Gonococcal Infections

Key Features

Essentials of Diagnosis

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

• In men

  • Urethritis

  • Epididymitis

  • Prostatitis

  • Proctitis

  • Pharyngitis

• In women

  • Asymptomatic or cervicitis with purulent discharge

  • Vaginitis, salpingitis, proctitis also occur

• Disseminated disease

  • Two clinical syndromes, though there can be overlap

    • Purulent arthritis or

    • Triad of rash, tenosynovitis and arthralgias

• 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 and has its greatest incidence in the 15- to 29-year-old age group

Clinical Findings

Symptoms and Signs

• Asymptomatic infection is common and occurs in both sexes

• Other sites of primary infection (eg, the pharynx) must always be considered

Urethritis

• In men

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

  • One to 3 days later, urethral pain is more pronounced, 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

  • Chronic infection leads to prostatitis and urethral strictures

  • Rectal infection is common in homosexual men

• In women

  • Dysuria

  • Urinary frequency and urgency, with a purulent urethral discharge

Cervicitis

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

• Vaginitis and cervicitis with 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

• Rectal infection may result from spread of organism from the genital tract or from anal coitus

  Disseminated disease

• Skin lesions

  • Maculopapular, pustular or hemorrhagic

  • Tend to be few in number and peripherally located

• Tenosynovitis: often in hands, wrists, feet and ankles

• Arthritis: can occur in one or more joints and may be migratory

• Rare: gonococcal endocarditis or meningitis

Conjunctivitis

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

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

Differential Diagnosis

• Nongonococcal urethritis

• Cervicitis or vaginitis due to

  • Chlamydia trachomatis

  • Gardnerella vaginalis

  • Trichomonas

  • Candida

  • Other pathogens associated with sexually transmitted infections

• Pelvic inflammatory disease

• Proctitis

• Reactive arthritis

Diagnosis

Laboratory Tests

• Nucleic acid amplification tests

  • The preferred testing method for diagnosing gonococcal infection at ...