Chapter 16. Gonorrhea

• • In men, findings include urethral discharge, urethral burning with urination, and swelling of the glans penis.
• • In women, findings include lower abdominal pain; cervicovaginal discharge, “spotting,” and bleeding; and pain with intercourse.
• • Disseminated infection produces a rash consisting of papules or pustules with an erythematous border; monoarticular arthritis or tenosynovitis may also be present.
• • Definitive diagnosis can be made by Gram stain, culture, molecular probe assay, or nucleic acid amplification testing.

Neisseria gonorrhoeae may cause several adverse health outcomes, including local genitourinary infections, upper reproductive tract disease, and disseminated gonococcal infections. An important impact of N gonorrhoeae infection is that it can facilitate acquisition of the human immunodeficiency virus (HIV) and shedding of HIV in semen.

The global incidence of gonorrhea infections remains high, with an estimated 62 million new cases each year. The highest rates occur in sub-Saharan Africa, south and Southeast Asia, the Caribbean, and Latin America. Although the overall prevalence of gonorrhea has declined in the United States since 1975, it remains the second most commonly reported communicable disease. Rates remain high in certain groups, including African-Americans and Hispanics, men who have sex with men (MSM), adolescents, and populations in the southeastern United States. Race in itself is not a risk factor for gonorrhea but may be a surrogate marker for socioeconomic and behavioral factors that increase the risk for infection.

Screening is an important tool for identifying and treating asymptomatic infection, the most common manifestation of gonorrhea, which serves as a source of ongoing community transmission. In addition to screening efforts directed at women to reduce the complications of untreated disease in this population, routine screening in specific risk groups, such as adolescents, MSM, or HIV-infected individuals is recommended.

The transmission of N gonorrhoeae following a single episode of vaginal intercourse has been estimated to be approximately 70–80% from male to female partners, and 20–30% from female to male partners. Transmission through either receptive or insertive rectal intercourse may be less efficient than vaginal intercourse but data are limited. Penile-oral and oral-penile transmission is probably the least efficient means of transmission but does occur; again, data on the true frequency of transmission are limited.

Following introduction into a mucosal site, gonococci attach to the surface of columnar epithelial cells and colonize mucosal cells through parasite-directed endocytosis. The exuberant host immune response to gonococcal infection, while leading to control of infection, can account for many of the signs and symptoms of disease.