Gonorrhea

Gonorrhea Zhang Jiang-an Dept. of Dermatology The first affiliated hospital of zhengzhou university

Definition  A common sexually-transmitted disease

causing urethritis in men and cervicitis in women.  Extension of infection and late scarring

may complicate the course of gonorrhea.

Incidence  The incidence in industrialized countries

fell after the high levels of World War II, and rose during the 'sexual revolution' of the 1960s and 1970s.  There were an estimated 2 million cases in the USA in 1983.  The incidence is high among homosexual men. Prostitutes are an important source of the infection, especially in developing countries.

Pathogen Neisseria gonorrhoeae  a gram-negative, aerobic diplococcus  found in pairs (diplococci) within

polymorphonuclear leukocytes (PMNL) in purulent material.  is a fragile organism that survives

only in a moist environment approximating body temperature.

Pathogen-- Neisseria gonorrhoeae

 gram-negative diplococci in

polymorphonuclear leukocytes

Pathogen  Most cases of gonorrhoea are sexually

transmitted, although accidental inoculation may account for some cases.  If a mother has genital infection at the time of delivery, gonococcal ophthalmia may occur in the neonate.  In the adult, the conjunctivae may be infected by auto-inoculation from the genitalia.

History  Gonorrhea is transmitted almost

exclusively by sexual contact.

 Persons under 25 years of age who

have multiple sexual partners are at highest risk.

 Often, gonorrhea is acquired from a

sexual partner who is either asymptomatic or who has only minimal symptoms.

Clinical manifestation （ 1 ）  In the majority of cases, gonococcal

infection are limited to mucosal surfaces. 



Infection occurs in areas of columnar epithelium including the cervix, urethra, rectum, pharynx, conjunctiva, and prepubertal vaginal tract. Squamous epithelium is not susceptible to infection by the gonococcus.

 Incubation Time: 2~10 days (average 3~5 d)

Clinical manifestation （ 2 ） Gonorrhea in Males  After a 3-to 5-day incubation period,

most infected men have a sudden onset of  

Burning, frequent urination A yellow, thick, purulent urethral discharge

Clinical manifestation （ 3 ）  Those who ignore their symptoms or

have asymptomatic infection are at risk of developing complications ： 

Prostatitis



Seminal vesiculitis



Epididymitis

Clinical manifestation （ 4 ）

 a yellow, thick, purulent urethral discharge

Clinical manifestation （ 5 ）

 a yellow, thick, purulent urethral discharge

Clinical manifestation （ 6 ）

fistula cannula

 a yellow, thick, purulent discharge from fistula cannula

Clinical manifestation （ 7 ）： gonococcal epididymitis

Swelling , erythema, with pain fellling of one side epididymis

Clinical manifestation （ 8 ）  Gonorrhea in Females  At least one-half of infected women are

asymptomatic or have symptoms that are mild to nonspecific.  Cervical infections may be accompanied by vaginal discharge, abnormal vaginal bleeding, or dysuria. On examination, the cervical os may be erythematous and friable, with a purulent exudate, or may be normal.  Local complications include abscesses in Bartholin’s glands.

Clinical manifestation （ 9 ）

vaginal discharge

Clinical manifestation （ 10 ）

vaginal discharge

Clinical manifestation （ 11 ）

purulent exudate from the cervical os

Clinical manifestation （ 12 ）

abscess in Bartholin’s glands, with swelling

Clinical manifestation （ 13 ） Complications Gonorrheal endometritis Salpingitis Pelvic inflammatory disease Peritonitis Clinical manifestation  The most common presenting symptom is lower abdominal tenderness and pain, usually bilateral.  Adnexal tenderness, and pain on manipulation of the cervix.  Vaginal discharge  Fever, leukocytosis  Gonococcal PID has an abrupt onset with fever and peritoneal irritation.    

Clinical manifestation （ 14 ）  Extragenital Gonorrheal Disease  Rectal gonorrhea

(correlate with the practices of passive rectal intercourse)  Oropharyngeal gonorrhea

(correlate with fellation)  Ophthalmoblennorrhea

Clinical manifestation （ 15 ）  Rectal gonorrhea  is acquired by anal intercourse. Women

with genital gonorrhea may also acquire rectal gonorrhea from contamination of the anorectal mucosa by infectious vaginal discharge.  Some patients report pain on defecation, blood in the stools, pus on undergarments, or intense discomfort while walking.

Clinical manifestation （ 16 ）  Oropharyngeal gonorrhea  Gonococcal pharyngitis is acquired by penile-

oral exposure and rarely by cunnilingus or kissing.  Most cases are asymptomatic, and the gonococcus can be carried for months in the pharynx without being detected.  In those with symptoms, complaints range from mild sore throat to severe pharyngitis with diffuse erythema and exudates.

Clinical manifestation （ 17 ）  Ophthalmoblennorrhea  Occurs most frequently in the newborns  Begins 1~5 days after the baby has passed

through the birth canal infected with gonorrhea.  Ophthalmoblennorrhea of adults is more severe than other conjunctival disease.  The intense involvement of the conjunctiva is remarkable, with massive pus formation.  The great danger of conjunctivitis is involvement of the cornea (about 25% of cases), the cornea may be destroyed and perforation might occur.

Clinical manifestation （ 18 ）

Ophthalmoblennorrhea Massive purulent exudate discharges from the eyes

Clinical manifestation （ 19 ） Ophthalmoblennorrhea

 Massive purulent exudate in a 30-year-old man

Clinical manifestation （ 19 ）

 Disseminated gonococcal infection （ 1 ）  also called arthritis-dermatitis syndrome, is the result

of gonococcal bacteremia  The following triad is indicative of its presence  intermittent febrile attacks  migratory joint pain  skin lesions  It is the most common form of infectious arthritis  Skin lesions, which are distributed sparsely on the extensor surfaces of the distal extremities, may be macular, pustular, centrally necrotic, or hemorrhagic

Clinical manifestation （ 20 ）  Disseminated gonococcal infection

（ 2）  The skin lesions typically are few in number (often less than a dozen) and concentrated on the extremities, usually acral, and often around the joints.

Clinical manifestation （ 21 ）  Disseminated gonococcal infection （ 3 ）

pustule

Complications （ 1 ）  Extension of infection

Males prostatitis seminal vesiculitis Epididymitis  Females gonorrheal endometritis salpingitis pelvic inflammatory disease (ascending infection) Peritonitis 

Complications （ 2 ） Both sexes Hematogenous spread (gonococcemia)  Post-inflammatory scarring causing adhesions and infertility (females)--adverse reproductive sequelea 

Laboratory(1)  Gram stain 

The diagnosis of acute urethritis can be made with a high degree of certainty if gram-negative intracellular diplococci are found in the purulent exudate from the urethra or endocervical canal.

Laboratory(2)  Culture

is the most reliable technique for establishing the presence of gonococcal infections, especially in those who are asymptomatic.  A modified Thayer-Martin medium (chocolate agar) incubated in a candle jar to elevate CO2 levels provides optimum conditions for culture. 

 gram-negative diplococci in

polymorphonuclear leukocytes

Many small colonies in a modified Thayer-Martin medium

Treatment （ 1 ）  Recommended regimens for infections of

the urethra, cervix and rectum (CDC, US)      

Cefixime 400mg oral as single dose; or Ceftriaxone 250mg i.m. as single dose; or Ciprofloxacin 500mg oral as single dose; or Ofloxacin 400mg oral as single dose; or Azithromycin 1g oral as single dose; or Doxycycline 100mg twice daily for 7 days

 Alternative Regiments 

Spectinomyxin 2g i.m. as single dose

Treatment （ 2 ）  Special situations

Pregnancy/breastfeeding  Pharyngeal gonorrhea  β -lactam allergy  Gonococcal epididymitis  Disseminated gonococcal infection  Ophthalmia neonatorum 

Prevetion and special notes  Prevention  

Safe sex Treatment of sexual partners

 Special notes 

Look for chlamydia, treponema and HIV  Co-infection

of other sexually transmitted agents

is common 

Follow-up  Follow-up

cultures should be obtained only from persons with persisting symptoms

Nongonococca l Urethritis (NGU)

Introduction  Nongonococcal urethritis (NGU) and cervicitis

are the most common STD in US.  Routine diagnostic tests for identifying the various infecting organisms are now available.  Pathogen 



Chlamydia trachomatis  Causes 23% to 55% of cases of NGU Ureaplasma urealyticum  Causes 20% to 40% of cases

Nongonococcal urethritis in males  NGU begins 7 to 21 days after sexual

contact with a smarting sensation while urinating and a mucoid discharge.  Chlamydia trachomatis causes at least two thirds of the acute idiopathic epididymitis in sexually active men under the age of 35 years

a mucoid discharge in NGU patient

Nongonococcal urethritis in females  The signs and symptoms in females are

even more nonspecific.  Nongonococcal cervicitis is

asymptomatic  or begins with a mucopurulent endocervical exudate  or a mucoid vaginal discharge 

mucopurulent endocervical exudate

mucoid vaginal discharge

Laboratary(1)  Gram stain is made of the urethral

discharge  A gram stained urethral smear containing ≥5 PMNL per high-power (×1000) microscopic field confirms the diagnosis of urethritis  And the absence of gram-negative intracellular diplococci suggests urethritis is nongonococcal.

Laboratary(2)  For those patients with urethral symptoms but

without discharge, polymorphonuclear leukocytes may be seen in material obtained by a Calgiswab inserted approximately 2 cm beyond the urethral meatus.  Urethral discharge must be cultured for N. gonorrhoeae  Culture and/or nonculture diagnostic tests are performed for C. trachomatis and U. urealyticum.

Diagnosis  The diagnosis is made by

confirming the presence of urethritis  demonstrating the presence of C. trachomatis (Chlamydia trachomatis)  excluding gonococcal infection 

Differential Diagnosis NGU

gonococcal urethritis

Incubation period

7~28 days

3~5 days

Onset

Gradual

Abrupt

Dysuria

Smarting feeling

Burning

Discharge

Mucoid or purulent

purulent

Gram stain of Polymorphonuclear Gram-negative discharge leukocytes intracellular diplococci

Treatment  Recommended regimens (CDC, US)

Doxycycline 100mg twice daily for 7 days; or  Azithromycin 1g oral as single dose  Erythromycin is used  during pregnancy  To treat patients who have persistent symptoms of NGU after having been treated. (Persistent disease may indicate the presence of a tetracycline-resistant U. urealyticum organism)  Penicillin, ampicillin, cephalosporins, aminoglycosides, and metronidazole are ineffective. 

Prevetion and special notes  Management of sexual partners 

All persons who are sexual partners of patients with NGU should be examined and promptly treated.

 Follow-up  

Patients should be advised to return if symptoms persist or recur. Test-of-cure cultures may not produce positive results until 3 to 6 weeks after treatment.

Key points  The pathogen of gonorrhea and NGU  Differential Diagnosis of NGU