July 31, 2021
HEALTH

GONORRHEA: CLINICAL MANIFESTATION, DIAGNOSIS AND TREATMENT

INTRODUCTION

Gonorrhea is a sexually transmitted disease (STD). Gonorrhea is a purulent infection of the mucous membrane surfaces caused by the bacterium Neisseriagonorrhoeae.

Gonorrhea was the most common STD worldwide for at least most of the 20th century, although since the mid-1970s, public health initiatives in the industrialized world have resulted in declining incidence of the disease, however, gonococcal infection is still the second most common notifiable disease in the United States, and Western European rates approximate those in the United States (Brian, 2018). It tends to infect warm, moist areas of the body, including the: urethra (the tube that drains urine from the urinary bladder), eyes, throat, vagina, anus and female reproductive tract (the fallopian tubes, cervix, and uterus).

Gonorrhea passes from person to person through unprotected oral, anal, or vaginal sex. People with numerous sexual partners or those who don’t use a condom are at greatest risk of infection. The Centers for Disease Control (CDC) recommends that all patients with gonorrheal infection also be treated for presumed co-infection with Chlamydia trachomatis.

Gonorrhea, an important public health problem and the second most common notifiable disease in the United States, is a purulent infection of mucous membrane surfaces caused by the gram-negative diplococcusNeisseria gonorrhoeae. Although gonorrhea (known colloquially as the clap and the drip) is most frequently spread during sexual contact, it can also be transmitted from the mother’s genital tract to the newborn during birth, causing ophthalmia neonatorum and systemic neonatal infection.  In women, the cervix is the most common site of gonorrhea, resulting in endocervcitisand urethritis, which can be complicated by pelvic inflammatory disease (PID). In men, gonorrhea causes anterior urethritis. Gonorrhea can also spread throughout the body to cause localized and disseminated disease. Complications also include ectopic pregnancy and increased susceptibility to human immunodeficiency virus (HIV) infection.

Most commonly, the term gonorrhea refers to urethritis and or cervicitis in a sexually active person. Gonococcalinfections following sexual and perinatal transmission are a major source of morbidity worldwide. In the developed world, where prophylaxis for neonatal eye infection is standard, the vast majority of infections follow genitourinary mucosal exposure. In the pediatric population, the importance of gonorrhea is 3-fold, as follows:

  • As a common and preventable sexually transmitted disease (STD) in the sexually active teenage population
  • As a perinatal infection at childbirth
  • As a forensic aid in investigating sexual abuse

Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual contact. It also may be caused by inoculation of mucosa by contaminated fingers or other objects. Transmission through penile-rectal contact is fairly efficient. The risk of transmission of gonorrhoeae from an infected woman to the urethra of her male partner is approximately 20% per episode of vaginal intercourse and rises to 60-80% after 4 or more exposures. In contrast, the risk of male-to-female transmission approximates 50-70% per contact, with little evidence of increased risk with more sexual exposures. Persons who have unprotected intercourse with new partners frequently enough to sustain the infection in a community are defined as core transmitters.

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RISK FACTORS

Risk factors for gonorrhea include the following:a) Sexual exposure to an infected partner without barrier protection (eg, failure to use a condom or condom failure) b) Multiple sex partnersc) Male homosexualityd) Low socioeconomic statuse) History of concurrent or past STDsf) Exchange of sex for drugs or moneyg) Use of crack cocaineh) Early age of onset of sexual activityi) Pelvic inflammatory disease (PID) – Use of an intrauterine device (IUD)

CLINICAL MANIFESTATION 

Symptoms usually occur within two to 14 days after exposure. However, some people infected with gonorrhea never develop noticeable symptoms. It’s important to remember that a person with gonorrhea who doesn’t have symptoms, also called a nonsymptomatic carrier, is still contagious. A person is more likely to spread the infection to other partners when they don’t have noticeable symptoms (Dale and Justin, 2016).

Signs and symptoms of gonorrhea include:

  • gonococcal cervicitis
  • Dysuria
  • Intermenstrual bleeding
  • Dyspareunia (painful intercourse)
  • Mild lower abdominal pain

If the infection progresses to pelvic inflammatory disease (PID), symptoms may include the following:

  • Lower abdominal pain: Most consistent symptom of PID
  • Increased vaginal discharge or mucopurulenturethral discharge
  • Dysuria: Usually without urgency or frequency
  • Cervical motion tenderness
  • Adnexal tenderness (usually bilateral) or adnexalmass
  • Intermenstrual bleeding
  • Fever, chills, nausea, and vomiting (less common)

DIAGNOSIS

Traditionally, gonorrhea was diagnosed with Gram stain and culture; however, newer polymerase chain reaction (PCR)-based testing methods are becoming more common. In those failing initial treatment, culture should be done to determine sensitivity to antibiotics. Culture is the most common diagnostic test for gonorrhea, followed by the deoxyribonucleic acid (DNA) probe and then the polymerase chain reaction (PCR) assay and ligand chain reaction (LCR). The DNA probe is an antigen detection test that uses a probe to detect gonorrhea DNA in specimens.  Tests that use polymerase chain reaction (PCR, aka nucleic acid amplification) to identify genes unique to N. gonorrhoeae are recommended for screening and diagnosis of gonorrhea infection. These PCR-based tests require a sample of urine, urethral swabs, or cervical/vaginal swabs. Culture (growing colonies of bacteria in order to isolate and identify them) and Gram-stain (staining of bacterial cell walls to reveal morphology) can also be used to detect the presence of N. gonorrhoeae in all specimen types except urine.

Specific culture of a swab from the site of infection is a criterion standard for diagnosis at all potential sites of gonococcal infection. Cultures are particularly useful when the clinical diagnosis is unclear, when a failure of treatment has occurred, when contact tracing is problematic, and when legal questions arise.

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All people testing positive for gonorrhea should be tested for other sexually transmitted diseases such as chlamydia, syphilis, and human immunodeficiency virus. Studies have found co-infection with chlamydiaranging from 46 to 54% in young people with gonorrhea. (Dicker et al., 2003) For this reason, gonorrhea and chlamydia testing are often combined (Ryan and Ray, 2004). People diagnosed with gonorrhea infection have a fivefold increase risk of HIV transmission (Meyers et al., 2008). Additionally, infected persons who are HIV positive are more likely to shed and transmit HIV to uninfected partners during an episode of gonorrhea.

TREATMENT

Penicillin entered mass production in 1944 and revolutionized the treatment of several venereal diseases. Penicillin remains the treatment of choice for uncomplicated gonorrhea in the United States (1984) orAmoxicillin, 3.0 gm plua 1.0 gm Probenicid PO1 orAmpicillin, 3.5 gm plus 1.0 gm Probenicid PO1Spectinomycin, 2.0 gm or IPlus doxycycline 100 mg PO bid 2 or tetracycline 500 mg PO qid X 7 days. Spectinomycin is the drug of choice for patients infected with PPNG strains but the rapid increase in spectinomycin resistance is troublesome. Ampicillin3.5 gm or Amoxicillin 3.0 gm given orally with 1 gm of probenecid can be substituted for penicillin. Because at least 40% of patients have a concomitant chlamydiainfection, the addition of a tetracycline antibiotic is important, especially when the ability to verify thediagnosis of chlamydia is poor or lacking. Doxycycline100 mg bid or tetracylcine 0.5 gm for 7 days is usually adequate. Patients with DGI should be hospitalized to rule out endocarditis, meningitis, and optimally manage septic joints. Since patients with disseminated gonococcal infection are usually infected with strains that are quite sensitive to penicillin, hospitalization for 3 days of intravenous penicillin is usually adequate to cure the infection. Furthermore, surgical drainage of infected joints is not necessary. Patients with gonococcal oropharyngitis are more difficult to treat,and may require more than one course of treatment. Spectinomycin is not reliable as treatment for pharyngeal gonorrhea. Since pelvic inflammatory disease is so frequently a mixed infection and the possible consequence is so devastating, antimicrobial combinations to cover N. gonorrhoeae, anaerobic bacteria, enterobacteriaceae andnC. trachomatis are warranted. The length of treatment depends unonseverity of disease. Most often 10-14 days of treatment is sufficient. Toxic patients should be admitted to the hospital. 3Daily dose depends on drug chosen and renal status for 14 days of treatment. As of 2010, injectable ceftriaxone is one of the few effective antibiotics. This is typically given in combination with either azithromycin or doxycycline (Datta et al., 2007).As of 2015 and 2016 the CDC and WHO only recommends both ceftriaxone and azithromycin.Because of increasing rates of antibiotic resistance local susceptibility patterns must be taken into account when deciding on treatment (Deguchi et al., 2015). Adults may have eyes infected with gonorrhoea and require proper personal hygiene and medications. (Baarda et al., 2015) Among persons in the United States between 14 and 39 years of age, 46% of people with gonorrheal infection also have chlamydialinfection (Groopman, 2012). It is recommended that sexual partners be tested and potentially treated. One option for treating sexual partners of people infected is patient-delivered partner therapy (PDPT), which involves providing prescriptions or medications to the person to take to his/her partner without the health care provider’s first examining him/her.

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The United States’ Centers for Disease Control and Prevention (CDC) currently recommend that individuals who have been diagnosed and treated for gonorrhea avoid sexual contact with others until at least one week past the final day of treatment in order to prevent the spread of the bacterium.

The emergence of antibiotic-resistant strains of gonorrhea is a growing challenge. These cases may require more extensive treatment, with a seven-day course of an oral antibiotic or dual therapy with two different antibiotics, usually for a total of seven days of therapy. The antibiotics used for extended therapy are usually given once or twice a day. Some common antibiotics used include azithromycin and doxycycline. Scientists are working to develop vaccines to prevent gonorrhea infection.

CONCLUSION

Neisseria gonorrhoeae is the causative agent of the sexually transmitted infection gonorrhea which is the second most prevalent bacterial sexually transmitted infection worldwide. Its formal identification was in 1879 by the German bacteriologist Albert Neisser. Gonorrhea grows mainly in the warm, moist areas of the reproductive tract for both men and women. It can also grow in the mouth, throat, eyes, and anus.Neisseria gonorrhoeae infections are acquired in humans by sexual contact. It is able to infect the lower genital tract, urethra in men and cervix in women. Infected women may be asymptomatic (show no symptoms), but up to 50% show nonspecific symptoms including odorless mucopurulent, vaginal discharge and vaginal bleeding. Even infections without symptoms can also result in severe consequences. On the other hand, 90% of men with urethral infection have symptomatic mucopurulent penile discharge and dysuria. Gonococci can ascend to the upper genital tract, leading to serious diseases, such as epididymitisin men and cervicitis, endometriosis, and pelvic inflammatory disease in women. The safest way to prevent gonorrhea or other STDs is through abstinence, practice of safe sex using condoms, it’s important to be open with one’s sexual partners, getting regular STD testing, and find out if they’ve been tested. Sexual contacts should be avoided with a partner that shows signs of infections. Risk of infection is higher in the case of one having multiple sexual partners or a new partner. In the course of treatment, it’s important to take the full course of pills to ensure that the infection is completely treated, as abusing the drugs can make the bacteria more likely to develop resistance to the antibiotic. Undergoing medical check-up one to two weeks later to make sure that your infection has clearedis paramount.

By Akubuo Chigaemezu Martin

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