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.

• Incidence ^[1][2]
  • Second most commonly reported infectious disease in the US after chlamydia
  • ∼ 820,000 cases per year in the US
• Age: primarily individuals between 15–24 years of age

Epidemiological data refers to the US, unless otherwise specified.

• Pathogen
  • Neisseria gonorrhoeae (N. gonorrhoeae, gonococcus)
  • Gram-negative, intracellular, aerobic, diplococci
• Transmission
  • Sexual (oral, genital, or anal)
  • Perinatal
• Risk factors
  • Sexual risk behavior (lack of barrier protection, multiple partners)
  • Asplenia, complement deficiencies
• Risk groups
  • Men who have sex with men (MSM)
  • Individuals with low socioeconomic status

Overview

• An asymptomatic course is common, particularly in women, and increases the risk of further spread and complications.
• Incubation time: 2–7 days

Urogenital manifestations

• Urethritis
  • Purulent urethral discharge (yellow-green, possibly blood-tinged)
  • Dysuria
  • ↑ Urinary frequency
• In male individuals
  • Potentially epididymitis: one-sided scrotal pain and swelling
  • Prostatitis
  • Penile shaft edema without other signs of inflammation
• In female individuals
  • 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
  • Vulvovaginitis may occur but is rare.

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)

• Epidemiology
  • ∼ 2% of cases
  • Most common in individuals < 40 years old and female individuals (4:1)
• Clinical features: Two distinct clinical presentations are possible.
  • 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 with 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
  • Genitourinary manifestations in only 25% of affected individuals
  • Not to be confused with reactive arthritis

• 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: 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 (USPSTF recommendations)
  • Annual NAAT screening of gonorrhea (typically also chlamydia) for:
    • Sexually active women ≤ 24 years
    • Women > 24 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, T. pallidum, HIV)

• Uncomplicated gonorrhea ^[3]
  • First-line treatment: single-dose ceftriaxone IM
  • In case Chlamydia infection can not be ruled out: PLUS doxycycline twice a day for 7 days
• Complicated gonorrhea: : single-dose ceftriaxone IM PLUS doxycycline PO for 10–14 days
• DGI
  • Ceftriaxone IM or IV PLUS single-dose azithromycin PO
  • Drainage of purulent joint(s)
• In all patients
  • Evaluate and treat the patient's sexual partners from the past 60 days
  • Provide expedited partner therapy if the timely evaluation of sexual partners is not feasible ^[4]
    • Single-dose cefixime PO (if chlamydia has been excluded in the patient)
    • Single-dose cefixime PO PLUS doxycycline PO for 7 days ^[4]

Sexual partners must be treated simultaneously to avoid reinfections.

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

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

1. Sancta St. Cyr, Lindley Barbee, Kimberly A. Workowski, Laura H. Bachmann, Cau Pham, Karen Schlanger, Elizabeth Torrone, Hillard Weinstock, Ellen N. Kersh, Phoebe Thorpe. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69 (50): p.1911-1916. doi: 10.15585/mmwr.mm6950a6 . | Open in Read by QxMD
2. Guidance on the Use of Expedited Partner Therapy in the Treatment of Gonorrhea. https://www.cdc.gov/std/ept/gc-guidance.htm. Updated: March 1, 2021. Accessed: March 9, 2021.
3. Chlamydia and Gonorrhea — Two Most Commonly Reported Infectious Diseases in the United States. https://www.cdc.gov/features/dsstddata/. Updated: April 22, 2011. Accessed: April 10, 2017.
4. Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States, 2008.