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  • More than 20 million new sexually transmitted diseases (STDs) occur annually in the United States.

  • In the United States, chlamydia is currently the most common reported STD. It is also the most common cause of pelvic inflammatory disease in women.

  • Urethritis is a common presenting symptom of STDs in both men and women.

  • High-risk patients often have coinfection with multiple STDs.

  • Diagnosis can usually be made through direct microscopy, culture, or newer diagnostic methods such as nucleic acid amplification tests.

  • Early and appropriate antimicrobial therapy of STDs results in good prognosis.



Gonorrhea is a bacterial infection by Neisseria gonorrhoeae, a gram-negative, aerobic coccus-shaped bacterium found in pairs. The organisms are usually visualized intracellularly, located within polymorphonuclear leukocytes (Fig. 175-1). Gonorrhea is a common sexually transmitted disease (STD) affecting both men and women, particularly teenagers and young adults. In adult patients, gonococcal infection can affect the genitals, anus, or pharynx and can be acquired through vaginal, anal, or oral intercourse. It can also be transmitted vertically from mother to child during vaginal birth, manifesting as an inflammatory eye infection (ophthalmia neonatorum).

Figure 175-1

Diagnostic Gram-stained smear of urethral discharge of a man with acute gonorrhea. Gonococci (red) within a polymorphonuclear leukocyte. There are also some gram-positive cocci in this smear (dark blue). (Used with permission from Angelika Stary, MD.)

Albert Ludwig Sigismund Neisser first discovered the causative agent of gonorrhea in 1879. The origins of gonococcal infections are unknown, but references to gonorrhea, or “the clap” as it has been termed, go back to the 16th century in Europe.1 Before the advent of antibiotics, silver preparations including silver nitrate and silver proteinate (Protargol) were used to treat gonorrhea in the 19th and 20th centuries.


More than 820,000 people are estimated to acquire new gonococcal infections in the United States yearly according to the Centers for Disease Control and Prevention (CDC), although only about half are actually reported through the public health system. This makes gonorrhea the second most commonly reported infectious disease in the United States, second only to chlamydia. Higher endemic areas of the country include the southern United States and Alaska, with the lowest prevalence being in the northwestern states.2 The rate of new infections declined after the implementation of a national gonorrhea control program in the United States during the mid-1970s and continued to decrease through the late 1990s. The yearly prevalence of gonococcal infections reached an all-time low in 2009. It has risen every year since 2009, with the exception of 2013, when it decreased slightly.2 Newer epidemiologic data from the CDC and state registries indicates that there is increasing heterosexual transmission that may explain the increasing ...

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