Gonorrhea Clinical Presentation

The incubation period of gonorrhea is usually 2-7 days after exposure to an infected partner.

In all patients presenting with possible sexually transmitted disease (STD), history taking should include a history of STDs (including human immunodeficiency virus [HIV] infection 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 should also include the date of the last menstrual period and the details of parity, including any history of ectopic pregnancies.

A significant percentage of men and women with gonorrhea also have pharyngitis, which is usually 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.

Males

A male history may include the following:

• Urethral discharge (drip)
• Dysuria
• Condom nonuse or condom failure
• Infected contact
• Proctitis and/or pharyngitis, depending on types of intercourse and partners

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. Neisseria 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.

Females

A female history may include the following:

• Vaginal discharge
• Dysuria
• Slow onset and progression of lower abdominal pain, especially in progression to pelvic inflammatory disease (PID)
• Abnormal vaginal bleeding (spotting)
• Dyspareunia (painful intercourse)
• Condom nonuse or condom failure
• Proctitis and/or pharyngitis, depending on type of partners and intercourse

Vaginal discharge from endocervicitis is the most common presenting symptom and is usually 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 may also occur. Rectal infection may occur from anal intercourse, and, in women, by local spread of the organism.

Infants/neonates: ophthalmologic

Bilateral conjunctivitis (ophthalmia neonatorum) presents with eye pain, redness, and a purulent discharge. The organism is acquired during vaginal birth from the untreated, infected mother. If unrecognized and untreated, the infection can lead to serious destruction of the cornea and blindness.

Blindness from neonatal gonococcal infection is a serious problem in developing countries, but this 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.

Infection may also occur at the site of placement of scalp electrodes.

Disseminated gonococcal 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 appear, many patients no longer have any localized symptoms of mucosal infection.

Joint or tendon pain is the most common presenting complaint. About 25% of patients with disseminated gonococcal infection complain of pain in a single joint, whereas 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 this condition, usually affecting the small joints of the hands.

Skin rash is a presenting complaint in approximately 25% of patients, but a careful examination will reveal a rash in most patients with disseminated gonococcal infection. The rash is usually found below the neck and may also involve the palms and soles.

Although fever is common, the temperature is usually less than 39°C. However, 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 is usually 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 disseminated gonococcal infection. 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) may also be more prone to this complication.

Disseminated gonococcal infection can occur in infants born to infected mothers.

Neisseria 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.

With oropharyngeal infection, pharyngitis may be present, usually mild. With rectal infection, mucopurulent or purulent discharge may be present.

The physical examination should also always include scrutiny for signs of herpes simplex, syphilis, chancroid, lymphogranuloma venereum, and genital warts.

Males

Look for the following in males:

• Mucopurulent or purulent urethral discharge, obtained by milking the urethra along the shaft of the penis
• Possible epididymitis: Unilateral epididymal tenderness and edema

Females

Look for the following in females:

• Mucopurulent or purulent vaginal, urethral, or cervical discharge
• Vaginal bleeding; vulvovaginitis in children
• Cervical friability (tendency to bleed upon manipulation)
• Cervical motion tenderness during bimanual pelvic examination
• Fullness and/or tenderness of the adnexa, unilateral or bilateral (eg, ovaries, fallopian tubes)
• Lower abdominal pain/tenderness, with or without rebound tenderness
• Possible low back pain (more common in progression to pelvic inflammatory disease [PID])
• Upper right abdominal tenderness (with perihepatitis)

Neonates

Look for the following in neonates:

• Purulent discharge from the eyes (usually bilateral in ophthalmia neonatorum but most often is unilateral when secondary to self-inoculation in older patients) or other infected sites
• Temperature instability (fever, hypothermia) in disseminated sepsis

Disseminated gonococcal infection

Disseminated gonococcal infection 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; the 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: Disseminated gonococcal infection can cause abscess formation within the soft tissues, presenting as localized tenderness, edema, and pain with motion