gonorrhea

22 Jul

Gonorrhoea is a sexually transmitted infection caused by the bacteria, Neisseria gonorrhoea. Infections affecting the urethra (tube that allows the urine to leave the body) and cervix (body found between the vagina and uterus) which causes irritation, inflammation and discharge. In slang, it is known as ‘the clap’.

Epidemiology

According to the European Centre for Disease Prevention and Control, in 2019 a total of 117, 881 confirmed cases of gonorrhoea were reported by 28 EU member states [1]
In 2019, more than 70,000 people were diagnosed with gonorrhoea in England, with most cases affecting gay, bisexual and other men who have sex with men. [2]
Approximately 87 million new infections occur among the ages 15-49
The likelihood of transmission of Gonorrhea from women in men (22%) is higher than men to women after vaginal intercourse
Gonorrhoea, and chlamydia can exist at the same time in 15-25% of infected heterosexual men and 35% of women [3]

Pathophysiology [4]
- Medical Student
  - Gonorrhoea, known as Neisseria Gonorrhea, is a gram-negative, intracellular, aerobic diplococcus
  - It is primarily spread through sexual contact or vertical transmission during childbirth and mainly affects the host's columnar or cuboidal epithelium.
  - Gonococci can infect multiple mucous membranes, with adolescent females being particularly susceptible due to the physiology of the squamo-columnar junction onto the ectocervix.
  - Factors influencing gonococci's virulence and pathogenicity include pilli for attachment to mucosal surfaces, opacity-associated proteins for adherence and invasion of host cells, and porin channels in the outer membrane, which play key roles in virulence.
  - Acquired plasmids and genetic mutations can enhance virulence and confer resistance to antibiotics like penicillin and tetracycline
  - Gonococci attach to host mucosal cells using pili and opacity- associated proteins, penetrate the subepithelial space, and cause a host response characterised by neutrophil invasion, epithelial sloughing (shedding), and formation of submucosal microabscesses.
  - If left untreated, macrophage and lymphocyte infiltration replace neutrophils, and some strains can cause asymptomatic infections leading to patients being carriers.
  - Gonococci's ability to grow anaerobically allows them to invade lower genital structures (vagina and cervix) and progress to upper genital organs (endometrium, salpinx, ovaries) when mixed with menstrual blood or attached to sperm.
- Patients
  - N. gonorrhoea is a bacteria also known as the gonococcus.
  - It is primarily spread through sexual contact or transmission during childbirth and mainly affects the host's epithelium (a thin layer that covers the organs, glands and other structures)
  - Gonococci can infect mucous membranes (lining of the organs and other cavities) such as the nose, mouth, stomach, with adolescent (teenage years) females being particularly susceptible due to the area around the opening of the cervix where the endocervix (inner part) and ectocervix (outer part) meet.
  - Factors influencing gonococci's harmfulness and the ability to cause the disease include the long structures of the bacteria (pilli) for attachment to the surfaces of the mucous membranes, proteins for attachment and the entering and growth of host cells, as well as porin channels (pathways to allow the intake of antibiotics), which play key roles in disease harmfulness.
  - Circular rings of DNA called plasmids can be replicated and shared between bacteria, allowing growth of the infection. This, paired with genetic mutations can enhance harmfulness of the infection and allow resistance to be built against antibiotics like penicillin and tetracycline
  - The bacteria causing Gonorrhoea attaches to host mucosal cells using pili and proteins, creates a hole in the layers surrounding the lining of the organs and causes a response by the body to fight the infection. This causes the shedding of the organ lining, an immune system attack and the formation of small bumps, known as micro-absesses.
  - If left untreated, cells called macrophages and lymphocytes replace neutrophils, and some genetic variations of the infection can cause infections with no symptoms leading to the patient becoming a carrier of the infection.
  - Gonococci's ability to grow without oxygen allows them to invade lower genital structures (vagina and cervix) and progress to upper genital organs (endometrium, salpinx, ovaries) when mixed with menstrual blood or attached to sperm.

Gonorrhoea

A discharge of pus from the tip of the penis

Gonorrhoea

Close up view of the cervix (found at the end of the uterus that connects the uterus to the vagina). There is redness and.a slight discharge

Causes [5]

Bacterium Neisseria Gonorrhoeae
Spread through sexual contact with an infected person via the:
- Penis
- Vagina
- Mouth
- Anus
Spread from mother to baby during childbirth

Risk factors
- Younger age (15-24 years)
- More than one sexual partner
- Protection not being used regularly
- MSM (men who have sex with men)
- History of a sexually transmitted infection
- Social history of sexual or physical abuse
- Deprivation
- Being born by an infected person [6,7]

Presentations [3]
- Men:
  - Discomfort in the urethra
  - Tenderness in the penis
  - Pain when urinating and urinary frequency/urgency
  - Discharge (usually yellow-green colour)
  - Inflammation
  - Pain on the scrotum on one side (unilateral) (epididymitis)
- Women:
  - Dysuria
  - Vaginal discharge
  - Redness of the cervix
  - Inflammation of the urethra
  - Pelvic inflammatory disease
  - Inflammation of the fallopian tubes
  - Pelvic lumps (abscesses)
  - Lower abdominal pain (usually on both sides- bilateral)
- Fitz-Hugh-Curtis syndrome is the inflammation of the liver that causes right upper quadrant abdominal pain, fever, nausea, and vomiting
- Rectal gonorrhoea is usually asymptomatic but can include:
  - Rectal itching
  - Rectal discharge
  - Bleeding
  - Constipation
- Sore throat caused by gonorrhoea affecting the pharynx (tube inside the neck that extends from the nose and open into the oesophagus)
- Arthritis-dermatitis syndrome- Seen as a fever, migratory pain or joint swelling (polyarthritis), and pustular skin lesions.

Source: DermNetNZ.org

Gonorrhoea
Redness and lesion clusters on the wrist

Investigations [6]

Take a history including sexual activity, number and sex of sexual partners, protection used during sexual activity, and history of previous sexually transmitted infections.
For men:
- Assess using inspection and palpation (feeling using hands) of the male reproductive organs for swelling or tenderness. Include the;
  - Testes
  - Epididymis
  - Spermatic cord (cord that suspends the testes and epididymis)
- Inspect for discharge or pain in the:
  - Penis shaft
  - Head of penis (glans)
  - Meatus of penis
- Examine the prostate with associated symptoms:
  - Pain in lower back and genital area
  - Urinary frequency/ urgency
  - Pain or burning on urination
For women:
- Inspect the labia and clitoris
- Carry out a speculum examination (using a device called a speculum that is put into the vagina) to assess the cervix and vagina to assess for discharge or bleeding
- Carry out a bimanual pelvic exam (insertion of two fingers into the vagina to inspect the pelvic organs) to assess tenderness in the cervix, uterus and adnexal (fallopian tubes and ovaries)- indicates pelvic inflammatory disease
Assess for complications such as pelvic inflammatory disease and inflammation of the testes and epididymis

Differential diagnosis [7]
- Men
  - Urethritis (inflammation of the urethra) caused by bacteria such as Chlamydia trachomatis
  - Short term (acute) prostatitis (inflammation of the prostate)
  - Genital herpes
  - Candida infection (fungal)
- Women
  - Chlamydia
  - Candida infection
  - Bacterial vaginosis (infection caused by the excess of organisms such as Gardnerella Vaginalis)
  - Trichomoniasis (STI caused by Trichomonas vaginalis)
  - Pelvic inflammatory disease
  - Genital herpes

Management [3]
- Medical Students
  - Gonorrhoea affecting the urethra, cervix, rectum, and pharynx is treated with:

A single dose of ceftriaxone
Alternatively, use cefixime

If chlamydial infection is not ruled out, treat for chlamydia with:
- Doxycycline
- Alternatively, in patients allergic to doxycycline, use a single dose of azithromycin
Patients allergic to cephalosporins (including ceftriaxone) are treated with:
- Gentamicin
- Azithromycin
Disseminated gonococcal infection (DGI) with gonococcal arthritis is initially treated with IM or IV antibiotics for 24 to 48 hours until symptoms improve.
Then, oral therapy with antimicrobial susceptibility testing is continued for at least 7 days. If chlamydial infection is not ruled out, add doxycycline
If Gonococcal arthritis occurs, causing synovial fluid drainage and immobilisation of the joint, passive range-of-motion exercises should be started, and more active exercises can be done once pain subsides.
- Anti-inflammatory drugs may be beneficial.
Post-treatment cultures are unnecessary if symptomatic response is adequate.
For patients with symptoms lasting > 7 days, obtain specimens, culture, and test for antimicrobial sensitivity.
Patients should abstain from sexual activity until treatment is completed to avoid infecting sex partners.
All sex partners who had sexual contact with the patient within 60 days should be tested for gonorrhoea and other STIs and treated if positive.
Partners with contact within 2 weeks should be treated presumptively for gonorrhoea
Expedited partner therapy (EPT) involves giving patients a prescription or medications to deliver to their partner to enhance partner adherence and reduce treatment failure.
A health care visit is preferred to screen for other STIs and record medication allergies.

Patients
- Gonorrhoea affecting the urethra, cervix, rectum, and pharynx is treated with:

A single dose of ceftriaxone (a type of antibiotic)
Alternatively, use cefixime (a type of antibiotic)

If chlamydial infection is not ruled out, treat for chlamydia with:
- Doxycycline
- Alternatively, in patients allergic to doxycycline, use a single dose of azithromycin
Patients allergic to cephalosporins (including ceftriaxone) are treated with:
- Gentamicin
- Azithromycin
Disseminated gonococcal infection (when the infection invades the bloodstream) with gonococcal arthritis is initially treated with IM or IV antibiotics for 24 to 48 hours until symptoms improve.
Then, oral therapy with antimicrobial susceptibility testing (used to test which specific antibiotics a particular bacteria or fungus is sensitive to) is continued for at least 7 days. If chlamydial infection is not ruled out, add doxycycline
If Gonococcal arthritis occurs, causing synovial fluid drainage and immobilisation of the joint, passive range-of-motion exercises should be started, and more active exercises can be done once pain subsides.
- Anti-inflammatory drugs may be beneficial.
Post-treatment cultures are unnecessary if symptomatic response is adequate.
For patients with symptoms lasting more than 7 days, obtain specimens, culture, and test for antimicrobial sensitivity.
Patients should abstain from sexual activity until treatment is completed to avoid infecting sex partners.
All sex partners who had sexual contact with the patient within 60 days should be tested for gonorrhoea and other STIs and treated if positive.
Partners with contact within 2 weeks should be treated with the assumption that they are infected.
Expedited partner therapy involves giving patients a prescription or medications to deliver to their partner to enhance partner adherence and reduce treatment failure.
A health care visit is preferred to screen for other STIs and record medication allergies.

Source: Waikato District Health Board; DermNetNZ

Gonorrhoea
Lesions found on the lower legs

Complications [2]

Pelvic inflammatory disease (estimated in 10-20% of cases of untreated gonorrhoea)
Ectopic pregnancy
Infertility (in men and women)
During pregnancy can cause miscarriage, premature labour/birth and conjunctivits in newborns
In rare cases, can cause sepsis (life-threatening reaction to infection) if left untreated

Myths behind gonorrhoea

You can catch the infection from public toilets
Vaginal/anal sex is the only way you can spread gonorrhea
Gonorrhoea always produced symptoms
Gonorrhoea is not treatable
You can gonorrhoea once
Gonorrhoea can self resolve [8,9]

Questions you may want to ask your doctor
- Will I present with symptoms if I am diagnosed with gonorrhea eventually?
- How long does treatment take to work?
- What can I do to prevent re-infection or the infection of others?
- How can I tell if I start developing complications? and who can I contact?
- How can I tell my partner(s)?
- Are there specific foods I should est to help recovery?