Gonorrhoea
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| ICD-10 | A54 |
|---|---|
| ICD-9 | 098 |
Gonorrhoea (gonorrhea in American English; formally acute gonococcal perihepatitis), is among the most common sexually-transmitted diseases in the world and is caused by Gram-negative bacterium Neisseria gonorrhoeae. The term comes from Greek γονόρροια (gonórrhoia), literally "flow of seed"; in ancient times it was thought that the pus discharge associated with the disease contained semen.
Infection with gonorrhoea increases the risk of passing on or becoming infected with HIV (the virus that causes AIDS). This is likely due to weakening of the mucosal surface secondary to the gonorrhoea infection. Gonorrhoea might also increase the amount of HIV present in semen and other genital secretions. Note, however, that this effect is by no means limited to gonorrhoea and there is increased risk of HIV transmission with co-infection of most sexually-transmitted infections.
The first place this bacterium infects is usually the columnar epithelium of the urethra and endocervix. Non-genital sites in which it thrives are the rectum, the oropharynx and the conjunctivae of the eyes. The vulva and vagina in women are usually spared because they are lined by stratified epithelial cells — in women the cervix is the usual first site of infection.
Gonorrhoea spreads during sexual intercourse, whereby the infective partner does not need to be human.[1] Infected women also can pass gonorrhoea to their newborn infants during delivery, causing eye infections (conjunctivitis) in their babies. When the infection occurs in the genital tract, mouth, or rectum of a child, it is most commonly due to sexual abuse. Gonorrhoea among females can also be transmitted from one individual to another via contact to surfaces that may still be damp from prior contact.
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[edit] Epidemiology
In 2000, 358,995 cases of gonorrhoea were reported to the U.S. Centers for Disease Control and Prevention(CDC). In the United States, approximately 75 percent of all reported cases of gonorrhoea are found in younger persons aged 15 to 29 years. The highest rates of infection are usually found in 15- to 19-year old women and 20- to 24-year-old men. Health economists estimate that the annual cost of gonorrhoea and its complications is close to $1.1 billion. The disease can spread into the uterus and Fallopian tubes, resulting in pelvic inflammatory disease (PID). PID affects more than 1 million women in the United States (US) every year and can cause infertility in as many as 10 percent of infected women.
[edit] Vertical transmission
Pregnant mothers infected with gonorrhoea, can transmit the disease to their babies during childbirth. Gonococcal conjunctivitis is a major preventable cause of blindness in newborns, so if there is a known risk of transmitting gonorrhoea, prophylactic silver nitrate or other medications may be applied to the baby's eyes immediately after birth. Because of the risks of vertical transmission, doctors recommend that pregnant women have at least one test for gonorrhoea during pregnancy.
[edit] Symptoms of gonorrhoea
The incubation period varies from 2 to 14 days with most symptoms occurring between days 2 and 5 after being infected from an infected partner. A small number of people may be asymptomatic for up to a year.
[edit] Women
Between 30-60% of women with gonorrhoea are asymptomatic or have subclinical disease.[2] The woman may complain of vaginal discharge, difficulty urinating (dysuria), off-cycle menstrual bleeding, or bleeding after sexual intercourse. The cervix may appear anywhere from normal to the extreme of marked cervical inflammation (cervicitis) with pus. Infection of the urethra (urethritis) causes little dysuria or pus. The combination of urethritis and cervicitis on examination strongly supports a gonorrhoea diagnosis, as both sites are infected in most gonorrhoea patients.
More advanced symptoms, which may indicate development of pelvic inflammatory disease (PID), include cramps and pain, bleeding between menstrual periods, vomiting, or fever.
[edit] Men
It is not unusual for men to have asymptomatic gonorrhoea. Men may complain of pain on urinating and thick, copious, urethral pus discharge (also known as gleet) is the most common presentation. Examination may show a reddened external urethral meatus. Ascending infection may involve the epididymis, testicles or prostate gland causing symptoms such as scrotal pain or swelling.
The fact sheet from the Centers for Disease Control (CDC) states, "Many men with gonorrhea may have no symptoms at all, some men have some signs or symptoms that appear two to five days after infection; symptoms can take as long as 30 days to appear. Symptoms and signs include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. Sometimes men with gonorrhea get painful or swollen testicles."
[edit] Rectal gonorrhoea
Rectal gonorrhoea (gonococcal proctitis) may affect both men and women and is often asymptomatic. It may present with anal discharge, pain on defecating and rectal bleeding. Proctoscopy may show an inflamed mucous membrane with little mucus. Rectal infection also may cause no symptoms. It is transmitted by penetrative anal sex and is diagnosed on rectal swab. It cannot be treated with penicillin because rectal commensals produce.
[edit] Gonococcal pharyngitis
Infections of the throat are usually asymptomatic, but may cause a sore throat. It is diagnosed by throat swab.
[edit] Complications
In men, inflammation of the epididymis (epididymitis), prostate gland (prostatitis) and urethral structure (urethritis) can result from untreated gonorrhoea.
In women, untreated gonorrhoea can result in cyst and abscess formation in one or more of the greater vestibular glands (bartholinitis), causing trouble walking; PID; and Fitz-Hugh-Curtis syndrome.
The most common result of untreated gonorrhoea is PID, a serious infection of the female reproductive tract. PID causes scarring of the fallopian tubes which leads to increased risks of causing an ectopic pregnancy as a fertilized egg may not be able to pass through the narrowed, scarred fallopian tube. Ectopic pregnancies are serious conditions which are potentially life-threatening to the mother.
In both sexes, disseminated gonococcal infection (DGI) can occur, leading to multiple distant sites of infection which can include the brain, heart and joints.
[edit] Diagnosis of gonorrhoea
Doctors or other health care workers usually use three laboratory techniques to diagnose gonorrhoea: staining samples directly for the bacterium, detection of bacterial genes or DNA in urine, and growing the bacteria in laboratory cultures. Many doctors prefer to use more than one test to increase the chance of an accurate diagnosis.
The staining test involves placing a smear of the discharge from the penis or the cervix on a slide and staining the smear with a dye. Then the doctor uses a microscope to look for bacteria on the slide. One usually can get the test results while in the office or clinic. This test is quite accurate for men but not for women; only one in two women with gonorrhoea have a positive stain.
More often, doctors use urine or cervical swabs for a new test that detects the genes of the bacteria. These tests are as accurate or more so than culturing the bacteria, and many doctors use them.
The culture test involves placing a sample of the discharge onto a culture plate and incubating it up to 2 days to allow the bacteria to grow. The sensitivity of this test depends on the site from which the sample is taken. Cultures of cervical samples detect infection approximately 90 percent of the time. The doctor also can take a culture to detect gonorrhoea in the throat. The culture test allows testing for drug-resistant bacteria.
[edit] Treatment
The mainstay of treatment is the appropriate use of antibiotics. While penicillin was the most common antibiotic used to treat gonorrhoea up until the 1970's, an increase in antibiotic resistance has led to a decline in its use. Recommendations for first choice treatment of gonorrhoea must therefore depend on local information on resistance patterns and it is not possible to make treatment recommendations that are applicable to all parts of the world.
Antibiotics that may be used to treat gonorrhoea include:
- Cefixime 400 mg orally
- Ceftriaxone 125 to 250 mg by intramuscular injection
- Cefotaxime 500 mg by intramuscular injection
- Cefpodoxime 400mg orally
- Cefoxitin 2 g by intramuscular injection, plus probenecid 1 g orally
- Ciprofloxacin 500 mg orally
- Ofloxacin 400 mg orally
- Levofloxacin 250 mg orally
- Azithromycin 2 g orally
- Spectinomycin 2 g by intramuscular injection
- Amoxycillin 2 g plus probenecid 1 g orally
- Ampicillin 2 to 3 g plus probenecid 1 g orally
These drugs are all given as a single dose.
The level of tetracycline resistance in Neisseria gonorrhoeae is now so high as to make it completely ineffective in most parts of the world.
The fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) cannot be used in pregnancy. It is important to refer all sexual partners to be checked for gonorrhoea to prevent spread of the disease and to prevent the patient from becoming re-infected with gonorrhoea. Patients should also be offered screening for other sexually transmitted infections. In areas where co-infection with chlamydia is common, doctors may prescribe a combination of antibiotics, such as ceftriaxone with doxycycline or azithromycin, to treat both diseases.
Penicillin is ineffective at treating rectal gonorrhoea: this is because other bacteria within the rectum produce &beta- lactamases that destroy penicillin. All current treatment are less effective at treating gonorrhoea of the throat, so the patient must be rechecked by throat swab 72 hours or more after being given treatment, and then retreated if the throat swab is still positive.
Although, gonorrhoea usually does not require follow-up (with the exception of rectal or pharyngeal disease), patients are usually advised to phone for results 5 to 7 days after diagnosis to confirm that the antibiotic they received was likely to be effective. Patients are advised to abstain from sex during this time.
[edit] US recommendations
The US does not have a federal system of sexual health clinics, and the majority of infections are treated in family practices. A third-generation cephalosporin antibiotic such as ceftriaxone is recommended for use in most areas. Some areas such as Hawaii and California, have very high levels of resistance to fluoroquinolone antibiotics (ciprofloxacin, ofloxacin, levofloxacin) they are no longer used empirically to treat infections originating in these areas.
[edit] UK recommendations
In the UK, the majority of patients with gonorrhoea are treated in dedicated sexual health clinics. The current recommendation is for ceftriaxone or cefixime as first line therapy; no resistance to either drug has yet been reported in the UK. Levels of spectinomycin resistance in the UK are less than 1%, which would make it a good choice in theory, but intramuscular spectinomycin injection is very painful.
Azithromycin (given as a single dose of 2g) is recommended if there is concurrent infection with chlamydia. A single dose of oral ciprofloxacin 500mg is effective if the organism is known to be sensitive, but fluoroquinolones were removed from the UK recommendations for empirical therapy in 2003 because of increasing resistance rates. In 2005, resistance ratesfor ciprofloxacin were 22% for the whole of the UK (42% for London, 10% for the rest of the UK).[3]
[edit] Prevention
As gonorrhea is a sexually-transmitted infection, proper use of barrier contraceptives such as condoms and dental dams will significantly reduce the risk of getting gonorrhea and its complications. However, this does not eliminate risk. According to the Centers for Disease Control and Prevention, the only ways to eliminate risk are sexual abstinence, or sex with a faithful monogamous partner who has been previously tested.
[edit] Slang terms
[edit] "The Clap"
Gonorrhoea is also commonly known by the slang term "the clap". One suggested etymology is from the Old French word "clapier", meaning "brothel". Another suggested source for the term is from a notorious 18th century keeper of a brothel, Margaret Clap (better known as "Mother Clap"), though perhaps her name itself was derived from the slang term. It could also refer to the painful sting in the male urethra, which feels like the sting of a clap (as in clapping hands) when infected with the disease. Yet another suggested source refers to a traditional treatment used to clear the blockage in the urethra from gonorrhoeal pus, where the penis would be "clapped" on both sides simultaneously.[4]
The term "clap" is derived from its diplococcoid microscopic morphology, which is suggestive of two cocci "clapping".
This term has, in recent years, come to be used by extension to refer to any unspecified sexually transmitted disease.
[edit] Other
- Drippy dick: Used mainly because of the discharge coming from the urethral opening of the penis.
- The term gonorrhoea is built from the greek prefix gono (seed) and suffix rrhea (to flow), and stems from the belief that the discharge contained semen.[5]
[edit] References
- ^ Ellen Kleist, Harald Moi - Transmission of Gonorrhea Through an Inflatable Doll, Genitourinary Medicine, Vol. 69, Nr. 4, p. 332 ff. August 1993
- ^ YT van Duynhoven (1999). "The epidemiology of Neisseria gonorrhoeae in Europe". Microbes and Infection 1 (6): 455-464. PubMed.
- ^ Health Protection Agency. [http://www.hpa.org.uk/infections/topics_az/hiv_and_sti/sti-gonorrhoea/publications/GRASP_2005_Annual_Report.pdf The gonococcal resistance to antimicrobials surveillance programme: Annual report 2005]. Retrieved on 2006-10-28.
- ^ http://std-gov.org/stds/gonorrhea.htm
- ^ Definition of the term gonorrhea
[edit] External links
- Centers for Disease Control and Prevention: Gonorrhoea Information
- Drug-resistant gonorrhea on rise among gay men
- National Institute of Allergy and Infectious Diseases: Gonorrhoea Factsheet
- MayoClinic.Com: Gonorrhea
- Gonhorrhea News & Treatment Information
