Gonorrhea is one of the most common and oldest known sexually transmitted disease (STD). It can cause urethritis (infection of urethra), cervicitis (infection of cervix), epididymitis, pharyngitis (sore throat), proctitis (rectal inflammation) and pelvic inflammatory disease (PID). If not treated, the disease can spread throughout the body. However, because the genital symptoms are so unpleasant most individuals seek help before the disease has a chance of spreading. Gonorrhea is the second most common cause of PID in and caused by a bacteria known as Neisseria gonorrhea. The infection is acquired via sexual intercourse (both vaginal and anal). Recent data show that the disorder is increasingly being transmitted to the throat via oral sex. Gonorrhea is a reportable infectious disease in the United States (meaning that all doctors have to report the patient to a government agency which documents such infections). Gonorrhea had declined in the 80s and 90s, but there has been a resurgence of the infection in the last 2 decades. Estimates of total cases in the US indicate that there are about 700,000 cases per year. This number is significantly lower than the actual case load because many physicians fail to report the infection. Gonorrhea has also been encountered in sexually abused children. There are also a significant number of sexually active young females who are asymptomatic and have gonorrhea. Within the United States carriage rates are highly dependent on the geographical area, urban versus rural location, age, racial and ethnic group, and sexual preferences. The incidence of gonorrhea is highest in the South and Eastern USA, whereas the lowest rates are in the Midwest and Northeastern USA. Data from the CDC reveal that the rates of infection vary from about 250 per 100,000 in Mississippi to 7.5 per 100,000 in Idaho. The CDC has started a campaign to decrease the incidence to 19 cases per 100,000 by the year 2010. The only states currently exceeding this number are North Dakota, Maine, Vermont, Wyoming, New Hampshire, Montana, and Idaho. Rates of gonorrhea are difficult to obtain from Asia, South America and Africa since data are not complete/recorded and many patients do not have access to health care. In most of Europe, the disease rates are similar to North America.

 

Who is at Risk for gonorrhea? Gonorrhea is more common in some people and the highest infection rates have been reported in - young adults and teenagers - inner city males and females - blacks and Hispanics - IV drug users - Those who have sex with an infected partner - Multiple sex partners - Poor and minorities with no access to education/health care - Those who do not use condoms - Those with a prior history of STD - Those who use IV drugs The major reason why individuals acquire gonorrhea is by having unprotected sexual intercourse with an infected partner. Men have a 20% chance of getting the infection by having sexual relations with a woman infected with gonorrhea. However, women have a 50% chance of getting the infection by having sexual relations with a man infected with gonorrhea. The reason for this is that the females have a very short urethra which rapidly colonized the harmful bacteria. When an infected female gets pregnant, there is a good chance that the baby will be infected during vaginal birth.

 

Morbidity of untreated gonorrhea Gonorrhea unfortunately does not simply go away. The worst part of acquiring this infection is that the partner also needs treatment. For those who do not get proper treatment, the likelihood of the disease spreading are high. In males the infection can spread to other parts of the genitalia (testis and epididymitis) and produce sterility. In females, the infection can cause severe scarring and adhesions of the uterine tubes and this is one major reason why many females are not able to conceive later on in life. The infection can also spread to the liver, joints, brain and the heart. Symptoms Females Once a female gets infected, the symptoms are not immediate but gradually appear within 2-10 days. Some individuals, esp. women, generally do not tend to show any symptoms until 2-3 weeks after acquiring the infection. However, there are some females (at least 30%) who may not show any symptoms. Gonorrhea is the second most common cause of pelvic inflammatory disease that usually leads to infertility. In the majority of cases, it leads to irritation of the cervix, increased urgency to urinate and the need to urinate more frequently. A significant number of women also complain of vaginal itching, burring and a foul smelling vaginal discharge. Oral sex with an infected partner can result in pharyngitis, and, similarly, anal infection can arise from anal sex or local spread from a vaginal source. PID, especially if recurrent, is a major cause of future infertility and is also associated with infection of the ovary (tuboovarian abscess). In some cases, the infection is so rampant that it can cause rupture of the fallopian tubes, leading to rapid spread of infection in the pelvis and abdomen and frequently death is the end result. For those females who have had recurrent PID, the chances of developing an ectopic pregnancy and infertility are significantly higher compared to healthy females without PID. The typical symptoms of gonorrhea in a female include: - Dysuria (painful urination) - Vaginal/cervical discharge - Abnormal cervical/vaginal bleeding (spotting) - Dyspareunia (painful intercourse) - Cervical pain during examination - Condom nonuse or condom failure - Proctitis (anal gland infection after anal intercourse) - Pharyngitis (sore throat from oral sex) - Chronic lower abdominal and pelvic pain - Lower back pain (radiating pain from the pelvis) Males The majority of men will show some symptoms in a few days after acquiring the infection. Pain or burring during urination is the most common complaint. At least 50% of men will also have a penile discharge. A few men will also complain of mild tenderness along the penile shaft and testicles. Other symptoms include: - urethral discharge (drip from the tip of the penis) - Dysuria (painful urination) - Proctitis (anal gland infection associated with pain - Pharyngitis (sore throat from oral sex) With oral sex becoming an integral part of a sexual relationship, there is also an increasing incidence of gonococcal related infections of the throat. These individuals complain of sore throat after a sexual encounter and may have other features of a gonorrheal infection. For those who engage in anal sex, gonorrhea is fast becoming a major source of rectal pain and infection. Many men also develop infection of the prostate after having performed anal intercourse. Those males, who engage in routine anal sex with other men, generally tend to acquire a resistant form of gonorrhea. This resistant type of gonorrhea is gradually becoming more difficult to treat with the standard group of antibiotics available today. Children In newborns, vaginal transmission can cause conjunctivitis (infection of eye), known as ophthalmia neonatorum, and if left untreated can lead to blindness. In a young child with vaginal irritation or discharge, sexual molestation should always be suspected.

 

Diagnosis Diagnosis is easily confirmed by staining or culturing the discharge from the penis or vagina. Today commercial kits are available which can rapidly identify the presence of gonorrhea. All cases of gonorrhea must be reported to the publish health system. Because there are other organisms which are also sexually transmitted, it is recommended that a test for syphilis and Chlamydia be done at the same time. For those individuals who complain of a sore throat and rectal pain, swabs from these areas should be obtained for culture. Today there are nuclei acid probes which can identify gonorrhea with 100% sensitivity. For individuals with no secretions from the genitals, these nuclear probes are useful as they can detect gonorrhea on the minutest amount of secretion. Some individuals with gonorrhea also have the infection in the blood and may develop arthritis or infection of the heart. Any young male who is sexually active and presents with swelling and pain in the joint should always be suspected of gonorrhea. Blood or fluid from the joint can be cultured and the organism can be identified using the various nuclear probes.

 

Treatment There is no room for self care treatment at home in the case of gonorrhea. There are no herbs or nutritional supplements to treat this condition. Various antibiotics are used to treat gonorrhea. In the past decade the fluoroquinolones [examples are Cipro, and Levaquin] were widely used in the treatment of gonorrheal infection. Because of increasing resistance of many strains of N. gonorrhea to the fluoroquinolones drugs, the CDC now recommends that only one class of antibiotics should be used to treat the infection. Today, the cephalosporins are widely used to treat gonorrhea. The present day treatment of gonorrhea requires a single dose injection of an antibiotic (ceftriaxone or a single-dose pill such as Cipro). The majority of men are treated by a single injection of antibiotic and are discharged home. Admission to the hospital is done if there is evidence of spread of infection to other parts of the body (such as brain, joint, heart). If the patient shows evidence of infection in the blood or appears sick, admission to the hospital may be required for intravenous antibiotics. For females with gonorrhea, the treatment is more complex and may more often requires admission to the hospital because the complications and the non compliance rates are higher than males. Because, the majority of these females are seen in clinics and with rising health care costs and physician reluctance to admit these patients, the majority are discharged home, like their male counterparts. Most females should be informed about PID and future difficulties with pregnancy. Even though most females are given follow up appointments, less than 10% show up for future appointments.

 

Follow-up It is essential that the entire course of antibiotics be completed. Once the antibiotic course has been finished, it is important that the individual be retested to make sure that the infection has been treated. A major part of treatment for gonorrhea involves treatment of the partner. All sexual partners must be notified and tested for infection to ensure that the infection is not re-transmitted in a cycle. With a wide acceptance of an open sexual life style with multiple partners, it is highly recommended that the individual also get tested for other sexually transmitted disease like Chlamydia, syphilis and human immunodeficiency virus (HIV).

 

Prevention Prevention of gonorrhea required: - Use of latex condoms during sexual intercourse - Avoidance of sexual intercourse with high risk partners - Get partners tested for STDs prior to any sexual activity.

 

Outlook After the antibiotic treatment is completed, more than 95-99% of first time episodes of gonorrhea are cured. A few individuals may not respond and may require alternative drugs.

 

Consultations In cases of suspected rape or child abuse, it is mandatory to discuss the case with other specialists such as social workers, psychiatrists and pediatricians. It is important to obtain and stores the samples in the presence of some legal authority. Every detail about the case must be documented and all physical findings must be recorded/photographed for possible medico-legal reasons. All physicians are required to report the case to child protective services if there is any hint of abuse.

 

Also check out our information on HPV and vaginal warts.