Gonorrhea is caused by the bacteria Neisseria gonorrhoeae and results in a broad range of clinical syndromes. Most gonococcal infections are transmitted during sexual intercourse with an infected person. Infants born to mothers with untreated gonorrhea are also at high risk for infection.
Gonorrhea is the most common bacterial infection reportable to the Centers for Disease Control and Prevention (CDC). There were about 1 million reported cases of gonorrhea in 1978; the number of total cases has declined to about 620,000 cases in 1991. However, the rate of infection in high-risk adolescents has remained unchanged despite the overall decline. Young women between the ages of 15 to 19 years have proportionately the highest rate of infection.
In general, persons at highest risk of being infected with gonorrhea are those with multiple sexual partners; those who exchange sex for drugs, money, or shelter; individuals engaging in sexual activity associated with illicit drug use; and persons engaging in unsafe sexual practices. These same persons are also at risk for human immunodeficiency virus (HIV) infection and other sexually transmitted diseases.
The incubation period for gonorrhea in men is usually 2 to 5 days. Concurrent infection with both gonorrhea and chlamydia is common. Without testing, the two infections are difficult to distinguish in patients.
Serious complications of unrecognized gonococcal infection in women include pelvic inflammatory disease (PID) with subsequent infertility or ectopic pregnancy. Men may develop epididymitis. Disseminated gonococcal infection may occur in either men or women.
Testing for gonorrhea is recommended for those patients with indications of infection or for those who have had sexual contact with infected individuals. All persons with gonorrhea should be treated for presumptive chlamydia, have serologic screening for syphilis, and be offered confidential counseling and testing for HIV infection.
Patients should be counseled to refrain from sexual contact until treatment is completed and to refer their recent sex partners (less than 30 days) for examination and treatment. In addition, safer sex guidelines should be followed and condoms used during sexual intercourse to prevent future infections.
A swab of any infected or potentially infected site, including the male urethra, or urethral exudate if present, or the female endocervix should be Gram-stained and inoculated quickly onto selective media. If appropriate, rectal and oropharyngeal swabs should also be obtained. A Gram stain that shows Gram-negative diplococci within the polymorphonuclear leukocytes is considered diagnostic of gonorrhea.
Gonorrhea and chlamydia often occur together and patients infected with gonorrhea and their sex partners should also be treated for chlamydia. In addition, patients should have a blood test for syphilis and be offered confidential counseling and testing for HIV.
Gonorrhea causes a broad range of clinical syndromes including a urethral discharge and dysuria in men and a vaginal discharge, dysuria, and pelvic pain in women. Although many persons have these symptoms, a significant number of infected men and the majority of infected women are asymptomatic or have other manifestations of gonorrhea.
More than half of the men infected with gonorrhea may be asymptomatic. Acute urethritis, with urethral discharge and pain on urination, is the most common symptom and occurs after an incubation period of 2 to 5 days. The discharge is usually copious and purulent. Anorectal infection is not uncommon in men who have sex with other men and may be asymptomatic or cause acute proctitis.
Women infected with gonorrhea may be acutely symptomatic, have minor symptoms, or remain asymptomatic. Common symptoms are vaginal discharge, dysuria, and intermenstrual or heavy menstrual bleeding. Finding cervical, uterine, or adnexal tenderness on pelvic examination reflects ascending infection and PID, including possible salpingitis or tubo-ovarian abscess.
Gonorrhea may cause extragenital infection, including exudative pharyngitis and cervical lymphadenitis, and is usually spread by orogenital sexual exposure. The eyes may be infected through contact with genital secretions. A severe conjunctivitis with corneal ulceration may occur.
Gonorrhea may cause perihepatitis by local extension from the fallopian tube in women or bacteremia in either sex with an associated monoarticular or polyarticular arthritis and dermatitis with characteristic pustular lesions. Endocarditis and meningitis are rare complications of disseminated infection.
Prompt detection and treatment of gonorrhea in its early stages are medically important to avoid complications and continued transmission. The recommended treatment regimen for uncomplicated cases is presented in table 1.
Sexual partners of infected individuals should be tested and treated (without waiting for test results) to prevent the spread of the disease if their contact with the infected persons was within 30 days. If testing is not feasible, the sexual partners should be treated presumptively.
Women with possible gonococcal or nongonococcal pelvic inflammatory disease must be evaluated by an expert qualified to assess the appropriateness of outpatient oral versus inpatient intravenous treatment. Women with inadequate or delayed treatment of PID are at significant risk of being infertile.
The patient with possible disseminated gonococcal infection or ophthalmic involvement should be referred to a physician expert in the care of such patients.
The treatment of gonococcal infections in the United States has changed because of the spread of antibiotic-resistant strains of N. gonorrhoeae (NG) including penicillinase-producing, tetracycline-resistant, and other strains with chromosomally mediated resistance to multiple antibiotics. In addition, the difficulty of correctly diagnosing concomitant infection with chlamydia has modified the recommendations for treatment of gonorrhea.
Gonorrhea in pregnancy may cause spontaneous abortion, premature labor, early rupture of fetal membranes, and increased neonatal morbidity. A pregnant woman infected with gonorrhea risks infecting her infant during delivery. Therefore, all pregnant women should have an endocervical culture for gonorrhea during their first trimester and again late in the third trimester.
The recommended treatment regimen for the pregnant woman with uncomplicated gonorrhea is presented in table 2.
Infants born to infected mothers who have been properly treated rarely become infected. If the mother is not treated, the infection may cause conjunctivitis in infants. In a few cases, a more serious, systemic infection of the infant may occur.
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