Gonorrhea

Gonorrhea is a sexually transmitted disease (STD). It is caused by the bacterium Neisseria gonorrhoeae, and can be cured with antibiotics. It is the second most commonly-reported notifiable disease in the United States after chlamydia. Gonorrhea, and chlamydia are major causes of pelvic inflammatory disease in the United States.



Other Names

 * The Clap

Symptoms
The bacteria are carried in secretions (semen and vaginal fluids). Infection causes a discharge in both men and women. A small number of people may be infected for several months without showing symptoms.

For women, the early symptoms of gonorrhea often are mild. Symptoms usually appear within 2 to 10 days after sexual contact with an infected partner. When women have symptoms, the first ones may include


 * Bleeding during vaginal intercourse
 * Painful or burning sensations when urinating
 * Yellow or bloody vaginal discharge

More advanced symptoms, which may indicate development of pelvic inflammatory disease, include cramps and pain, bleeding between menstrual periods, vomiting, or fever.

Men have symptoms more often than women, including


 * White, yellow, or green pus from the penis with pain
 * Burning sensations during urination
 * Swollen or painful testicles

If left untreated, men can experience prostate complications and epididymitis (inflammation of the epididymis, an organ near the testicles).

Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood in the feces. Symptoms typically appear 2 to 5 days after infection but could appear as long as 30 days.

Gonorrhea can infect the throat if oral sex was performed on an infected person.

Cause
Gonorrhea is caused by bacteria called Neisseria gonorrhoeae. These bacteria can infect the genital tract, mouth, and rectum of both men and women. In women the opening to the uterus (cervix) is the first place of infection. N. gonorrhoeae targets the cells of the mucous membranes including:


 * the surfaces of the urethra, vagina, cervix and endometrium
 * the fallopian tubes
 * the anus and rectum
 * the lining of the eyelid
 * the throat

The genus Neisseria contains many species; some are part of the normal human flora, and a few cause disease in humans. When stained and examined in a microscope, Neisseria are round cells that cluster in pairs ("diplococci"). They are called "gram-negative" for the way they stain in the Gram test. These bacteria are able to enter, survive, and grow in host cells. Diagnosis of gonorrhea can be performed by seeing the gram-negative diplococci inside leukocytes white blood cells.

N. meningitidis is the other major disease-causing bacteria in the genus Neisseria. It can cause a rare, but serious infection of the brain or spinal cord, meningitis. N. meningitidis is often found in humans who don't have meningitis. On the other hand, N. gonorrhoeae is never part of the normal human flora. If a person has the bacterium, he will get gonorrhea from it.

Diagnosis
Health care providers usually use one of three laboratory tests to diagnose gonorrhea.


 * Staining samples to see the bacteria under a microscope
 * Detecting bacterial genes or DNA in urine (molecular test)
 * Growing the bacteria in laboratory cultures

Staining test results may be available right away in a doctor's office or clinic. This test is quite accurate for men but not so in women. Only half of women with gonorrhea has a positive stain.



More often, health care providers use urine or cervical swabs for a molecular test that detects the genes of the bacteria. These tests are more accurate than culturing the bacteria.

The molecular test, or nucleic acid amplification test (NAAT), is based on detecting and magnifying, or "amplifying," the DNA in N. gonorrhoeae. Molecular tests are generally more Sensitivity_and_Specificity|sensitive (able to pick up more cases) and specific (able to pick up cases accurately instead of confusing them with other diseases) than conventional culture. Still, all positive molecular tests for N. gonorrhoeae should be verified by the same or another method for confirmation.

Molecular testing for gonorrhea and chlamydia is generally done simultaneously as the two organisms can cause similar diseases, and they often occur together in the same person.

The laboratory culture test involves placing a sample of the discharge onto a culture plate. This may be done for throat infections. Culture also allows testing for drug-resistant bacteria.

Treatment
Health care providers usually prescribe a single dose of either of the antibiotics cefixime or ceftriaxone to treat gonorrhea. Formerly, the antibiotic ciprofloxacin was used, but in 2006 the CDC stopped recommending its use because the bacteria has grown resistant to it. (See "Antibiotic-resistant N. gonorrhoeae" below.)

Gonorrhea and chlamydia often infect people at the same time. So health care providers usually prescribe a combination of antibiotics which treat both diseases.

People with gonorrhea should have their sexual partners tested and treated if infected, even if the partners don't have symptoms. Health experts also recommend that people with gonorrhea not have sex until their infected partners have been treated.

Treatment guidelines are issued by the Centers for Disease Control and are periodically updated.

Prevention
The surest way to avoid transmission of STDs is to abstain from sexual contact or be in a long-term mutually monogamous relationship with a partner who has been tested and is not infected.

By using condoms correctly and consistently during vaginal or rectal sexual activity, people can reduce the risk of getting gonorrhea and developing complications.

Any genital symptoms such as discharge or burning during urination or unusual sore or rash should be a signal to stop having sex and to see a doctor immediately. If a person has been diagnosed and treated for gonorrhea, he or she should notify all recent sex partners so they can see a health care provider and be treated. This will reduce the risk that the sex partners will develop serious complications from gonorrhea, and will also reduce the person’s risk of becoming re-infected. The person and all of his or her sex partners must avoid sex until they have completed their treatment for gonorrhea.

How Gonorrhea is Spread
Gonorrhea is passed during vaginal sex, oral sex (performing or receiving), or anal sex. It is passed when a mucous membrane, the soft skin covering all the openings of the body, comes into contact with secretions or semen of an infected person. Gonorrhea can be passed even if the penis or tongue does not go all the way into the vagina or anus. Infections in mucous membranes can occur secondary to sexual contact. For example, a woman who has not had anal sex can get gonorrhea in the anus or rectum if bacteria are spread from the vaginal area, such as when wiping with toilet paper. Also, eye infections in adults may result when discharge caries the disease into the eye during sex or hand-to-eye contact. There is no evidence gonorrhea can be passed through things like shaking hands or sitting on toilet seats.

Treatment for gonorrhea will cure it, but won't prevent it from happening again. A person can be reinfected if they are exposed to N. gonorrhoeae again.

It can also be passed from mother to newborn as the baby passes through the infected birth canal. This can result in eye infections, pneumonia or other complications. In children, gonorrhea of the mouth, vagina, penis or rectum may be a sign of sexual abuse.

Complications
In untreated gonorrhea infections, the bacteria can spread up into the reproductive tract, or more rarely, can spread into the blood stream and infect the joints, heart valves, or the brain.

The most common result of untreated gonorrhea is pelvic inflammatory disease (PID). Gonococcal PID often appears immediately after the menstrual period. PID causes scar tissue to form in the fallopian tubes. If the tube is partially scarred, the fertilized egg may not be able to pass into the uterus. If this happens, the embryo may implant in the tube causing a tubal or ectopic pregnancy. This serious complication may result in a miscarriage and can cause death of the mother.

In men, gonorrhea causes epididymitis, a painful condition of the epididymis near the testicles that can lead to infertility if left untreated. Also, gonorrhea affects the prostate gland and may cause scarring in the urinary tract.

Rarely, untreated gonorrhea can spread through the blood to the joints. This can cause an infected joint, which is very serious. Although rare, conjunctivitis can also develop as a result of untreated gonorrhea.

Complications in newborns and children
Pregnant women with gonorrhea can spread the infection to the baby as it passes through the birth canal during delivery. A health care provider can prevent infection of the baby's eyes by applying silver nitrate or other medicine to the eyes immediately after birth.

Because of the risks from gonococcal infection to both mother and baby, pregnant women should have at least one test for gonorrhea during prenatal care.

Clinical Trials
For a list of completed, ongoing, and upcoming trials related to gonorrhea, go [http://www.medpedia.com/clinical-trials?q=Gonorrhea here[

Research
The National Institute of Allergy and Infectious Diseases (NIAID) continues to support research on N. gonorrhoeae. Researchers are trying to understand how gonococci infect cells while evading defenses of the human immune system. Studies are ongoing to find


 * How this bacterium attaches to host cells
 * How it gets inside cells
 * Gonococcal surface structures and how they can change
 * Human response to infection by gonococci

Together, these efforts have led to, and will lead to, further improvements in diagnosis and treatment of gonorrhea. They also may lead to development of an effective vaccine against gonorrhea.

Another important area of gonorrhea research concerns antibiotic resistance. This is particularly important because strains of N. gonorrhoeae that are resistant to recommended antibiotic treatments has been increasing and is becoming widespread in the United States. These events add urgency to conduct research on and develop new antibiotics and to prevent antibiotic resistance from spreading.

NIAID also supports research to develop topical microbicides (preparations that can be inserted into the vagina to prevent infection) that are effective and easy for women to use. Recently, scientists have determined the complete genome (genetic blueprint) for N. gonorrhoeae. They are using this information to help them better understand how the bacterium causes disease and becomes resistant to antibiotics.

Epidemiology
In 2006, 358,366 cases of gonorrhea were reported in the United States. The rate of reported gonorrhea in the United States was 120.9 cases per 100,000 population in 2006, an increase of 5.5% since 2005. Gonorrhea rates increased in 2006 for the second consecutive year.

From 1975 through 1997, the national gonorrhea rate declined 74% following implementation of the national gonorrhea control program in the mid-1970s. Gonorrhea rates subsequently appeared to plateau for several years.

Antibiotic-resistant N. gonorrhoeae
Formerly, treatment of gonorrhea was relatively straightforward, since the organism was sensitive to a wide range of antibiotics. Unfortunately, antibiotic resistance in N. gonorrhoeae contributed to a worldwide increase in cases of gonorrhea during the 1970s and 1980s. "N. gonorrhoeae" strains resistant to penicillins and tetracyclines, and more recently to fluoroquinolones like Cipro have been isolated.

Quinolone antibiotics were until recently the drug of choice for treating gonorrhea. But increases in the number of cases of quinolone-resistant N. gonorrhoeae (QRNG) in 2006 led to changes in national guidelines. Those quidelines now limit the recommended treatment of gonorrhea to a single class of drug, the cephalosporins. The combination of increases in gonorrhea morbidity with increases in resistance and decreased treatment options have increased the need for better understanding of the epidemiology of gonorrhea.

Prevalence
In 2006, the gonorrhea rate among African-Americans was 18 times greater than the rate for whites. This is a decrease from 2002 when there was a 23-fold difference in rates. Gonorrhea rates were 3.8 times greater among American Indian/Alaska Natives, and 2.1 times greater among Hispanics than among whites in 2006. Rates among Asian/Pacific Islanders were 1.7 times lower than among whites in 2006.

In 2006, gonorrhea rates continued to be highest among adolescents and young adults. The overall gonorrhea rate was highest for the 20- to 24-year-old age group, which is over four times higher than the national gonorrhea rate. Among females in 2006, 15- to 19- and 20- to 24-year-old women had the highest rates of gonorrhea; 20- to 24-year-old males had the highest rate. Gonorrhea rates increased in all regions of the country except the Northeast, among most age groups, and among all race/ethnic groups except Asian/Pacific Islanders.

Links to Clinical Images
DermAtlas: Gonorrhea Images

Skinsight: Gonorrhea Images

DermNetNZ: Gonorrhea Images