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Tuesday, August 12, 2025

Gonorrhoea


Definition

Gonorrhoea is a sexually transmitted infection (STI) caused by Neisseria gonorrhoeae, a Gram-negative diplococcus that infects mucous membranes of the urogenital tract, rectum, conjunctiva, and pharynx. It is a major public health concern due to its high prevalence, asymptomatic carriers, and growing antimicrobial resistance.

Etiology and Transmission

  • Causative organism: Neisseria gonorrhoeae

  • Transmission:

    • Unprotected vaginal, anal, or oral sexual contact with an infected partner

    • Perinatal transmission from mother to infant during childbirth (can cause neonatal conjunctivitis)

  • Incubation period: Usually 2–7 days after exposure, but can be up to 14 days

Pathophysiology

  • N. gonorrhoeae adheres to epithelial cells via pili and outer membrane proteins

  • Invades mucosal surfaces, triggers neutrophil-rich inflammatory response

  • If untreated, can spread locally and systemically, causing pelvic inflammatory disease (PID), epididymitis, disseminated gonococcal infection (DGI), and infertility

Risk Factors

  • Multiple or new sexual partners

  • Inconsistent condom use

  • Previous history of STIs

  • Men who have sex with men (MSM)

  • Sex work

  • Age <25 years

Clinical Features

1. Urogenital Infection

  • Men:

    • Urethritis with purulent urethral discharge

    • Dysuria

    • Testicular pain (epididymitis)

  • Women:

    • Often asymptomatic

    • Cervicitis: mucopurulent discharge, intermenstrual bleeding, postcoital bleeding

    • Dysuria, pelvic pain

    • Can progress to PID

2. Rectal Infection

  • Anal pain, discharge, pruritus, tenesmus

  • Often asymptomatic

3. Pharyngeal Infection

  • Mild sore throat or asymptomatic

4. Conjunctival Infection

  • Purulent conjunctivitis (in adults or neonates)

5. Disseminated Gonococcal Infection (DGI)

  • Triad: tenosynovitis, dermatitis, migratory polyarthritis

  • Can cause endocarditis or meningitis (rare)

Complications

  • Women: PID, infertility, chronic pelvic pain, ectopic pregnancy

  • Men: Epididymitis, infertility (rare)

  • Both: Disseminated infection, reactive arthritis, increased HIV transmission risk

  • Neonates: Ophthalmia neonatorum, blindness if untreated

Diagnosis

Recommended tests:

  • Nucleic acid amplification tests (NAATs) – preferred; high sensitivity and specificity; can be used on urine (first-catch), urethral, endocervical, vaginal, pharyngeal, and rectal swabs

  • Culture: Useful for antimicrobial susceptibility testing; taken from relevant site of infection

  • Microscopy (Gram stain): Gram-negative diplococci within polymorphonuclear leukocytes – useful for symptomatic men with urethral discharge

  • Screen for co-infections: HIV, syphilis, chlamydia

Management

Goals:

  • Eradicate infection

  • Prevent complications and reinfection

  • Reduce transmission to others

General principles:

  • Treat sexual partners from the last 60 days

  • Abstain from sexual contact for 7 days after treatment and until all partners are treated

  • Always provide concurrent chlamydia treatment unless excluded by testing

First-line Recommended Regimen (for uncomplicated urogenital, rectal, or pharyngeal gonorrhoea in adults and adolescents)

  • Ceftriaxone 500 mg intramuscularly as a single dose

    • If body weight ≥150 kg: 1 g IM single dose

    • Plus Doxycycline 100 mg orally twice daily for 7 days if chlamydia not excluded

Alternatives (where ceftriaxone unavailable or contraindicated) – guided by local resistance patterns

  • Cefixime 400 mg orally as a single dose (less effective for pharyngeal infection; resistance emerging)

  • Gentamicin 240 mg IM single dose plus Azithromycin 2 g orally as a single dose

  • Spectinomycin 2 g IM single dose (not effective for pharyngeal infection)

Treatment of Complicated Cases

  • Pelvic Inflammatory Disease due to gonorrhoea:

    • Ceftriaxone 1 g IV daily plus doxycycline 100 mg orally twice daily and metronidazole 500 mg orally twice daily for 14 days

  • Disseminated Gonococcal Infection:

    • Ceftriaxone 1 g IV or IM every 24 hours for at least 7 days (switch to oral cefixime 400 mg twice daily after clinical improvement if susceptibility confirmed)

  • Gonococcal Conjunctivitis (adults):

    • Ceftriaxone 1 g IM single dose plus saline eye lavage

  • Neonatal Ophthalmia:

    • Ceftriaxone 25–50 mg/kg IV or IM single dose (max 125 mg)

Antimicrobial Resistance Considerations

  • N. gonorrhoeae has developed resistance to sulfonamides, penicillin, tetracyclines, macrolides, fluoroquinolones, and some cephalosporins

  • Rising ceftriaxone resistance is a global concern – susceptibility testing is crucial in persistent or recurrent cases

Prevention

  • Consistent condom use

  • Regular STI screening for high-risk populations

  • Prompt treatment of cases and partners

  • Prenatal screening to prevent neonatal infection

  • Education on safer sexual practices

Prognosis

  • Excellent with prompt diagnosis and treatment

  • Delayed or inadequate treatment increases risk of complications and further transmission

  • Recurrent infection is common if sexual partners are untreated or preventive measures are not followed




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