Gonorrhoea (overview) A54.9

Author: Prof. Dr. med. Peter Altmeyer

Co-Autors: Dr. med. Eva Kämmerer, Jeton Luzha, Hadrian Tran, Nico Weinkauf

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Last updated on: 29.10.2020

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Synonym(s)

Gonococcal conjunctivitis; Gonorrhea; gonorrhoea spermatocystitis; Neisser M.; Neisser's disease; posterior urethritis gonorrhoica; Rectal gonorrhea; Two-glass sample; Urethritis gonorrhoica anterior acuta; Urethritis specific

Definition
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One of the most common sexually transmitted infectious diseases in the world. Gonorrhea is therefore an important indicator of the effectiveness of prevention for the human immunodeficiency virus (HIV) and other sexually transmitted diseases(STD). The pathogen is Neisseria gonorrhoeae. The disease usually manifests itself as urethritis gonorrhoeae or cervicitis.

Asymptomatic courses in men and women are possible. Ascending inflammation or haematogenic scattering can lead to complications.

Pathogen
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Neisseria gonorrhoeae, gram-negative, aerobic, oxidase-positive diplococci. Adhesive piles localized on the surface are responsible for specific adherence to mucosa cells. Gonococci are transmitted through direct contact with infectious secretions in the mucosa and cause a purulent inflammation of the mucosa, especially the cylindrical epithelia of the urethra, cervix, rectum and conjunctiva. Hematogenic spreading is rare but possible. The disease leaves no immunity. There is no vaccination.

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Occurrence/Epidemiology
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Worldwide there are about 300-600 million infected people. Incidence in the Federal Republic of Germany according to official statistics of the Robert Koch Institute: 2-5/100,000 per year (high dark figure!). For Saxony, the incidence was 10.1 cases/100,000 inhabitants in 2008. With more than 32,000 cases, gonorrhoea was the second most frequently reported sexually transmitted infection (STI) in Europe in 2010.

In 2014 almost half of those infected were homosexual men. The second group included heterosexual men and women.

Etiopathogenesis
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Transmission through sexual intercourse, rarely through smear infection.

Manifestation
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Adolescents and young adults between 15 and 24 years of age account for about 1/3 of all cases of illness, 1/3 concerns the age group between 25 and 40 years.

Localization
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Urethra, distal rectal mucosa (approx. 10 cm from ano); ano-rectal transition zone including the Morganian glandular ducts; vagina, labia.

A distinction is made between upper and lower gonorrhoea:

  • Lower gonorrhea (below the cervix; with few symptoms):
    • introitus inflammation (possibly in combination with bartholinitis)
    • Urethritis (about 90%)
    • Proctitis
    • Cervicitis (approx. 80-90%)
  • Upper g onorrhea (above the cervix; symptomatic):
    • Endometritis
    • Salpingitis
    • Pelveoperotinitis
    • Peritonitis

Clinical features
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Incubation period: 2-7 days, usually 3 days.

  • In men:
    • Infection of the pars anterior of the urethra (Urethritis gonorrhoica anterior acuta et chronica). Burning during urination, reddening of the meatus of the urethra, yellow-greenish, creamy, purulent fluorine, development of balanitis, possible paraphimosis.
  • In the female:
    • Urethritis gonorrhoica acuta with serous purulent fluorine, burning and pain during urination. Possibly trigonum cystitis. Development of urethritis gonorrhoica chronica. Irritation of the mucous membranes in the small and large labia: redness, swelling, impetiginisation, erosions, superficial ulcerations. The clinical symptoms remain mildly symptomatic or asymptomatic in > 50% of infected women.
    • S.u. Cervicitis gonorrhoica;
    • s.u. Bartholinitis.
  • Anorectal infection (in men and women): often asymptomatic or asymptomatic course. Possible symptoms are blood and mucus deposits on the stool, purulent secretion, feeling of pressure and tenesmus, possibly defecation pain. Itching and soreness can occur as so-called secondary phenomena in the sense of toxic-irritative anal eczema.
  • In girls: see below Vulvovaginitis gonorrhoica infantum.
  • Pharyngeal gonorrhoea: about 90% of this type of infection is asymptomatic. In this respect a throat swab should be taken in all STI patients. Pharyngeal gonorrhoeae is an essential reservoir for the spread of N. gonorrhoeae.
  • Disseminated gonorrhoeae: septic gonorrhoeae is rare and occurs in about 0.5-3% of patients with localized gonorrhoeae. It is significantly more common in women than in men. It is mainly caused by gonococcal strains with the protein IA phenotype. Clinically impressive: undulating fever, acute polyarthritis and acral vasculitic skin lesions.

Diagnosis
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Microscopic evidence: Intraleucocytic, Gram-negative diplococci ( methylene blue and Gram staining).

Cultural evidence from urethral, cervical or anal swab.

PCR from urethral, cervical or anal swab.

Serology: GO complement fixation reaction in metastatic inflammation (arthritis gonorrhoica).

To exclude co-infections, if necessary syphilisserology before treatment and 6 weeks later, PCR for chlamydia, mycoplasma and ureaplasma, HIV-ELISA, hepatitis serology.

Rectoscopy/Proctoscopy: inflammatory changes of the distal rectal mucosa and the anorectal transition zone. These impress as redness as well as oedema with increased vulnerability (contact bleeding) or fibrin coatings. Rare ulcerations. Crypts and anal papillae may also have inflammatory changes. If necessary, endoscopic smear collection.

Complication(s)
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Male: Subsequent infection of the posterior urethra pars (posterior urethritis gonorrhoica, two-lens specimen), prostatitis, vesiculitis, funiculitis, epididymitis, spermatocystis, cowperitis, cavernitis, anal infection, gonococcal sepsis, perihepatitis gonorrhoica, endocarditis, meningitis and gonarthritis.

Woman: Endometritis gonorrhoica, salpingitis, perioophoritis, oophoritis, peritonitis gonorrhoica, pelvic gonorrhoica, rectal gonorrhoea, vulvovaginitis gonorrhoica adultorum, gonococcal sepsis, perihepatitis gonorrhoica, endocarditis, meningitis and gonarthritis.

Therapy
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Worldwide increase of plasmid-borne penicillin resistance (in Germany 5%) and chromosomal tetracycline resistance, therefore the use of cephalosporins, aminoglycosides is recommended (see table). Due to the increasing development of resistance to fluoroquinolones, especially in the USA, fluoroquinolones can no longer be recommended, contrary to the recommendations of the German STD Society.

Caution! Co-treatment of the sexual partner to avoid the so-called ping-pong effect and mutual re-infection. Repeated controls are absolutely necessary!

S.a. p. 12/13 of the current guidelines of the STI Society

Tables
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Therapy of gonorrhoea

antibiotic

Example preparations

Dosage

Duration

Uncomplicated gonorrhoea

ceftriaxone +azithromycin

Rocephin + Zithromax

1,0 g i.m. or i.v. + 1,5g p.o.

once only

cefixim +azithomycin Suprax, Cephoral 800 mg p.o. + 1.5g p.o. once only

Complicated gonorrhoea or chronic gonorrhoea (endometritis, pelvic inflammatory disease, rectal gonorrhoea, vulvovaginitis, etc.)

Ceftriaxone

Rocephin

1-2 g/day i.m.

over 7 days, depending on the clinic longer

Cefotaxime

Claforan

1-2 g/day i.v.

Cefuroxime

Zinacef

1-2 g/day i.m.

Erythromycin

Erythromycin Wolff

4 times 500 mg/day p.o.

Gonorrhoea, oropharyngeal

Ceftriaxone

Rocephin

250 milligrams I.M.

once

Azithromycin

Zithromax

1 g p.o.(Development of increasing resistance!)

once

Gonococcal Conjunctivitis

Erythromycin

Ecolicin eye ointment, eye drops

Local therapy: Apply initially every half hour, later every hour

at least 5-6 days

Ceftriaxone

Rocephin

System therapy: 1 g/day i.m.

7 days

Gonococcal sepsis (for endocarditis)

Ceftriaxone

Rocephin

2-4 g/day i.v.

over 2-3 weeks

Cefotaxime

Claforan

4-6 g/day i.v.

over 2-3 weeks

Cefuroxime

Zinacef

4-6 g/day i.v.

over 2-3 weeks

Note(s)
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Pregnant women and nursing mothers receive Ceftriaxone 1g i.v.

Literature
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  1. Burstein GR et al (2002) Ciprofloxacin for the treatment of uncomplicated gonorrhea infection in adolescents: does the benefit outweigh the risk? Clin Infect Dis 35(Suppl 2): S191-199
  2. Golden MR et al (2003) Partner notification for HIV and STD in the United States: low coverage for gonorrhea, chlamydial infection, and HIV. Sex Transm Dis 30: 490-496
  3. Lutz AR (20159 Screening for Asymptomatic Extragenital Gonorrhea and Chlamydia in Men Who Have Sex with Men: Significance, Recommendations, and Options forOvercoming
    Barriers to Testing. LGBT Health 2:27-34.

  4. Palusci VJ et al (2003) Testing for genital gonorrhea infections in prepubertal girls with suspected sexual abuse. Pediatric Infect Dis J 22: 618-623

  5. Rietmeijer CA et al (2003) Increases in gonorrhea and sexual risk behaviors among men who have sex with men: a 12-year trend analysis at the Denver Metro Health Clinic. Sex Transm Dis 30: 562-567
  6. Sena Corrales G et al(20169 Gonococcal arthritis in human immunodeficiency virus-infected patients. Review of the literature. Reumatol Clin doi: 10.1016/j.reuma.2015.12.001.

  7. Wong ML et al (2002) Promoting condoms for oral sex: impact on pharyngeal gonorrhea among female brothel-based sex workers. Sex Transm Dis 29: 311-318

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.