Approach to the Patient with Gonorrhea
Benjamin Davis
Like other sexually transmitted diseases (STDs), gonorrhea remains a major public health problem in the United States. Gonorrhea ranks just behind chlamydial infection as the most common reportable STD in the United States, with more than 350,000 cases reported annually and an incidence rate of 125 per 100,000. Gonorrhea is most prevalent among teenagers and young adults, with African American men and women bearing a disproportionate burden of disease, accounting for 69% of all gonorrhea cases in 2006. The incidence of gonorrhea is also increasing in men who have sex with men (MSM).
Antibiotic resistance is becoming an increasing concern. Penicillinase-producing strains are now commonplace, and there is a growing problem of resistance to quinolone antibiotics. Treatment failures with use of oral cephalosporins and rare reports of ceftriaxone-resistant strains have forced new treatment recommendations.
The majority of patients with STDs present to an ambulatory care facility and should be diagnosed and treated in this setting. At the same time, the physician must be alert to serious systemic complications requiring hospitalization. In addition, patient education is critical to prevent inadequate treatment and recurrent infections. Finally, the responsibility of the physician must extend beyond the diagnosis and treatment of an individual patient to the identification and treatment of sexual contacts who may otherwise harbor and disseminate these infections, even if they are asymptomatic.
Gonococcal infection invariably begins with the direct infection of a mucosal surface during sexual activity. Organisms may then gain access to the bloodstream to produce bacteremia and systemic spread of infection. This is most common in women, especially at the time of menstruation, but it occurs in men also. The clinical features of gonorrhea differ greatly between the sexes. Moreover, symptoms of the primary gonococcal infection may be absent or mistaken for those of another condition, making the diagnosis more difficult.
In Men
In men, clinical symptoms usually follow within 2 to 10 days of sexual exposure. The risk that a man will acquire gonorrhea after a single exposure to an infected partner is approximately 35%. Absence of symptoms does not indicate absence of infection. Indeed, up to 10% of infected men are asymptomatic carriers of the gonococcus and are fully capable of transmitting the disease. In men, gonorrhea is principally an infection of the anterior urethra, and hence, the major symptom is purulent urethral discharge, often accompanied by urinary frequency and dysuria. Although spread of infection to the prostate or epididymis is uncommon in the antibiotic era, gonococci occasionally gain entry into the bloodstream to produce disseminated infection.
In Women
In women, the cervix is the favored site of gonococcal infection. However, up to 25% of women with gonococcal infection are asymptomatic and must be identified through epidemiologic case finding. When symptoms do occur, cervical discharge is most common. Although the vagina is usually spared, the gonococcal infection may spread downward from the cervix to produce urethritis, which presents as dysuria and frequency. Infection of the Bartholin glands presents as labial swelling and pain, and rectal infection presents as anorectal discomfort. If, on the other hand, gonococcal infection spreads upward from the cervix, more serious processes may develop. Such upward spread is particularly likely at the time of menstruation and can produce a variety of syndromes. Gonococcal endometritis can cause pelvic pain and abnormal vaginal bleeding, whereas salpingitis characteristically leads to fever, chills, leukocytosis, and a tender adnexal mass. Both systemic and pelvic signs and symptoms are even more pronounced in frank pelvic peritonitis, and further intraperitoneal spread may produce gonococcal perihepatitis with right upper quadrant pain and tenderness.
In Both Men and Women
Primary extragenital infections are being recognized more frequently. Gonococcal infection of the pharynx is usually asymptomatic but can present as an acute exudative pharyngitis, with fever and cervical lymphadenopathy. Gonococcal proctitis may be asymptomatic but can present with anorectal discomfort, tenesmus, or rectal bleeding and discharge.
Gonococcal bacteremia is manifested by the dermatitis-arthritis syndrome. Patients have fever, chills, and other constitutional symptoms. Skin lesions are an important clue to diagnosis; these are typically pustular, hemorrhagic, or papular; are few in number; and tend to be most common on the distal extremities. Tenosynovitis, especially involving the extensor surfaces of the hands and feet, and migratory polyarthritis are typically seen. During the early stage of systemic infection, blood cultures are often positive, but joint cultures are characteristically negative. Later in the course of untreated disease, however, gonococci can produce frank septic arthritis. Such patients have less fever, no skin lesions, and negative blood cultures but more impressive joint swelling and pain, often with purulent synovial fluid, in which gonococci can be demonstrated by Gram stain or culture. In rare instances, gonococci can produce osteomyelitis or even life-threatening bacterial meningitis or endocarditis.
The organisms besides Neisseria gonorrhoeae capable of producing female genital infections include Chlamydia, Gardnerella, Trichomonas, and Candida (see Chapter 117). The differential diagnosis of gonococcal salpingitis and peritonitis mainly encompasses the causes of nongonococcal pelvic inflammatory disease (see Chapter 116), but other conditions, such as appendicitis, ectopic pregnancy, hemorrhagic ovarian cysts, and endometriosis, can produce similar clinical findings and often require urgent therapy very different from that of pelvic inflammatory disease. In the male patient, the causes of nongonococcal urethritis enter the differential diagnosis (see Chapter 136). Gonococcal infection also needs to be considered among the causes of pharyngitis (see Chapter 220) and proctitis (see Chapter 66).
