Gonococcal Infections

Key Features

Essentials of Diagnosis

• Purulent, profuse urethral discharge with dysuria, especially in men; yields positive gram-stained smear

• In men

  • Epididymitis

  • Prostatitis

  • Periurethral inflammation

  • Proctitis

  • Pharyngitis

• In women

  • Asymptomatic or cervicitis with purulent discharge

  • Vaginitis, salpingitis, proctitis also occur

• Disseminated disease

  • Fever

  • Rash

  • Tenosynovitis

  • Septic arthritis

• Nucleic acid amplification is preferred diagnostic test

General Considerations

• Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus

Demographics

• Gonorrhea is transmitted as a result of sexual activity; greatest incidence is in the 15- to 29-year-old age group

Clinical Findings

Symptoms and Signs

• Asymptomatic infection is common and occurs in both sexes

• Atypical sites of primary infection (eg, the pharynx or rectum) must always be considered

Urethritis

• In men

  • Initially, burning on urination and a serous or milky discharge

  • One to 3 days later, more pronounced urethral pain and the discharge becomes yellow, creamy, and profuse, sometimes blood tinged

  • May regress and become chronic or progress to involve the prostate, epididymis, and periurethral glands with acute, painful inflammation

  • Rectal infection is common in men who have sex with men

• In women

  • Dysuria

  • Urinary frequency and urgency

Cervicitis

• Infection may be asymptomatic, with only slightly increased vaginal discharge and moderate cervicitis on examination

• Infection often becomes symptomatic during menses

• Vaginitis and cervicitis with purulent discharge and inflammation of Bartholin glands are common

• Infection may remain as a chronic cervicitis

• It may progress to involve the uterus and fallopian tubes with acute and chronic salpingitis and ultimate scarring of tubes and sterility

• In pelvic inflammatory disease, anaerobes and chlamydiae often accompany gonococci

Conjunctivitis

• Direct inoculation of gonococci into the conjunctival sac occurs by autoinoculation from a genital infection or during childbirth

• The purulent conjunctivitis may rapidly progress to panophthalmitis and loss of the eye unless treated promptly

Differential Diagnosis

• Nongonococcal urethritis, eg, Chlamydia, Ureaplasma urealyticum

• Septic arthritis of other bacterial cause

• Reactive arthritis

• Vaginal discharge due to candidiasis, bacterial vaginosis, or trichomoniasis

• Chronic meningococcemia

Diagnosis

Laboratory Tests

• In men, Gram stain of urethral or rectal discharge, especially during the first week after onset, typically shows gram-negative diplococci within polymorphonuclear leukocytes

• Gram stain is less often positive in women

• Nucleic acid amplification tests

  • The preferred testing method for diagnosing all types of gonococcal infection due to its excellent sensitivity and specificity

  • Detects N gonorrhoeae in endocervical, vaginal, and urethral swab specimens and in urine

  • Can also detect N gonorrhoeae in oropharyngeal and rectal sites, although test ...