GONORRHOEA

INTRODUCTION

Gonorrhoea is caused by Neisseria gonorrheae, a gram-negative aerobic diplococcus.

It prefers the columnar epithelium of the urethra, the cervical canal, the rectum and the conjunctivae.

The keratinizing epithelium of the adult vagina is quite resistant to N. gonorrhea, but that of the pre-pubertal girls, pregnant women and the elderly is more easily colonized.

Occasionally N. Gonorrhoeae reaches the blood stream causing sepsis.

GONORRHOEA IN MALES

Clinical features

Presents as foul-smelling urethral discharge of pus with dysuria painful 2-6 days after exposure.

Some patients have a scanty discharge that cannot be distinguished from non-gonococcal urethritis.

Often asymptomatic during the day but there may be drop of discharge in the morning.

Urethral orifice is usually inflamed; there may be balanitis because of the irritation from the discharge and secondary infection.

About half of infected males are asymptomatic.

Ascending infection is common and may lead to inflammation of the epididymis (epididymitis).

Epididymitis usually manifests by acute onset of unilateral testicular pain and swelling, often with tenderness of the epididymis and vas deferens.

Occasionally there is erythema and oedema of the overlying skin.

The adjacent testis is often also inflamed (orchitis), living rise to epididymo-orchitis.

Complications

Local complications (now uncommon):

Litre abscess involving periurethral glands,

Paraurethral abscesses,

Proximal urethral involvement with frequency and terminal haematuria,

Cowper’s gland abscess involving the bulbourethral glands, producing a swelling behind the base of the scrotum that can produce a proximal or Cowper’s stricture.

  • Prostatitis
  • Proctitis

Urethral stricture leading to hydroureters and hydronephrosis.

Chronic epididymo-orchitis leading to sterility.

Contaminated fingers or other fomites can also lead to infection of the eyes gonococcal conjunctivitis.

  • Haematogenous spread leading to meningitis, arthritis etc.

Differential diagnoses

Urethral discharge:

Spermatorrhea/prostatorrhoea (sexual arousal)

  • Trichomonas vaginalis and Candida albicans can also give rise to urethral discharge and balanitis.

Ascending infections:

Escherchia coli, a common cause in the insertive male homosexuals.

  • Other organisms may be transmitted non-sexually following genitourinary infections surgery and instrumentation (including catheterization).

Scrotal swelling (epididymo-orchitis):

In older man, where there may have been no risk of STIs, other general infections may be responsible, e.g Escherichia coli, Klebsiella spp. Or pseudomonas aeruginosa.

Tuberculous epididymo-orchitis, secondary to lesions elsewhere, especially in the lungs or bones.

Brucellopsis, caused by Brucella melitensis or Brucella abortus.

  • Orchitis is usually clinically more evident than an epididymitis.

In pre-pubertal children the usual aetiology is coliform, pseudomonas infection or mumps virus.

Non-infectious causes of scrotal swelling:

Trauma (haematocoele)

Testicular torsion

Tumor

Hydrocoele of the tunica vaginalis

Cyst of epididymis

Varicocoele

Inguinoscrotal hemia

Investigations

Urethral swab for microscopy and culture and sensitivity.

GONORRHOEA IN WOMEN

Clinical features

Inflammation of the cervix and cervical canal (cervicitis) is the commonest presentation in women.

Rethritis: the urethra becomes the most common site in women who have had hysterectomy.

The most frequent complaint is discharge, often accompanied with burning on urination.

over 50% of infected women are asymptomatic Oropharyngeal gonorrhea from orogenital sex (fellation) may present as sore throat.

Complications

Local:

Infections of skene’s periurethral glands and Bartholin’s labial glands; a Bartholin’s gland abscess may cause pain on sitting or walking

Vulvitis

Ascending infection to the endometrium, fallopian tubes, ovaries and peritoneum (pelvic inflammatory disease)

Ectopic Pregnancy

Infertility

Perithepatic abscess (Fitz-Hugh-Curtis syndrome).

Risk of disseminated gonococcal infection during pregnancy and menstruation.

Risk to the newborn infant:

  • Premature rupture of membranes
  • Premature labour
  • Chorioamnionitis
  • Septic obortion
  • Ophthalmia neonatorum
  • Oropharyngeal gonorrhea

Differential diagnose

Other causes of vaginal discharge:

Accentuation of physiological discharge

  • Premenstrual
  • At the time of ovulation
  • In pregnancy
  • Use of contraceptive pills or an intrauterine device infective causes
  • Candidiasis
  • Trichomoniasis
  • Bacterial vaginosis
  • Chlamydia
  • Cervical herpes genitalis
  • Cervical warts
  • Syphilitic chancre
  • Toxic shock syndrome (Staphylococcus aureus)
  • B-haemolytic streptococcal infection, Mycoplasma infection

Non-infective causes:

  •   Cervical ectropion
  • Cervical polyp(s)
  • Neoplasia e.g. cancer of the cervix
  • Retained products (tampon, post abortion, post-natal)
  • Trauma
  • Semen (post-coital)
  • Contact irritants and sensitizers e.g. from douches or feminine hyginene sprays
  • Bullous diseases of the mucous membranes

Investigations

Endocervical swab (through a vaginal speculum) for microscopy, culture and sensitivity.

GONORRHOEA IN CHILDREN

Clinical features

Sexual abuse is a common cause of gonorrhea in young girls

Usually symptomatic in young girls.

Pruritus and dysuria are common complaints.

Discharge may cause irritant dermatitis of the supper thighs.

Differential diagnose

Other causes of vaginal discharge in young girls;

A vaginal foreign body such as a small toy, bead, or even a piece of food.

Other infections caused by T. vaginalis, and C. albicans.

Intestinal bacteria or pin worms due to adequate cleaning after defeacation.

Ophthalmia neonatorum

Gonococcal conjunctivitis in the neonate can be acquired prenatally.

Purulent conjunctivitis; the lids swell; eyes are red and tender

If not treated promptly, the cornea may be eroded and conophthalmus and blindness.

  •   About 30%of babies infected will also have oropharyngeal gonorrhea.
  • Differential diagnose    The silver nitrate prophylaxis can produce a chemicalconjunctivitis, usually appearing 6 – 8 hours after treatment and resolving over 24 hours.

    The most common cause of neonatal conjunctivitis in most countries is C. trachomatis.

  • E.coli, staphylococci, streptococci and pseudomonas sp. Can also cause conjunctivitis in the neonate.

     Treatment objectives

Eliminate the organism in the patient and sexual partner(s),

Prevent re-infection,

Prevent complication,

Counsel and screen for possible co-infection with HIV so that appropriate management can be instituted.

Drug therapy

Recommended regimen:

Ciprofloxacin 500 mg orally, as a single dose.

Or:

Ceftriaxone 125 mg by intramuscular injection, as a single dose.

Neonatal gonocpccal conjunctivitis

Recommended regimen:

Cerftriaxone 50 mg/kg by intramuscular injection, as a single dose, to a maximum of 125 mg.

Or:

Spectinomycin 25 mg/kg by intramuscular injection as a single dose, to a maximum of 75 mg/kg.

Note: single dose ceftriaxone and kanamycin are of proven efficacy.

The addition of tetracycline eye ointment to these regimens is of no documented benefit.

Adjunctive therapy for gonococcal ophthalmia

  • Systemic therapy: as well as local irrigation with saline or other appropriate solution.
  • Irrigation is particularly important when the recommended therapeutic regimens are not infected patients is essential.

Fellow-up

Review patients after 48 hours.

Notable averse drug reactions, caution and contraindications

Ciprofloxacin

  • Avoid in pregnancy and breast feeding, children below   12 years.
  • Reduce dose in renal impairment cerftriaxone
  • Caution in persons with known sensitivity to betalactam antibiotics.
  • May cause diarrhea (and rarely antibiotic-associated colitis): nausea, vomiting and abdominal discomfort spectinemycin.
  • Nausea, diszziness, fever and urticaria.

Prevention

Counseling, Compliance, Condom use and Contact treatment.

Ocular prophylaxis provides poor protection against C. trachomatis conjunctivitis.

Prevention of ophthalmia neonatorum

Clean the eyes carefully immediately after birth

The application 0f 1% sliver nitrate solution or 1% Tetracycline ointment to be eyes of all infants at the time of delivery is strongly recommended as a prophylactic measure.

Infant born to mothers with gonococcal infection should receive additional antibiotic treatment (as those with clinical neonatal conjunctivitis). 

 

 

 

 

 

 

 

 

 

 

 

 

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