Gonorrhea
Gonorrhea or gonorrhoea, colloquially known as the clap, is a sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. Infection may involve the genitals, mouth, or rectum.
Gonorrhea is spread through sexual contact with an infected person, or from a mother to a child during birth. Infected males may experience pain or burning with urination, discharge from the penis, or testicular pain. Infected females may experience burning with urination, vaginal discharge, vaginal bleeding between periods, or pelvic pain. Complications in females include pelvic inflammatory disease and in males include inflammation of the epididymis. Many of those infected, however, have no symptoms. If untreated, gonorrhea can spread to joints or heart valves. Globally, gonorrhea affects about 0.8% of women and 0.6% of men. An estimated 33 to 106 million new cases occur each year. In 2015, it caused about 700 deaths.
Diagnosis is by testing the urine, urethra in males, vagina or cervix in females. It can be diagnosed by testing a sample collected from the throat or rectum of individuals who have had oral or anal sex, respectively. Testing all women who are sexually active and less than 25 years of age each year as well as those with new sexual partners is recommended; the same recommendation applies in men who have sex with men.
Gonorrhea can be prevented with the use of condoms, having sex with only one person who is uninfected, and by not having sex. Certain vaccines originally designed to protect against infection caused by related bacteria, meningococcus serotype B, have been found to provide some protection against gonorrhea. Treatment is usually with ceftriaxone by injection and azithromycin by mouth. Resistance has developed to many previously used antibiotics and higher doses of ceftriaxone are occasionally required.
Signs and symptoms
Gonorrhea infections of mucosal membranes can cause swelling, itching, pain, and the formation of pus. The time from exposure to symptoms is usually between two and 14 days, with most symptoms appearing between four and six days after infection, if they appear at all. Both men and women with infections of the throat may experience a sore throat, though such infection does not produce symptoms in 90% of cases. Other symptoms may include swollen lymph nodes around the neck. Either sex can become infected in the eyes or rectum if these tissues are exposed to the bacterium, which can lead to pain with bowel movements, rectal discharge, or constipation.Women
Half of women with gonorrhea are asymptomatic but the other half experience vaginal discharge, lower abdominal pain, or pain with sexual intercourse associated with inflammation of the uterine cervix. Common medical complications of untreated gonorrhea in women include pelvic inflammatory disease which can cause scars to the fallopian tubes and result in later ectopic pregnancy among those women who become pregnant.Men
Most infected men with symptoms have inflammation of the penile urethra associated with a burning sensation during urination and discharge from the penis. In men, discharge with or without burning occurs in half of all cases and is the most common symptom of the infection. This pain is caused by a narrowing and stiffening of the urethral lumen. The most common medical complication of gonorrhea in men is inflammation of the epididymis. Gonorrhea is also associated with increased risk of prostate cancer.Infants
If not treated, gonococcal ophthalmia neonatorum will develop in 28% of infants born to women with gonorrhea.Spread
If left untreated, gonorrhea can spread from the original site of infection and infect and damage the joints, skin, and other organs. Indications of this can include fever, skin rashes, sores, and joint pain and swelling. In advanced cases, gonorrhea may cause a general feeling of tiredness similar to other infections. It is also possible for an individual to have an allergic reaction to the bacteria, in which case any appearing symptoms will be greatly intensified. Very rarely it may settle in the heart, causing endocarditis, or in the spinal column, causing meningitis. Both are more likely among individuals with suppressed immune systems, however.Cause
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. Previous infection does not confer immunity – a person who has been infected can become infected again by exposure to someone who is infected. Infected persons may be able to infect others repeatedly without having any signs or symptoms of their own.Spread
The infection is usually spread from one person to another through vaginal, oral, or anal sex. Men have a 20% risk of getting the infection from a single act of vaginal intercourse with an infected woman. The risk for men who have sex with men is higher. Insertive MSM may get a penile infection from anal intercourse, while receptive MSM may get anorectal gonorrhea. Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man.A mother may transmit gonorrhea to her newborn during childbirth; when affecting the infant's eyes, it is referred to as ophthalmia neonatorum. It may be able to spread through the objects contaminated with body fluid from an infected person. The bacteria typically does not survive long outside the body, typically dying within minutes to hours.
Risk factors
It is discovered that sexually active women younger than 25 and men who have sex with men are at increased risk of getting gonorrhea.Other risk factors include:
- Having a new sex partner
- Having a sex partner who has other partners
- Having more than one sex partner
- Having had gonorrhea or another sexually transmitted infection
Complications
- Infertility in women. Gonorrhea can spread into the uterus and fallopian tubes, causing pelvic inflammatory disease. PID can result in scarring of the tubes, greater risk of pregnancy complications and infertility, and can be fatal, particularly in the immunocompromised. PID requires immediate treatment.
- Infertility in men. Gonorrhea can cause a small, coiled tube in the rear portion of the testicles where the sperm ducts are located to become inflamed. Untreated epididymitis can lead to infertility.
- Infection that spreads to the joints and other areas of the body. The bacterium that causes gonorrhea can spread through the bloodstream and infect other parts of the body, including the joints. Fever, rash, skin sores, joint pain, swelling and stiffness are possible results.
- Increased risk of HIV/AIDS. Having gonorrhea increases the susceptibility to infection with human immunodeficiency virus, the virus that leads to AIDS. People who have both gonorrhea and HIV are able to pass both diseases more readily to their partners.
- Complications in babies. Babies who contract gonorrhea from their mothers during birth can develop blindness, sores on the scalp and infections.
Diagnosis
Tests that use PCR 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 and Gram-stain can also be used to detect the presence of N. gonorrhoeae in all specimen types except urine. Studies of the swab sample method for gonorrhea infections have not shown any difference in the number of patients treated, whether the sample was collected at home or in the clinic. The implications for number of patients cured, reinfection rates, partner management, and safety are unknown.
If Gram-negative, oxidase-positive diplococci are visualized on direct Gram stain of urethral pus, no further testing is needed to establish the diagnosis of gonorrhea infection. However, direct Gram stain of cervical swabs is not useful because the N. gonorrhoeae organisms are less concentrated in these samples. The chance of a false positive test is also higher for a cervical swab, as Gram-negative diplococci native to the normal vaginal flora cannot be distinguished from N. gonorrhoeae in that context. Thus, cervical swabs must be cultured under the conditions described above. If oxidase positive, Gram-negative diplococci are isolated from a culture of a cervical/vaginal swab specimen, then the diagnosis is made. Culture is especially useful for diagnosis of infections of the throat, rectum, eyes, blood, or joints—areas where PCR-based tests are not well established in all labs. Culture is also useful for antimicrobial sensitivity testing, analyzing treatment failure, and epidemiological purposes.
In patients who may have disseminated gonococcal infection, all possible mucosal sites should be cultured. Three sets of blood cultures should also be obtained. Synovial fluid should be collected in cases of septic arthritis.
All people testing positive for gonorrhea should be tested for other sexually transmitted infections such as chlamydia, syphilis, and human immunodeficiency virus. Studies have found co-infection with chlamydia ranging from 46 to 54% in young people with gonorrhea. Among persons in the United States between 14 and 39 years of age, 46% of people with gonorrheal infection also have chlamydial infection. For this reason, gonorrhea and chlamydia testing are often combined. People diagnosed with gonorrhea infection have a fivefold increase risk of HIV transmission. Additionally, infected persons who are HIV positive are more likely to shed and transmit HIV to uninfected partners during an episode of gonorrhea.