Gonorrhea

Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae that leads to genitourinary tract infections such as urethritis, cervicitis, pelvic inflammatory disease (PID) and epididymitis. The disease primarily affects individuals between 15–24 years of age and has an incubation period of 2–7 days. Gonorrhea is commonly asymptomatic, especially in women, which increases the chance of further spreading and complications. In symptomatic cases, typical clinical symptoms include purulent vaginal or urethral discharge, dysuria, and signs of epdidymitis (e.g., scrotal pain) or PID (e.g., pelvic pain, dyspareunia). Gonorrhea may also cause extragenitourinary manifestations, such as proctitis and pharyngitis. Rarely, disseminated disease may occur, which typically manifests with a triad of arthritis, pustular skin lesions, and tenosynovitis. Diagnostic tests include nucleic acid amplification testing, gram stains, and bacterial cultures from urine or swabs of the genitourinary tract as well as blood and synovial fluid in disseminated infection. Treatment consists of antibiotics, mainly ceftriaxone and azithromycin, but may require different approaches in more severe cases. Without treatment, prolonged infection may lead to complications, such as a hymenal and tubal synechiae that lead to infertility in women.

• Second most commonly reported infectious disease in the US after chlamydia
• Incidence: ∼ 820,000 cases per year in the US
• Age: primarily individuals between 15–24 years of age

References:^[1][2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

• Pathogen
  • Neisseria gonorrhoeae (N. gonorrhoeae, gonococcus)
  • Gram-negative, intracellular, aerobic, diplococci
• Transmission
  • Sexual contact (oral, genital, or anal) with an infected individual
  • Perinatal transmission
• Risk factors
  • Multiple sexual partners
  • Low socioeconomic status
  • Lack of barrier protection (e.g., condomless sex)
  • Men who have sex with men (MSM)

References:^[1][5]

Gonorrhea can present with a wide variety of symptoms and courses. An asymptomatic course is common, particularly in women, and increases the risk of further spreading and complications!

• Incubation time: 2–7 days
• Urethritis: purulent urethral discharge (yellow-green, possibly blood-tinged) , dysuria and urinary frequency
• In males: potentially epididymitis: one-sided scrotal pain and swelling
• In females
  • Cervicitis
    • Purulent, yellow, malodorous cervical discharge
    • Cervical pain and bleeding on manipulation (e.g., pelvic exam)
  • Pelvic inflammatory disease (PID)
    • Fever, abdominal/pelvic pain, dyspareunia
    • Abnormal, intermenstrual bleeding
    • Fitz-Hugh-Curtis syndrome (perihepatitis with RUQ pain)
  • Bartholinitis: pain, edema, and discharge of the labia
  • Vaginitis is usually not present
• Extragenital manifestations
  • Pharyngitis (sore throat, pharyngeal exudate, cervical lymphadenitis)
  • Proctitis
    • Purulent discharge, possible anorectal bleeding and pain
    • Rectal mucosa inflammation
    • Rectal abscess (less common)
• Disseminated gonococcal infection (DGI; ∼ 2% of cases)
  • Usually occurs in patients < 40 years old
  • More common in women (4:1)
  • Two possible clinical presentations
    • Clinical triad (arthritis-dermatitis syndrome)
      • Polyarthralgias: migratory, asymmetric arthritis that may become purulent
      • Tenosynovitis: simultaneous inflammation of several tendons (e.g., fingers, toes, wrist, ankle)
      • Dermatitis: vesicular, pustular, or maculopapular lesions, possibly with a necrotic or hemorrhagic center
        • Most commonly distributed on the trunk, extremities (sometimes involving the palms and soles)
        • Typically < 10 lesions that have a transient course (subside in 3–4 days)
      • Additional manifestations: fever and chills (especially in the acute phase)
    • Purulent gonococcal arthritis
      • Abrupt inflammation in up to 4 joints (commonly knees, ankles, and wrists)
      • No skin manifestations, rarely tenosynovitis
  • Only 25% of patients present with genitourinary manifestations
  • Not to be confused with reactive arthritis

References:^{[1][5][6][7][8][9]}

• Specimens for testing include
  • First-catch urine
  • Swab specimens of secretions: urine, urethra, endocervix, pharynx
  • For DGI: collect blood and synovial fluid (gained via arthrocentesis)
• Test of choice: rapidly detect N. gonorrhoea via nucleic acid amplification testing (NAAT)
  • Alternatives
    • Gonococcal gram stain
    • Gonococcal culture
      • Useful in determining antibiotic resistance
      • Results are not rapidly available (about 48 hours)
      • Sensitivity is lower than NAAT
• Additionally for arthritis: synovial fluid analysis
  • May be clear (nonpurulent) or cloudy (purulent)
  • ↑ Leukocyte count (up to 50,000 cells/mm³): especially segmented neutrophils
  • Gram stain sometimes positive (< 25% of cases)
• Screening for gonorrhea (CDC recommendations)
  • Annual NAAT screening of gonorrhea (typically also chlamydia) for:
    • Sexually active women < 25 years
    • Women > 25 years with risk factors (e.g., new or multiple sex partners, sex partner with an STI)
  • Evaluate for other STIs if positive (e.g., Chlamydia, syphilis, HIV)

References:^{[1][6][8][10][11]}

• Uncomplicated gonorrhea
  • Combination therapy is recommended due to high resistance rates to cephalosporins and to cover a possible coinfection with Chlamydia trachomatis.
  • First-line treatment: single-dose ceftriaxone IM + single-dose azithromycin PO
  • Alternatively: single-dose cefixime PO + single-dose azithromycin PO
• Complicated gonorrhea: : single-dose ceftriaxone IM + doxycycline PO for 10–14 days
• DGI: ceftriaxone IM or IV; + single-dose azithromycin PO
  • If purulent joint(s) → drain
• Evaluate and treat the patient's sexual partners from the past 60 days

Sexual partners must be treated simultaneously to avoid reinfections!

References:^[1][12]

• Hymenal and tubal synechiae, tubal motility disorders → infertility
• Gonococcal conjunctivitis (particularly in neonates, see neisserial conjunctivitis)
• Of DGI: sepsis with endocarditis, meningitis, osteomyelitis, or pneumonia

References:^[8][9]

We list the most important complications. The selection is not exhaustive.