Gonorrhea is one of the commonest sexually transmitted disease prevalent all over the world. It is caused by a gram negative diplococcus called Neisseria gonorrhea which is found in pairs with adjacent surfaces flattened. A number of strains of neisseria are present and it is differentiated from them by its ability to utilize glucose and immunologic reactions.
Gonococcal strains can be typed on the basis of nutritional requirements or surface antigenic variation of protein 1. It is an intracellular organism and depends for its spread upon direct transfer from host to host. The only natural hosts for the organism are humans.
The organism is rapidly killed by antiseptics, heat and by drying. It does not survive for more than a few hours outside the body.
Pathology
Sexual intercourse is the commonest mode of infection. Sometimes newly born children may be infected from the mother’s genitalia.
The organism after gaining entry gets attached to the columnar or transitional epithelial cells penetrating deeply to reach the subepithelial connective tissue. Attachment of gonococci to mucosal cells is mediated in part by pili genes and protein II.
In sub epithelial tissue, gonococci interact with serum antibody to initiate inflammatory reaction. Extension from the site of infection leads to complications such as uretheritis, epididymoorchitis and prostatitis in men while in females uretheritis, endometritis, bartholinitis and salpingitis may develop.
Clinical features
The clinical picture in a case of gonococcal infection depel?ds on the virulence of the organism, duration of infection local or systemic spread and body defence mechanism as well as immunity. The disease presents variations in its presentation and course both in males and females.
Gonorrhea in male
Usual incubation period is from two to seven days following sexual contact. Longer intervals are also known. Some men may not develop symptoms. An earliest symptom is buming or tingling sensation in the urethra followed by a discharge which soon becomes mucopurulent. There is dysuria and increased frequency of micturition.
Pus which is greenish yellow is teeming with gonococci and is highly infective. Patient may have slight malaise. Infection soon spreads to epididymis, testes, spermatic cord and prostrate. The margins of extemal meatus are often inflamed and reddened.
If patient is not treated, it may reach posterior urethra and patient now has more severe dysuria. Sometimes in severe cases a few drops of blood may be passed after micturition. Local complications include involvement of cowper’s glands and ducts, prostate gland and extension of suppuration into periuretheral tissues and scrotum often resulting in fistulous openings.
Rectum is important site of involvement in homosexual men. There is anorectal pain, tenesmus and a bloody mucopurulent discharge from rectum. Ulceration develops in the rectum and anal canal. Gonococcal organisms from homosexual men tend to be more resistant to antimicrobials as compared to those from hetrosexual contact.
Gonorrhea in females
An uncomplicated case of gonorrhea generally has uretheritis, cervicitis and sometimes infection of vaginal orifices. Symptoms are as that in men like buming micturition, dysuria but they are less marked. There is often leucorrhoea, and features of pelvic problem.
Extension of infection leads to salpingitis, bartholinitis and abdominal pain. Coexisting trichomonas infection may further increase inflammatory reaction. Chronic salpingo oophritis and tubo ovarian masses may develop. Exacerberation of disease may occur during mensturation. Pelvic problem may lead to abscess formation with resultant toxaemia.
Complications of gonococcal infection
These occur both in males and females and include gonococcal arthritis conjunctivitis, iridocyclitis, cutaneous lesions and septicaemia. Endocarditis and pericarditis are rare complications. Men who suffer from gonococcal are left behind with stricture urethra which may take some time to develop.
Laboratory diagnosis
1. Diagnosis of gonorrhea may be made by demonstration of intracellular gram negative diplococci in smears obtained from urethral discharge and staining with gram’s stain.
2. Organisms can be identified by culture, sugar utilization test, rapid enzyme test or agglutination reaction using antibodies that are specific for N. gonorrhea.
3. Immuno-fluorescent antibody technique test is important for quick diagnosis.
4. ELISA test is done for detecting gonococcal antigens in urethral or cervical secretions.
Treatment
Various regimens are followed:
Penicillin has long been used in dose of 2.4 to 4.8 mega units (Procaine penicillin intramuscular once only along with probenecid 1 U) Alternative therapy consists of Ampicillin or Amoxycillin in a dose of 3 U orally as a single dose along with Probenecid 1 U or Co-trimoxazole 4 U in single dose.
Present trend is to give Ceftriaxone 250 mg I/M single dose and Doxycycline 100 mg twice daily for seven days. For patients who are sensitive to penicillin or in pregnant women with gonococcal infection Erythromycin 500 mg four times a day for seven days is the line of treatment.
Treatment of complicated gonorrhea
These are the patients who have pelvic inflammatory pathology or disseminated gonococcal infection. These patients may require hospitalization. Treatment is by Ceftriaxone 1 0 JIM or I/V once in twenty four hours or Cefotaxime 101/V eight hourly. This has to been given for period ranging from seven to ten days.
