Gonorrhea

Gonorrhea is an infectious disease caused by the infectious agent gonococcus, transmitted mainly sexually and characterized mainly by lesions of the mucous membranes of the urogenital organs. Gonococcal lesions of the oral mucosa and rectum are also observed, which is detected mainly after orogenital or homosexual contacts. When the infection spreads, the epididymis and prostate gland in men, the endometrium and pelvic organs in women can be involved in the pathological process. Hematogenous spread of infection from the mucous membranes can also be observed, although this phenomenon is rare.

The anatomical and physiological characteristics of the male, female and child organisms, some specificity in the spread of infection, clinical manifestations, the course of gonorrhea, the development of complications and differences in the treatment of these patients serve as the basis for distinguishing male, female and child gonorrhea.

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Causes of gonorrhea

The source of infection is mainly patients with chronic gonorrhea, mainly women, since in them the chronic process proceeds almost unnoticed, is longer, and is more difficult to diagnose. This leads to complications such as inflammatory diseases of the pelvic organs (PID). PID, regardless of the presence or absence of symptoms, can lead to obstruction of the fallopian tubes, which, in turn, can lead to reproductive disorders, including infertility, ectopic pregnancy, etc.

In some cases, non-sexual infection is possible through underwear, sponges, towels, on which undried gonorrheal pus remains. Infection of a newborn can occur during childbirth when the fetus passes through the birth canal of a sick mother.

Depending on the intensity, the body's reaction to the introduction of gonococci, the duration of the course and the clinical picture, the following forms of gonorrhea are distinguished:

• fresh (acute, subacute, torpid), when no more than 2 months have passed since the onset of the disease;
• chronic, if the time of illness is unknown or more than 2 months have passed since the start of treatment for the disease;
• latent, or gonococcal carriage, when patients do not have clinical signs of the disease, but pathogens are detected.

It is necessary to distinguish between a gonococcal infection that has occurred for the first time in a patient, a repeated infection (reinfection) and a relapse of the disease. In some patients, gonorrhea occurs without complications, in others - with complications. It is necessary to distinguish between uncomplicated and complicated forms of gonorrhea. Extragenital and disseminated forms of gonorrhea are also distinguished.

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Acute gonorrhea

Clinical symptoms of gonorrhea in men are characterized by discharge from the urethra, as well as itching and burning during urination. During an objective examination, the urethral lips are sharply hyperemic, edematous, the urethra itself is infiltrated, and painfulness is noted by palpation. Abundant purulent discharge of a yellowish-green color freely flows from the urethra, which often macerates the inner layer of the foreskin. In case of late treatment, hyperemia and swelling of the skin of the glans penis and foreskin can be observed. Superficial erosions can form on the glans penis. With rectal infection, discharge from the anus or pain in the perineum are observed. In men under 40 years of age, as well as in individuals with reduced resistance, epididymitis occurs due to the penetration of gonococci into the appendage from the prostatic part of the urethra through the vas deferens. The disease begins suddenly with pain in the epididymis and in the groin area. Patients have a fever of 39-40°C, chills, headache, and weakness. On palpation, the appendage is enlarged, dense, and painful. The skin of the scrotum is tense, hyperemic, and there is no skin folding. Gonococcal infection of the appendages leads to the formation of scars in the ducts of the epididymis. This results in azoospermia and infertility. Asymptomatic progression can be observed in 10% of cases with urethral lesions, 85% with rectal lesions, and 90% with pharyngeal lesions. Disseminated gonococcal infection (DGI) most often manifests itself as an increase in body temperature, lesions of the joints (one or more) and skin. The manifestation of gonococcal dermatitis is accompanied by the formation of necrotic pustules on an erythematous base, and erythematous and hemorrhagic spots, papulopustules, and blisters may also be observed. The most common localization of the rash is the distal parts of the limbs or near the affected joints. Also affected are the tendon sheaths, mainly of the hands and feet (tenosynovitis). DGI develops more often in women than in men. The risk of developing DGI increases during pregnancy and in the premenstrual period. Manifestations of gonococcal infection in the form of meningitis or endocarditis are very rare.

Clinical symptoms of gonorrhea in women are almost asymptomatic, which leads to late detection of the disease and the development of complications. The primary localization of the lesion is the cervical canal, with inflammatory changes developing both in the integumentary epithelium and in the stroma of the uterine mucosa. Lesions of the urethra (urethritis) are observed in 70-90% of patients, and lesions of the vulva and vagina usually develop secondarily. Upon examination, the discharge is mucopurulent in nature, contact bleeding may be observed. Lesions of the basal layer of the endometrium occur as a result of the penetration of gonococci into the uterine cavity during menstruation or after childbirth and abortions. Penetration of gonococci from the endometrium into the muscular layer of the uterus (endometritis) is often observed after an abortion and childbirth. A characteristic feature of ascending gonorrhea is the rapid spread of infection from the uterus to the fallopian tubes, ovaries, and peritoneum. When the purulent process spreads into the gas peritoneum, pelvic peritopitis occurs, the fibrin-rich transudate causes the formation of adhesions and fusions of the fallopian tube and ovary with adjacent organs. This is accompanied by acute pain in the lower abdomen and tenderness on palpation, an increase in body temperature to 39° C.

In 50% of cases of cervical lesions, 85% of cases of rectal lesions, and 90% of cases of pharyngeal lesions, asymptomatic infection is observed.

The infection often occurs as a mixed infection (gonorrhoeal-trichomoniasis, gonorrhea-chlamydial, etc.). As a rule, several organs are infected (multifocal lesion).

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Gonococcal conjunctivitis in newborns

Conjunctiva lesions in newborns occur during passage through the birth canal of a mother with gonorrhea and are accompanied by redness, swelling, and sticking of the eyelids. Pus flows from under their edges or the inner corner of the eye, the conjunctiva of the eye becomes hyperemic and swells. If appropriate treatment is not started in a timely manner, ulceration of the cornea up to its perforation is possible, which can subsequently lead to complete blindness. Gonococcal eye lesions in adults can be the result of gonococcal sepsis or, more often, direct transfer of infection by hands, "dirty discharge from the genitourinary organs. When the conjunctiva is inflamed, purulent discharge appears, its partial or even complete destruction.

Indications for testing

• symptoms or signs of urethral discharge;
• mucopurulent cervicitis;
• the presence of a sexually transmitted infection (STI) or PID in a sexual partner;
• STI screening at the patient's request or with the recent appearance of a new sexual partner;
• vaginal discharge in the presence of risk factors for STIs (age under 25, recent sexual partner);
• acute orchyoepididymitis in men under 40 years of age;
• acute PID;
• casual unprotected sexual intercourse;
• purulent conjunctivitis in newborns.

Laboratory diagnostics

Verification of the diagnosis of gonorrhea is based on the detection of Neisseria gonorrhea in materials from the genitals, rectum, pharynx, eyes using one of the methods.

A rapid diagnostic test (microscopy of Gram-stained smears from the urethra, cervix or rectum with methylene blue) allows rapid detection of typical Gram-negative diplococci.

All samples must be tested using culture and antigen amplification methods (nucleic acid amplification).

Additional research

• setting up a complex of serological reactions for syphilis;
• determination of antibodies to HIV, hepatitis B and C;
• clinical analysis of blood and urine;
• Ultrasound of the pelvic organs;
• urethroscopy, colposcopy;
• cytological examination of the mucous membrane of the cervix;
• 2-glass Thompson test;
• examination of prostate gland secretion.

The advisability of conducting a provocation is decided individually by the attending physician. Indications, volume and frequency of additional studies are determined by the nature and severity of the clinical manifestations of gonococcal infection.

Frequency of serological tests: before treatment, again after 3 months (if the source of infection is unknown) for syphilis and after 3-6-9 months for HIV, hepatitis B and C.

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Treatment of gonorrhea

For uncomplicated gonorrheal cervicitis, urethritis, and proctitis, the CDC (Centers for Disease Control and Prevention) recommends the following antibiotics (recommended regimens): ceftriaxone 250 mg IM once or cufixime 400 mg orally, once or ciprofloxacin (Syspres) 500 mg orally, once or ofloxacin 400 mg orally, once or cefuroxime (MegaSeph) 750 mg IM every 8 hours.

In the absence of the above antibiotics, alternative regimens are prescribed: spectinomycin 2 g intramuscularly once or single treatment regimens with cephalosporins (ceftizoxime 500 mg intramuscularly once, or cefoxitin 2 g intramuscularly once with probenecid 1 g orally).

For gonococcal conjunctivitis, ceftriaxone is recommended at 1 g intramuscularly once.

For ophthalmia neonatorum caused by N. gonorrhoeae, ceftriaxone is recommended at 25-50 mg/kg intravenously or intramuscularly once, no more than 125 mg.