eMedicine Specialties > Emergency Medicine > Infectious Diseases

Gonorrhea

Author: Amy J Behrman, MD, Associate Professor, Department of Emergency Medicine, Director, Division of Occupational Medicine, University of Pennsylvania School of Medicine
Coauthor(s): William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Contributor Information and Disclosures

Updated: Nov 12, 2009

Introduction

Background

Gonorrhea is a purulent infection of mucous membrane surfaces caused by a sexually transmitted microorganism, Neisseria gonorrhoeae. Virtually any mucous membrane can be infected by this highly infectious, gram-negative diplococcal organism.
 
Gonococcal infections following sexual and perinatal transmission are a major source of morbidity worldwide. In the developed world, where prophylaxis for neonatal eye infection is standard, the vast majority of infections follow genitourinary mucosal exposure. Infections can involve cervicitis, proctitis, urethritis, pelvic inflammatory disease, and pharyngitis. Complications include ectopic pregnancy and increased susceptibility to HIV.

Pathophysiology

The pathophysiology of N gonorrhoeae and the relative virulence of different subtypes depend on the antigenic characteristics of the respective surface proteins. Certain subtypes are able to evade serum immune responses and are more likely to lead to disseminated (systemic) infection.
 
Well-characterized plasmids commonly carry antibiotic-resistance genes, most notably penicillinase. Plasmid and nonplasmid genes are transmitted freely between different subtypes. The ensuing exchange of surface protein genes results in high host susceptibility to reinfection. The exchange of antibiotic resistance genes has led to extremely high levels of resistance to beta-lactam antibiotics over the last 2 decades. More recently, fluoroquinolone resistance has also been documented on multiple continents and in widespread populations within the United States.

Infection of the lower genital tract, the most common clinical presentation, primarily manifests as male urethritis and female endocervicitis. Infection of the pharynx, rectum, and female urethra occur frequently but are more likely to be asymptomatic or minimally symptomatic. Retrograde spread of the organisms occurs in as many as 20% of women with cervicitis, often resulting in pelvic inflammatory disease (PID), with salpingitis, endometritis, and/or tubo-ovarian abscess. Retrograde spread can lead to frank abdominal peritonitis and to a perihepatitis known as Fitz-Hugh-Curtis syndrome.

Long-term sequelae of PID, such as tubal factor infertility, ectopic pregnancy, and chronic pain, may occur in up to 25% of affected patients. Epididymitis or epididymo-orchitis may occur in men after gonococcal urethritis. Lower genital infection is a risk factor for the presence of other sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV).
 
Conjunctivitis can occur in adults as well as in children following direct inoculation of organisms and can lead to blindness.
 
Disseminated gonococcal infection (DGI) occurs following approximately 1% of genital infections. Patients with DGI may present with symptoms of rash, fever, arthralgias, migratory polyarthritis, septic arthritis, tendonitis, tenosynovitis, endocarditis, or meningitis. Three fourths of the cases of DGI occur in women; susceptibility is increased if the primary mucosal infection occurs during menstruation or pregnancy. Changes in the vaginal environment at these times may foster changes in the gonococcal surface features and phenotype that render the organisms more resistant to host defenses in the bloodstream and more likely to disseminate.

Frequency

United States

N gonorrhoeae has been the most common STD worldwide for at least most of the 20th century, with an estimated 200 million new cases annually. Public health initiatives in the developed world have resulted in declining incidence of the disease since the mid 1970s, but gonorrheal infection is still the second most common notifiable disease in the United States. More than 350,000 cases were reported in the United States in 2007,¹ but that number may underestimate the true case rate by 50% due to underdiagnosis and underreporting.

The incidence of antibiotic-resistant strains has been rising since the late 1940s. Of greatest concern historically was the high percentage of cases due to penicillinase-producing N gonorrhoeae (PPNG). However, fluoroquinolone resistance has increased rapidly over the past decade on most continents and within the United States. The CDC reported fluoroquinolone resistance in 6.8% of 2004 isolates, 9.4% of 2005 isolates, and 13.3% of 2006 isolates.²

International

Approximately 200 million new cases of gonorrhea occur each year.

Mortality/Morbidity

• The most common long-term sequelae of gonorrhea are chronic pelvic pain in women after PID, septic abortion, chorioamnionitis in pregnancy, blindness after neonatal or adult conjunctivitis, and infertility of either sex.
• Ectopic pregnancy is a life-threatening complication that may follow scarring of the female upper reproductive tract from PID.
• Disseminated infection may lead to meningitis or endocarditis.

Race

• Race has no intrinsic effect on susceptibility, but, in the United States, the disease is most commonly diagnosed among the urban poor and minorities. This may reflect bias due to data collection site preference (eg, urban EDs and STD clinics) as well as true differences in prevalence.
• All sexually active populations are at risk and the level of risk rises with the number of sex partners and the presence of other STDs.

Sex

• Gonococcal infections are 1.5 times more common in men than in women.
• Gonococcal infections rates are higher among men who have sex with men (MSM).
• Serious sequelae are much more common in women, in whom PID may lead to ectopic pregnancy or infertility and for whom DGI is more likely.

Age

• Gonococcal infections are diagnosed most frequently in adolescents and young adults.¹
• Infection in children is a marker for child sexual abuse and should be reported as such, although a recent review provided some support for nonsexual transmission between children and for transmission from adults to children related to poor hand hygiene.³

Clinical

History

In all patients presenting with possible STDs, history should include history of STDs (including HIV and viral hepatitis), known symptoms of STDs in current or past partners, type of contraception used, and any history of sexual assault. In women, the history also should include the date of the last menstrual period and the details of parity, including any history of ectopic pregnancies.

Genitourinary tract, male

• Urethral discomfort, dysuria, and discharge due to uncomplicated urethritis are the most common symptoms in men. Degree of discomfort and discharge are variable, and subjective symptoms may be absent.
• The classic presentation of epididymitis is of unilateral pain and swelling localized posteriorly within the scrotum. N gonorrhoeae and Chlamydia trachomatis account for most cases of epididymitis in men younger than 35 years.
• Urethral strictures due to gonococcal infection are now uncommon in the antibiotic era, but they can present with decreased and abnormal urine stream as well as with the secondary complications of prostatitis and cystitis.
• Rectal infection may present with pain, pruritus, discharge, or tenesmus.
• A significant percentage of men and women with gonorrhea also have pharyngitis, which usually is asymptomatic but may cause mild-to-severe dysphagia and discomfort.
• Secondary gonococcal bacterial conjunctivitis may follow accidental inoculation by fingers in either sex and is usually unilateral.

• Vaginal discharge from endocervicitis is the most common presenting symptom. The discharge usually is described as thin, purulent, and mildly odorous. Many patients have minimal or no symptoms from gonococcal cervicitis.
• Dysuria or a scant urethral discharge may be due to urethritis accompanying cervicitis.
• Pelvic or lower abdominal pain suggests ascending infection of the endometrium, fallopian tubes, ovaries, and peritoneum. Pain may be midline, unilateral, or bilateral. Fever, nausea, and vomiting may be present. The possibility of ectopic pregnancy should always be considered in patients with pelvic or lower abdominal pain.
• Right upper quadrant pain from perihepatitis (Fitz-Hugh-Curtis syndrome) may occur following the spread of organisms upward along peritoneal planes. 
• Rectal infection is often asymptomatic, but rectal pain, pruritus, tenesmus, and rectal discharge may be present if the rectal mucosa is infected. Bloody diarrhea also may occur. Rectal infection may occur from anal intercourse, and, in women, by local spread of the organism.  

Ophthalmologic, infants 

• In neonates, bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal delivery by an infected mother without treatment. The symptoms of gonococcal conjunctivitis are eye pain, redness, and a purulent discharge.
• The organism can cause permanent injury to the eye in a very short time; prompt recognition and treatment are essential to avoid blindness. Blindness from neonatal gonococcal infection is a serious problem in developing countries but is uncommon in the United States and other countries where neonatal prophylaxis is routine. Nevertheless, infants of mothers with untreated infections, poor prenatal care, and unmonitored births continue to be at risk.

Disseminated gonorrheal infection 

• Disseminated gonococcal infection (DGI) may follow 1-2% of mucosal infections, with symptoms that vary greatly from patient to patient. By the time the symptoms of DGI appear, many patients no longer have any localized symptoms of mucosal infection.
• DGI can occur in infants born to infected mothers.
• Joint or tendon pain is the most common presenting complaint. About 25% of patients with DGI complain of pain in a single joint, while as many as two thirds describe polyarthralgia, which is often migratory. Severe pain, swelling, and decreased mobility in a single joint suggest a purulent arthritis with effusion. The knee is the most common site of purulent gonococcal arthritis.
• Tenosynovitis is also common in DGI, usually affecting the small joints of the hands.
• Fever is common, but the temperature is usually less than 39°C.
• Skin rash is a presenting complaint in approximately 25% of patients, but a careful examination will reveal a rash in most patients with DGI. The rash is usually found below the neck and may also involve the palms and soles.
• Headache, neck pain and stiffness, fever, and decreased sensorium may indicate gonococcal meningitis. This disease may be clinically indistinguishable from meningococcal meningitis on presentation, although the course of gonococcal meningitis usually is less rapid.
• Subacute onset of fever, chills, sweats, and malaise may indicate the presence of gonococcal endocarditis. Patients with endocarditis may develop atypical chest pain, cough, and dyspnea, as well as the arthralgias and rash typical of DGI. Rarely, gonococcal endocarditis can cause severe valvular damage and death if not recognized and treated rapidly. Gonococcal endocarditis is more common in men than in women. Patients with collagen vascular disease (especially those with systemic lupus erythematosus) also may be more prone to this complication.

Physical

N gonorrhoeae infection may be recognized by the typical signs and symptoms of the disease, but it is important to remember that, by the time disseminated or upper reproductive tract disease is present, the primary site of mucosal infection may be normal in appearance, and the patient may have no localized signs or symptoms.
 
Genitourinary tract, male   

• Mucopurulent or purulent urethral discharge
• Unilateral epididymal tenderness and edema

Lower genitourinary tract, female 

• Mucopurulent or purulent cervical discharge
• Vaginal discharge or bleeding; vulvovaginitis in children

• PID symptoms  
• Lower abdominal tenderness with or without rebound tenderness        
• Cervical motion tenderness
• Adnexal tenderness, unilateral or bilateral
• Fever
• Upper right abdominal tenderness (with perihepatitis)

• Mucopurulent or purulent discharge

Oropharyngeal 

• Pharyngitis, usually mild

Ophthalmologic

• Purulent conjunctivitis is usually bilateral in ophthalmia neonatorum but most often is unilateral when secondary to self-inoculation in older patients.

Disseminated gonococcal infection 

DGI may present with any of the following findings:

• Fever (usually temperature <39°C)
• Skin: Maculopapular, pustular, necrotic, or vesicular rash, typically occurring on the torso, limbs, palms, and soles may be present. The rash usually spares the face, scalp, and mouth. Hemorrhagic lesions, erythema nodosum, urticaria, and erythema multiforme occur less frequently. Skin lesions are usually in different stages of development at the time of clinical presentation.
• Joints: Most patients may have polyarthralgia with joint tenderness, decreased range of motion, and erythema. Less often, purulent arthritis may affect a single joint with severe pain, tenderness, edema, erythema, and decreased range of motion.
• Tenosynovitis presents as erythema and local tenderness along a tendon sheath, with pain on active or passive range of motion. Tenosynovitis most often occurs in the hands but may be found in the tendons of the lower extremities as well.
• Central nervous system: Patients with gonococcal meningitis may present with meningismus or decreased mental status.
• Cardiac: Patients with gonococcal endocarditis may have a new murmur, tachycardia, and fever. Embolic lesions may be present.
• Muscle: DGI can cause abscess formation within the soft tissues, presenting as localized tenderness, edema, and pain with motion.

Causes

• Gonococcal infection usually follows mucosal inoculation during vaginal, anal, or oral sexual contact. It also may be due to inoculation of mucosa by contaminated fingers or other objects.
• Neonatal infection may follow conjunctival inoculation during birth or direct infection through the scalp at the sites of fetal monitoring electrodes.

Risk factors 

• Sexual exposure to an infected individual without barrier protection
• Multiple sexual partners
• Infants - Passage through the infected birth canal of the mother
• Children - Sexual abuse by an infected individual, possibly nonsexual contact in household or institutional settings
• PID - Use of an intrauterine device (IUD)

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