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Gonorrhea

Source: Knodel LC. Sexually Transmitted Diseases. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th edition. http://accesspharmacy.com/content.aspx?aid=8004605. Accessed July 16, 2012.

  • “Clap”

  • Venereal disease involving inflammatory discharge from urethra or vagina.

  • Neisseria gonorrhoeae is gram-negative diplococcus estimated to cause up to 600,000 infections per year in United States.
    • Humans only known host of this intracellular parasite.

  • Gonococci attach to mucosal cell membranes via surface pili.
  • Mucosal damage leads to tissue invasion by polymorphonuclear leukocytes followed by formation of submucosal abscesses and secretion of purulent exudates.

  • Difficult to control due to rapid incubation period and large numbers of asymptomatic individuals.
  • Sexually transmitted infection (STI)
  • Two-thirds of STIs occur in persons in teens and twenties.
  • Number of reported cases in United States stable over past 10 years.

  • Mutually monogamous sexual relationship between uninfected partners
  • Barrier contraceptive methods

  • Patients who seek STI testing should be screened for syphilis and HIV.

  • Unprotected sex
  • Multiple sexual partners
  • Sexual preference
  • Age

  • Infected individuals may be symptomatic or asymptomatic, have complicated or uncomplicated infections, and have infections involving several anatomical sites.

Signs and Symptoms

  • Most common clinical features of gonococcal infections presented in Table 1.
  • Gonococci invade bloodstream in 0.5–3% of patients and produce disseminated disease.
  • Clinical manifestations of disseminated gonococcal infection:
    • Tender, necrotic skin lesions
    • Tenosynovitis
    • Monoarticular arthritis

Table 1. Presentation of Gonorrhea Infections
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Table 1. Presentation of Gonorrhea Infections
MenWomen

General

Incubation period 1–14 days

Incubation period 1–14 days

Symptom onset in 2–8 days

Symptom onset in 10 days

Site of infection

Most common—urethra

Most common—endocervical canal

Others—rectum (usually due to rectal intercourse in men who have sex with men), oropharynx, eye

Others—urethra, rectum (usually due to perineal contamination), oropharynx, eye

Symptoms

May be asymptomatic or minimally symptomatic

May be asymptomatic or minimally symptomatic

Urethral infection—dysuria and urinary frequency

Endocervical infection—usually asymptomatic or mildly symptomatic

Anorectal infection—asymptomatic to severe rectal pain

Urethral infection—dysuria, urinary frequency

Pharyngeal infection asymptomatic to mild pharyngitis

Anorectal and pharyngeal infection—symptoms same as for men

Signs

Purulent urethral or rectal discharge can be scant to profuse

Abnormal vaginal discharge or uterine bleeding; purulent urethral or rectal discharge can be scant to profuse

Anorectal—pruritus, mucopurulent discharge, bleeding

Complications

Rare (epididymitis, prostatitis, inguinal lymphadenopathy, urethral stricture)

Pelvic inflammatory disease and associated complications (i.e., ectopic pregnancy, infertility)

Disseminated gonorrhea

Disseminated gonorrhea (3 times more common than in men)

Reprinted with permission from Wells BG, DiPiro JT, Schwinghammer TL, et al. Pharmacotherapy Handbook. 8th ed. New York: McGraw-Hill, 2012.

Means of Confirmation and Diagnosis

  • Culture of infected fluids is diagnostic test of choice because of high specificity.

Laboratory Tests

  • Gram-stain smears
  • Culture of infected fluids
  • Methods based on detection of cellular components of gonococcus (e.g., enzymes, antigens, DNA, or lipopolysaccharide) in clinical specimens
  • Alternative methods of diagnosis:
    • Enzyme immunoassay
    • DNA probes
      • ...

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