucus and pus may be visible on the wall of the rectum.

Oral sex with an infected partner may result in gonorrhea of the throat (gonococcal pharyngitis). Usually, these infections cause no symptoms, but the throat may be sore.

If infected fluids come into contact with the eyes, gonococcal conjunctivitis may develop, causing swelling of the eyelids and a discharge of pus from the eyes. In adults, often only one eye is infected. Newborns usually have infection in both eyes. Blindness may result if the infection is not treated early.

In children, gonorrhea usually results from sexual abuse. In girls, the genital area (vulva) may be irritated, red, and swollen, and they may have a discharge from the vagina. If the urethra is infected, children, mainly boys, may have pain during urination.

Rarely, disseminated gonococcal infection (arthritis-dermatitis syndrome) develops. It occurs when the infection spreads through the bloodstream to other parts of the body, especially the skin and joints. Joints become swollen, tender, and extremely painful, limiting movement. The skin over infected joints may be red and warm. If the bloodstream is infected, people may have a fever, feel generally ill, and develop arthritis in one or more joints. Small, red spots may appear on the skin, usually on the arms and legs. The spots are slightly painful and may be filled with pus. Joint, bloodstream, and heart infections can be treated, but recovery from arthritis may be slow.

Gonococcal septic arthritis is a form of disseminated gonococcal infection that causes painful arthritis. Usually, it affects one or two large joints, such as the knees, ankles, wrists, or elbows, Symptoms often begin suddenly. People usually have a fever. Infected joints are painful and swollen, and movement is limited. The skin over the infected joints may be warm and red.

Diagnosis of Gonorrhea

  • Examination of the discharge under a microscope or in a laboratory

In more than 95% of infected men with a discharge, gonorrhea may be diagnosed within an hour by identifying the bacteria (gonococci) in samples of the discharge examined under a microscope. If a discharge is obvious, doctors touch a swab or slide to the end of the penis to collect the sample. If there is no obvious discharge, doctors insert a small swab a half inch or more into the urethra to collect a sample. Men are asked to refrain from urinating for at least 2 hours before the sample is collected.

Identifying bacteria in a sample of discharge from the cervix is more difficult. The bacteria can be seen in only about half of infected women.

The sample (from the urethra or cervix) is also sent to a laboratory for culture (to grow the organisms) and for other tests. Such tests are very reliable in both sexes but take longer than a microscopic examination. If a doctor suspects an infection of the throat, rectum, or bloodstream, samples from these areas are sent for testing in a laboratory.

Highly sensitive tests can be done to detect the DNA of gonococci and of chlamydiae (which are often also present). Laboratories can test for both infections in a single sample. For some of these tests (called nucleic acid amplification tests, or NAATS), techniques that increase the amount of the bacteria's genetic material are used. Because these techniques make the organisms easier to detect, urine samples can be used. Thus, these tests are convenient for screening men and women who have no symptoms or who are unwilling to have fluid samples taken from their genitals.

Because many people have more than one STD, doctors may test samples of blood and genital fluids for other STDs, such as syphilis and HIV infection.

If a joint is red and swollen, doctors draw fluid from the joint using a needle. The fluid is sent for culture and other tests.

Screening for gonorrhea

Certain people who have no symptoms are screened for gonorrhea because they have characteristics that increase their risk of this infection.

For example, women who are not pregnant are screened if they

  • Are age 24 or younger and are sexually active

  • Have had a previous STD

  • Participate in risky sexual activities (such as having many sex partners, not using condoms regularly, or engaging in sex work)

  • Have a sex partner who participates in risky sexual activities

Pregnant women are screened at their first prenatal visit and, if they have risk factors for infection, again during the 3rd trimester.

Heterosexual men are not routinely screened unless they are considered at high risk of infection—for example, when they have several sex partners, are patients at an adolescent or STD clinic, or are entering a correctional facility.

Men who have sex with men are screened only if they have been sexually active within the last year.

Prevention

The following general measures can help prevent gonorrhea (and other STDs):

  • Regular and correct use of condoms (see How to Use a Condom)

  • Avoidance of unsafe sex practices, such as frequently changing sex partners or having sexual intercourse with prostitutes or with partners who have other sex partners

  • Prompt diagnosis and treatment of the infection (to prevent spread to other people)

  • Identification of the sexual contacts of infected people, followed by counseling or treatment of these contacts

Not having sex (anal, vaginal, or oral) is the most reliable way to prevent STDs but is often unrealistic.

Treatment of Gonorrhea

  • The antibiotics ceftriaxone plus azithromycin

  • Testing and treatment of sex partners

Doctors usually give people with gonorrhea a single injection of the antibiotic ceftriaxone into a muscle, plus a single dose of azithromycin by mouth. Sometimes instead of azithromycin, doctors use doxycycline given by mouth, twice a day for 1 week. Although ceftriaxone cures most people in the United States, azithromycin is given with ceftriaxone because this drug may help keep gonococci from becoming resistant to treatment. Also, azithromycin and doxycycline kill chlamydiae, which are often present in people with gonorrhea.

If people are allergic to ceftriaxone, they are given a high dose of azithromycin and either gemifloxacin by mouth or gentamicin injected into a muscle.

If gonorrhea has spread through the bloodstream, people are usually treated in the hospital and given antibiotics intravenously or by injection into a muscle.

If symptoms recur or persist after treatment, doctors may take samples for culture to determine whether people are cured and may do tests to determine whether the gonococci are resistant to the antibiotics used.

People with gonorrhea should abstain from sexual activity until treatment is completed to avoid infecting sex partners.

Sex partners

All sex partners who have had sexual contact with infected people in the past 60 days should be tested for gonorrhea and other STDs and, if the tests are positive, should be treated. If sex partners were exposed to gonorrhea within the past 2 weeks, they are treated for it without waiting for test results.

Expedited partner therapy is an option doctors sometimes use to make it easier for sex partners to be treated. This approach involves giving people with gonorrhea a prescription or drugs to give to their partner. Thus, the sex partner does not need to see a doctor before being treated. Seeing a doctor is better because then the doctor can check for drug allergies and the presence of other STDs. However, if the partner is unlikely to see a doctor, expedited partner is useful.

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  • GENOPTIC
  • ZITHROMAX
  • FACTIVE
  • PERIOSTAT, VIBRAMYCIN
  • ROCEPHIN

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