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Gonorrhea
is a sexually transmitted disease caused by the bacteria Neisseria
gonorrhoeae, which infect the lining of the urethra,
cervix, rectum, and throat or the membranes that cover the front
part of the eye (conjunctiva and cornea).
In the United States, the number of gonorrhea cases reported each year has decreased by 75% since it peaked at nearly 900,000 in 1985. However, the number appears to have leveled off for about the last 10 years, with about 360,000 cases reported in 2006.
Gonorrhea is almost always spread through sexual contact. After one episode of vaginal intercourse with an infected person, the chance of spread from women to men is about 20%. The chance of spread from men to women may be higher. If pregnant women are infected, the bacteria can spread to the eyes of the fetus during birth. However, in most developed countries, infection is prevented because all newborns are routinely treated after delivery with medicated eye ointment.
Many people with gonorrhea have other sexually transmitted diseases (STDs), such as chlamydial infection, syphilis, or human immunodeficiency virus (HIV) infection.
Symptoms
In men, symptoms begin within about 3 to 10 days after infection. Usually, gonorrhea causes symptoms only at the sites of initial infection. In some people, infection spreads through the bloodstream to other parts of the body, especially to the skin, joints, or both.
Men feel mild discomfort in the urethra, followed a few hours later by mild to severe pain during urination, a yellow-green discharge of pus from the penis, and a frequent urge to urinate. The opening at the tip of the penis may become red and swollen. The bacteria sometimes spread to the epididymis (the coiled tube on top of each testis), which swells and feels tender to the touch.
About 10 to 20% of infected women have minimal or no symptoms. Thus, the infection may be detected only during routine screening or after diagnosis of the infection in their male partner. Symptoms typically do not begin until at least 10 days after infection. Some women feel only mild discomfort in the genital area and have a puslike discharge from the vagina. However, other women have more severe symptoms, such as a frequent urge to urinate, pain during urination, and fever because the urethra may also be infected.
Bacteria commonly spread up the genital tract and infect the tubes that connect the ovaries to the uterus (fallopian tubes). This infection, called salpingitis or pelvic inflammatory disease, causes severe lower abdominal pain, especially during intercourse. In some women, the lining of the abdominal cavity (peritoneum) becomes inflamed. This inflammation, called peritonitis, causes severe pain in the entire abdomen. Infection in the abdomen may concentrate around the liver. This infection, called perihepatitis or Fitz-Hugh-Curtis syndrome and also caused by chlamydia, causes pain in the upper right part of the abdomen. Women who have had pelvic inflammatory disease have an increased risk of infertility and mislocated (ectopic) pregnancies.
Anal sex with an infected partner may result in gonorrhea of the rectum, which makes bowel movements painful. Other symptoms include constipation, itching, bleeding, and a discharge from the rectum. The area around the anus may become red and raw, and stool may be coated with mucus and pus. When a doctor examines the rectum with a viewing tube (anoscope), mucus and pus may be visible on the wall of the rectum.
Oral sex with an infected partner may result in gonorrhea of the throat (gonococcal pharyngitis). Usually, the infection causes no symptoms, except uncommonly a sore throat.
If infected fluids come into contact with the eyes, gonococcal conjunctivitis may develop (see Conjunctival and Scleral Disorders: Infectious Conjunctivitis), causing swelling of the eyelids and a discharge of pus from the eyes. In adults, often only one eye is infected. Newborns usually have infection in both eyes. Blindness may result if the infection is not treated early.
Gonorrhea in children usually results from sexual abuse. In girls, the genital area (vulva) may be irritated, red, and swollen, and they may have a discharge from the vagina. If the urethra is infected, children, mainly boys, may have pain during urination.
Rarely, the infection spreads through the bloodstream to other parts of the body, especially the skin and joints. Joints become swollen, tender, and extremely painful, limiting movement. The skin over infected joints may be red and warm. If the bloodstream is infected, people may have a fever, feel generally ill, and develop arthritis in one or more joints. Red spots may appear on the skin. This infection is called disseminated gonococcal infection or arthritis-dermatitis syndrome.
Joint, bloodstream, and heart infections can be treated, but recovery from arthritis may be slow.
Diagnosis
In more than 90% of infected men, gonorrhea may be diagnosed within an hour by identifying the bacteria (gonococci) in samples of the discharge examined under a microscope. The sample is usually obtained by inserting a small swab a few centimeters into the urethra. However, identifying bacteria in a sample of discharge from the cervix is more difficult. The bacteria can be seen in only about half of infected women.
The sample of discharge is also sent to a laboratory for tests. Such tests are very reliable in both sexes but take longer than a microscopic examination. If a doctor suspects an infection of the throat, rectum, or bloodstream, samples from these areas are sent for culture (to be grown in a laboratory).
Other highly sensitive tests can be done to detect the DNA of gonococci and of chlamydia (which are often also present). Laboratories can test for both infections in a single specimen. For some of these tests, urine samples can be used. Thus, these tests are convenient for screening men and women who have no symptoms or who are unwilling to have fluid samples taken from their genitals.
Because many people have more than one STD, doctors may test samples of blood and genital fluids for other STDs, such as syphilis and HIV infection.
If a joint is red and swollen, doctors draw fluid from the joint using a needle. The fluid is sent for culture and other tests.
Treatment
A single injection of a cephalosporin antibiotic, such as ceftriaxone , into a muscle or a single dose of cefixime taken by mouth, cures most people. Some antibiotics (such as penicillin, ciprofloxacin , levofloxacin , and ofloxacin ) are no longer used because many strains of gonococci have developed resistance to them. Usually, people with gonorrhea are also given antibiotics to kill chlamydiae because people are often infected with both. A single dose of azithromycin is most commonly used. A single high dose of azithromycin can cure both gonorrhea and chlamydial infection if people are allergic to cephalosporins, but the required dose often causes stomach upset.
If gonorrhea has spread through the bloodstream, people are usually treated in the hospital and given antibiotics intravenously.
If symptoms recur or persist after treatment, doctors may take samples for culture to make sure people are cured and do tests to determine whether the gonococci are resistant to the antibiotics used.
People with gonorrhea should abstain from sexual activity until treatment is completed to avoid infecting sex partners. All sex partners who have had sexual contact with infected people in the past 60 days should be tested for gonorrhea and other STDs and, if the tests are positive, should be treated. People who were exposed to gonorrhea within 2 weeks are treated for it without waiting for test results.
Last full review/revision October 2008 by J. Allen McCutchan, MD, MSc
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