DEFINITION
Gonorrhea is a sexually transmitted disease (STD). Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract, including the cervix (opening to the womb), uterus (womb), and fallopian tubes (egg canals) in women, and in the urethra (urine canal) in women and men. The bacterium can also grow in the mouth, throat, eyes,and anus.
Morphology of Neisseria gonorrhoeae
Neisseria gonorrhoeae is a Gram-negative coccus, 0.6 to 1.0 μm in diameter, usually seen in pairs with adjacent flattened sides. The organism is frequently found
intracellularly in polymorphonuclear leukocytes (neutrophils) of the gonorrhea
pustular exudates . Fimbriae, which play a major role in adherence, extend
several micrometers from the cell surface.
Bacteriology
Neisseria gonorrhoeae possesses a typical Gram-negative outer
membrane composed of proteins, phospholipids, and lipopolysaccharide (LPS).
However, neisserial LPS is distinguished from enteric LPS by its highly-branched
basal oligosaccharide structure and the absence of repeating O-antigen subunits.
For these reasons, neisserial LPS is referred to as lipooligosaccharide (LOS).
The bacterium characteristically releases outer membrane fragments called
"blebs" during growth. These blebs contain LOS and probably have a role in
pathogenesis if they are disseminated during the course of an infection.
N. gonorrhoeae is a relatively fragile organism, susceptible to temperature
changes, drying, UV light, and other environmental conditions. Strains of N.
gonorrhoeae are variable in their cultural requirements so that media containing
hemoglobin, NAD, yeast extract and other supplements are needed for isolation
and growth of the organism. Cultures are grown at 35-36 degrees in an
atmosphere of 3-10% added CO2.
pathology
a) Organism is equipped with fimbria, which enable it to attach to inner surface tissue or urethra. Incubation period is 2 to 8 days.
b) Organism spreads intercellularly to deeper urethral tissues. Endotoxin in the bacterial cell wall causes inflammation of these tissues. Large amounts of pus (yellow) are exuded into the urethra and out of urethral opening.
c) Accumulation of pus in urethra makes urination painful. Endotoxin also causes inflammatory pain. Symptoms usually milder in women.
d) The untreated infection in women may spread to fallopian tubes and other abdominal tissues to cause PID (pelvic inflammatory disease). Sterility may result from PID involvement in females and vas deferens involvement in males.
e) During birth from an infected mother, the child's eyes may become infected, causing blindness (ophthalmia nenoatorum). This is prevented by adding 1% AgNO3 or penicillin to eyes of newborns.
Habitat and Portal of Entry
Genitourinary tract and the eyes of infected persons
Mode of Transmission
Gonorrhea is spread through contact with the penis, vagina, mouth, or anus. Ejaculation does not have to occur for gonorrhea to be transmitted oracquired. Gonorrhea can also be spread from mother to baby during delivery (through passage of fetus in the infected genital tract).
Signs and Symptoms
Although 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.
Males:
# Urethritis (pain during and frequency of urination).
#Urethral Discharge.
In women, the symptoms of gonorrhea are often mild, but most women who are infected have no symptoms. Even when a woman has symptoms, they can be so non-specific as to be mistaken for a bladder or vaginal infection. The initial symptoms and signs in women include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods.
Women with gonorrhea are at risk of developing serious complications from the infection, regardless of the presence or severity of symptoms.
Females:
- Urinary Tract Infection.
- Bartholin’s Glands may become inflamed and painful.
- Increased Vaginal Discharge (slight yellowish/ thick greenish yellow).
Symptoms of Extreme Inflammation
Symptoms of rectal infection in both men and women may include discharge,anal itching ,soreness, bleeding, or painful bowel movements. Rectal infection also may cause no symptoms.Infections in the throat may cause a sore throat but usually causes no symptoms.
Assessment and Diagnostic Findings
1. Assess for fever; urethral, vaginal and rectal discharge; and for signs of arthritis.
2. Specimen Culture.
* Urine – for gonococcal bacillus.
* Vaginal on all children with vulvovaginitis.
* Urethral or urethral discharge.
where to obtain specimens?
In males: Urethra, anal canal, and pharynx.
In females: Endocervix, anal canal and pharynx.
Diagnosis
a) Presence of Gram negative diplococci in exuded pus.
b) Transfer pus specimen to plates of Thayer-Martin agar (selective for N.gonorrhoeae) Observe for growth of N. gonorrhoeae.
c) Gonozyme test - ELISA test for Ag in urethral samplings (does notdetect Ag very well in rectal or pharyngeal forms of the disease).
Complications
Untreated gonorrhea can cause serious and permanent health problems in both women and men.
In women, gonorrhea is a common cause of pelvic inflammatory disease(PID). Women with PID do not necessarily have symptoms. When symptoms are present, they can be very severe and can include abdominal pain and fever. PID can lead to internal abscesses (pus-filled “pockets” that are hard to cure) and long-lasting, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube.
In men, gonorrhea can cause epididymitis, a painful condition of the testicles that can lead to infertility if left untreated.
Gonorrhea can spread to the blood or joints. This condition can be life threatening. In addition, people with gonorrhea can more easily contract HIV, the virus that causes AIDS. HIV-infected people with gonorrhea are more likely to transmit HIV to someone else.
Medical Management
The recommended treatment for uncomplicated infections is a thirdgeneration cephalosporin or a fluoroquinolone plus an antibiotic (e.g., doxycycline or erythromycin) effective against possible coinfection with Chlamydia trachomatis. Sex partners should be referred and treated. The current CDC Treatment Guidelines recommend treatment of all gonococcal infections with antibiotic regimens effective against resistant strains. The recommended antimicrobial agents are ceftriaxone, cefixime, ciprofloxacin, or oflaxacin.
1. Administration of ceftriaxone (Rocephine) (or cefixime [Suprax] ciprofloxacin [Cipro]), or ofloxacin [Floxin]) along with doxicycline.
2. Note: If the patient is pregnant, give amoxicillin.
3. Serologic Testing for syphilis and HIV.
