eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Gonorrhea

Author: Nicholas John Bennett, MBBCh, PhD, Staff Physician, Department of Pediatrics, State University of New York Upstate Medical University
Coauthor(s): Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University; Marc Grella, MD, Clinical Instructor, Department of Pediatrics, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Dec 6, 2007

Introduction

Background

Gonorrhea is one of the most common and oldest known sexually transmitted diseases (STDs). It causes urethritis, cervicitis, epididymitis, pharyngitis, proctitis, and pelvic inflammatory disease (PID) and can spread throughout the body to cause both localized and disseminated disease. Most commonly, the term gonorrhea refers to urethritis and/or cervicitis in a sexually active person.

In the pediatric population, the importance of gonorrhea is 3-fold, as follows:

• As a common and preventable STD in the sexually active teenage population
• As a perinatal infection at childbirth
• As a forensic aid in investigating sexual abuse

Pathophysiology

Neisseria gonorrhoeae is a gram-negative, intracellular diplococcus that grows best in the laboratory in an environment rich in carbon dioxide. Organisms are spread by sexual contact and can also be vertically transmitted during childbirth. N gonorrhoeae has a predilection for columnar mucosal cells. The physiologic ectopy of the squamocolumnar junction onto the ectocervix in the adolescent female is one factor that causes particular susceptibility to this infection.

Frequency

United States

Gonorrhea is the second most commonly reported infectious disease in the United States, after chlamydia. Actual incidence is difficult to determine due to high rates of asymptomatic carriage, as well as underreporting; however, in 2005, 339,593 cases were reported in the United States (up slightly from 2004).¹ The national average is 115.6 cases per 100,000 population, with considerable state-to-state variation.²  The rate is up slightly from 2004, when it was at its lowest level since 1941. The estimate of total cases is approximately 700,000 cases per year. In children who have been sexually abused, rates of recovery of gonorrhea range from 1-30%. In female adolescents who are sexually active, asymptomatic carriage of gonorrhea occurs in 1-5%.

Within the United States, carriage rates highly depend on the geographical area, the racial and ethnic group, and sexual preferences.

The South-Eastern States have the highest rates of infection; the rates in the midwest and northeast are much lower. Rates of infection range from about 250 cases per 100,000 population in Mississippi to 8.5 cases per 100,000 population in Idaho. The Centers for Disease Control and Prevention (CDC) has a campaign (Healthy People 2010) that targets an incidence rate of 19 cases per 100,000 population. Maine, Vermont, Wyoming, New Hampshire, Montana, and Idaho are the only states currently exceeding that target. See Media file 1.

International

Disease rates are unknown for most developing countries. In much of Western Europe, rates approximate those in the United States.

Mortality/Morbidity

When untreated, gonorrhea may progress locally to cause PID in females, epididymitis and orchitis in males, and sterility in both sexes. It can also spread to cause septic arthritis, perihepatitis (Fitz-Hugh-Curtis syndrome), and disseminated gonococcal infection (DGI). In newborns, vertical transmission can cause conjunctivitis, known as ophthalmia neonatorum, and blindness, if untreated. Oral sex with an infected partner can result in pharyngitis, and, similarly, anal infection can arise from anal sex or local spread from a vaginal source. PID often causes decreased fertility and can lead to tubo-ovarian abscess and, rarely, tubal perforation with peritonitis and death, especially if recurrent. Females with recurrent PID have high rates of ectopic pregnancy and infertility (approximately 8% after 1 episode, 20% after 2 episodes, and 40% after 3 or more episodes).

Race

Frequency is increased among individuals of lower socioeconomic status and among minorities of any population because of decreased access to diagnosis and treatment. Lack of adequate care (ie, education, diagnosis, and treatment) leads to increased transmission rates.

Sex

• The male-to-female ratio is approximately 1.2:1; females may be asymptomatic, whereas males are rarely asymptomatic.
• Men who have sex with men are much more likely to acquire and carry gonorrhea and also have far higher rates of antibiotic-resistant bacteria.

Age

The highest incidence in the United States is among persons aged 15-24 years. This is likely due to the following:

• Increased numbers of sexual partners
• Decreased access to or use of health care
• Physiologic ectopy of the squamocolumnar junction in females
• Decreased use of barrier contraceptives

Clinical

History

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

• Males
  • Urethral discharge (drip)
  • Dysuria
  • Condom nonuse or condom failure
  • Infected contact
  • Proctitis and/or pharyngitis, depending on types of intercourse and partners
• Females
  • Dysuria
  • Vaginal discharge
  • Abnormal vaginal bleeding (spotting)
  • Dyspareunia (painful intercourse)
  • Condom nonuse or condom failure
  • Proctitis and/or pharyngitis, depending on type of partners and intercourse
  • Slow onset and progression of lower abdominal pain, especially in progression to PID
• Neonates
  • Ophthalmia neonatorum presents with eye pain, redness, and a purulent discharge. The organism is acquired during birth from the infected mother.
  • If unrecognized and untreated, the infection can lead to serious destruction of the cornea and blindness.
  • Infection may also occur at the site of placement of scalp electrodes.

Physical

• Males
  • Urethral discharge, obtained by milking the urethra along the shaft of the penis
  • Possible epididymitis
• Females
  • Vaginal, urethral, or cervical discharge
  • Cervical friability (tendency to bleed upon manipulation)
  • Cervical tenderness during bimanual pelvic examination
  • Fullness and/or tenderness of the adnexa (eg, ovaries, fallopian tubes)
  • Lower abdominal pain
  • Possible low back pain (more common in progression to PID)
  • Vaginal bleeding
• Neonates
  • Purulent discharge from the eyes or other infected sites
  • Temperature instability (fever, hypothermia) in disseminated sepsis

Causes

Risk factors for gonorrhea include the following:

• Sex with an infected partner
• Multiple sex partners
• Low socioeconomic status
• Minority status (African Americans, Hispanics, and Native Americans have the highest rates in the United States.)
• Failure to use a condom or condom failure
• History of concurrent or past STDs
• Exchange of sex for drugs or money
• Use of crack cocaine
• Early age of onset of sexual activity

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