Gonorrhea is a sexually transmitted disease (STD), caused by Neisseria gonorrhoeae, which commonly infect the epithelium cervix (cervicitis), urethra (urethritis), rectum (proctitis), and conjunctiva of eye (conjunctivitis). Gonorrhea if left untreated can lead to complications such as periurethritis and epididymitis in men, endometritis, salpingitis, abscess (in Fallopian tubes and ovaries), bartholinitis, peritonitis, and perihepatitis in women and ophthalmia neonatorum in newborns infants.

Global scenario of gonorrhea:

Gonorrhea is still a major public health problem in most parts of the world and a major cause of morbidity in developing countries. Gonorrhea may play a role in transmission of HIV infection.

It is estimated that the incidence of gonorrhea in United States at present is 120 cases of gonorrhea per 100,000 populations per year (although decreasing slowly due to use of condoms to prevent transmission of HIV), which is highest among industrialized countries. The incidence of gonorrhea is higher in developing countries than developed countries.

Mode of transmission of gonorrhea:

Gonorrhea is a STI (sexually transmitted infection). Transmission of gonorrhea is more efficient from male to female, than female to male. The risk of transmission of gonorrhea from infected men to women is approximately 40-60% in a single unprotected sexual encounter. The risk of transmission of oropharyngeal gonorrhea to a woman who practices fellatio with infected sexual partner is approximately 20%. Transmission of gonorrhea through cunnilingus is rare.

Clinical features of gonorrhea in men:

The incubation period of gonorrhea is generally 2-7 days. The most common clinical feature of gonorrhea in men is acute urethritis, which manifest as burning during urination, discharge and difficulty in urination. Generally there is no increase in frequency of urination and there is no urgency. The discharge from urethra is scant (and mucoid) at first, but become profuse and purulent (presence of pus) in a day or two. Gram’s stain of purulent discharge will show presence of diplococcus and WBCs (neutrophils). In general symptoms of nongonococcal urethritis are less severe, but this can not be relied upon.

Epididymitis is a rare symptom of gonorrhea in men these days. Prostatitis due to gonococcus is also rare. Edema of the penis (due to dorsal lymphangitis), thrombophlebitis, periurethral abscess or fistulae, inflammation or abscess of Cowper's gland, and seminal vesiculitis are some other uncommon symptoms of gonococcal infection in men.

Most of the man with symptomatic gonorrhea seek treatment and after appropriate treatment do not transmit infection. The problem is with asymptomatic men with gonococcal infection, who does not get medical attention and as a result the number of asymptomatic men with gonococcal infection increases and constitute approximately two-third of men with gonococcal infection. These asymptomatic men with gonococcal infection serve as source of infection.

Clinical features of gonorrhea in women:

Common manifestations of gonococcal infection in women include gonococcal cervicitis (infection of cervix) and gonococcal vaginitis (infection of vagina).

Gonococcal cervicitis:

Cervicitis with mucopurulent discharge is the commonest STIs (Sexually Transmitted Infections) in many countries including United States and commonly caused by N. gonorrhoeae, C. trachomatis. There may be coexistence of candida (a type of fungus) infection of cervix with gonococcal infection. Infection of Bartholin's glands may sometimes occur with gonococcal cervicitis.

Sometimes gonococcal infection in women may cause dyspareunia (pain during sexual intercourse) and lower abdominal or back pain etc. due to presence of infection in deep. Women with gonococcal infection may have dysuria (pain during urination), pyuria (pus in urine) etc.

Unlike men, most of the women infected with gonococcus (N. gonorrhoeae), are symptomatic and only a small percentage of infected women are asymptomatic or have mild symptoms. This small number of asymptomatic or mildly symptomatic women with gonococcal infection may serve as source of infection.

Gonococcal vaginitis:

Gonococcal infection of vaginal mucosa is less common, due to the stratified squamous epithelium lining. But gonococcal infection may occur in girls before puberty or in women after menopause because vaginal stratified squamous epithelium is often thinned down to the basilar layer and can be infected by N. gonorrhoeae. In gonococcal vaginitis physical examination may be very painful due to severe inflammation. The mucosa becomes red and swollen and there is purulent discharge from vagina. There may be infection of Skene's and Bartholin's glands and urethra.

Diagnosis of gonorrhea:

In men diagnosis of gonorrhea can be done rapidly by demonstration of N. gonorrhoeae (gram-negative intracellular monococci and diplococci) in urethral discharge by Gram's staining. But in women Gram's staining of cervical discharge can identify only approximately 50% of gonococcal infection and not used for diagnosis of gonococcal cervicitis. Samples (from urethra or cervix) should be collected with Dacron or rayon swabs and inoculated gonococcal selective media for culture. Samples should be processed immediately to prevent drying as gonococci can not withstand drying. Culture is generally required for women as gonorrhea in men can be diagnosed rapidly from urethral discharge by Gram's staining.

Nucleic acid probe tests can be substituted for culture for direct detection of N. gonorrhoeae in urogenital specimens.

In children the diagnosis of gonococcal infection is done generally done by culture only. Nucleic acid amplification tests (NAATs) can also be used.

Treatment of Gonorrhea:

Prompt and effective treatment of gonorrhea is important as inappropriate treatment may lead to continued transmission of gonococcal infection and the emergence of antibiotic resistance. CDC (Centers for Disease Control and Prevention), Atlanta advocates the following regimens for effective and complete treatment of gonorrhea with single dose regimes:

First line regimes for treatment of gonorrhea:

· Ceftriaxone 1.25 gram single intramuscular dose or

· Cefixime 400 mg orally single dose or

· Azithromycin 1 gram orally single dose or

· Doxycycline 100 mg orally twice a day for 7 days.

Alternative or second-line regimes for treatment of gonorrhea:

· Ceftizoxime 500 mg, single intramuscular dose or

· Cefotaxime 500 mg single intramuscular dose or

· Spectinomycin 2 gram single intramuscular dose or

· Cefotetan 1 gram intramuscular single dose plus probenecid 1 gram oral single dose or

· Cefoxitin 2 gram intramuscular single dose plus probenecid 1 gram oral single dose.

Other associated infections such as candida infection, trachoma should also be treated with appropriate antibiotics. As trachoma is a frequently coexisting infection with gonorrhea, any initial treatment regimen should contain azithromycin or doxycycline (effective against chlamydial infection).

Prevention of Gonorrhea:

Proper use of condoms for prevention HIV and other STIs (Sexually Transmitted Infections) can effectively prevent gonococcal infection as well. All sex partners of N. gonorrhoeae infected individuals should be evaluated and treated for gonorrhea and trachoma if their last sexual contact with the patient took place within 60 days before the onset of symptoms or the diagnosis of gonorrhea. If the gonorrhea patient's last sexual encounter was more than 60 days before onset of symptoms or diagnosis of gonorrhea, the patient's most recent sex partner (s) should be treated for gonorrhea.

Public health education, counseling for individual patients, and behavior modification should be used as strategy for prevention of gonorrhea and other STIs. Screening for STIs for sexually active persons, especially adolescents can be used. If legal, the use of same medication for gonorrhea treatment by sexual partners can reduce the rate of transmission of gonococcus.

At present there is no effective vaccine available for gonorrhea, although several are under clinical trial.

Related Articles:

1. Ocular Gonorrhea
2. Pharyngeal Gonorrhea
3. Anorectal Gonorrhea
4. Gonorrhea and HIV
5. Gonorrhea during Pregnancy
6. Gonorrhea in Neonates and Children
7. Gonococcal Arthritis.