A. Urethritis and Cervicitis
Initial symptoms seen in men include burning on urination and a serous or milky discharge. One to 3 days later, the urethral pain is more pronounced and the discharge becomes yellow, creamy, and profuse, sometimes blood-tinged. The disorder may regress and become chronic or progress to involve the prostate, epididymis, and periurethral glands with painful inflammation. Chronic infection leads to prostatitis and urethral strictures. Rectal infection is common in men who have sex with men. Atypical sites of primary infection (eg, the pharynx) must always be considered. Asymptomatic infection is common and occurs in both sexes.
Gonococcal infection in women often becomes symptomatic during menses. Women may have dysuria, urinary frequency, and urgency, with a purulent urethral discharge. Vaginitis and cervicitis with inflammation of Bartholin glands are common. Infection may be asymptomatic, with only slightly increased vaginal discharge and moderate cervicitis on examination. Infection may remain as a chronic cervicitis—an important reservoir of gonococci. It can progress to involve the uterus and tubes with acute and chronic salpingitis, with scarring of tubes and sterility. In pelvic inflammatory disease, anaerobes and chlamydiae often accompany gonococci. Rectal infection may result from spread of the organism from the genital tract or from anal coitus.
Nucleic acid amplification tests are the preferred method for diagnosing all types of gonorrhea given their excellent sensitivity and specificity. In women with suspected cervical infection, endocervical or vaginal swabs (clinician- or self-collected) as well as first catch am urine specimen (later specimens have 10% reduced sensitivity) are options. In men with urethral infection, first catch am urine is recommended. Nucleic acid amplification tests are also recommended by the CDC for oropharyngeal and rectal sites testing although they are not FDA approved for these specimen types. Gram stain of urethral or rectal discharge in men, especially during the first week after onset, shows gram-negative diplococci in polymorphonuclear leukocytes. Gram stain is less often positive in women. Cultures should still be obtained when evaluating a treatment failure to assess for antimicrobial resistance.
Systemic complications follow the dissemination of gonococci from the primary site via the bloodstream. Two distinct clinical syndromes—either purulent arthritis or the triad of rash, tenosynovitis, and arthralgias—are commonly observed in patients with disseminated gonococcal infection, although overlap can be seen. The skin lesions can range from maculopapular to pustular or hemorrhagic, which tend to be few in number and peripherally located. The tenosynovitis is often found in the hands and wrists and feet and ankles. These unique findings can help distinguish among other infectious syndromes. The arthritis can occur in one or more joints and may be migratory. Gonococci are isolated by culture from less than half of patients with gonococcal arthritis. Rarely, gonococcal endocarditis or meningitis develops.
The most common form of eye involvement is direct inoculation of gonococci into the conjunctival sac. In adults, this occurs by autoinoculation of a person with genital infection. The purulent conjunctivitis may rapidly progress to panophthalmitis and loss of the eye unless treated promptly.