GONORRHEA History The disease gonorrhea is a specific type of urethritis that practically always involves mucous membranes of the

urethra, resulting in a copious discharge of pus, more apparent in the male than in the female. The first usage of the term "gonorrhea", by Galen in the second century, implied a "flow of seed". For centuries thereafter, gonorrhea and syphilis were confused, resulting from the fact that the two diseases were often present together in infected individuals. Paracelsus (1 !"# thought that gonorrhea was an early symptom of syphilis. The confusion was further heightened by the classic blunder of $nglish physician %ohn &unter, in 1'('. &unter intentionally inoculated himself with pus from a patient with symptoms of gonorrhea and wound up giving himself syphilis. The causative agent of gonorrhea, )eisseria gonorrhoeae, was first described by *. )eisser in 1+', in the pustular e-udate of a case of gonorrhea. The organism was grown in pure culture in 1++ , and its etiological relationship to human disease was later established using human volunteers in order to fulfill the e-perimental re.uirements of /och0s postulates. Definition Gonorrhea is a se-ually transmitted disease (1T2#. Gonorrhea is caused by )eisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract, including the cervi- (opening to the womb#, uterus (womb#, and fallopian tubes (egg canals# in women, and in the urethra (urine canal# in women and men. The bacterium can also grow in the mouth, throat, eyes, and anus. Morphology of )eisseria gonorrhoeae )eisseria gonorrhoeae is a Gram3negative coccus, ".( to 1." 4m in diameter, usually seen in pairs with ad5acent flattened sides. The organism is fre.uently found intracellularly in polymorphonuclear leu6ocytes (neutrophils# of the gonorrhea pustular e-udates (Figure 1#. Fimbriae, which play a ma5or role in adherence, e-tend several micrometers from the cell surface (Figure 7#.

Fig 1. Gram stain of male urethral exudates showing N. gonorrhoeae inside a PMN (LM x500)

Fig 2. N. gonorrhoeae

Bacteriology )eisseria gonorrhoeae possesses a typical Gram3negative outer membrane composed of proteins, phospholipids, and lipopolysaccharide (8P1#. &owever, neisserial 8P1 is distinguished from enteric 8P1 by its highly3branched basal oligosaccharide structure and the absence of repeating 93antigen subunits. For these reasons, neisserial 8P1 is referred to as lipooligosaccharide (LOS#. The bacterium characteristically releases outer membrane fragments called "blebs" during growth. These blebs contain 891 and probably have a role in pathogenesis if they are disseminated during the course of an infection. ). gonorrhoeae is a relatively fragile organism, susceptible to temperature changes, drying, :; light, and other environmental conditions. 1trains of ). gonorrhoeae are variable in their cultural re.uirements so that media containing hemoglobin, )*2, yeast e-tract and other supplements are needed for isolation and growth of the organism. <ultures are grown at ! 3!( degrees in an atmosphere of !31"= added <97. Pathology a# 9rganism is e.uipped with fimbria, which enable it to attach to inner surface tissue or urethra. >ncubation period is 7 to + days. b# 9rganism spreads intercellularly to deeper urethral tissues. $ndoto-in in the bacterial cell wall causes inflammation of these tissues. 8arge amounts of pus (yellow# are e-uded into the urethra and out of urethral opening. c# *ccumulation of pus in urethra ma6es urination painful. $ndoto-in also causes inflammatory pain. 1ymptoms usually milder in women. d# The untreated infection in women may spread to fallopian tubes and other abdominal tissues to cause P>2 (pelvic inflammatory disease#. 1terility may result from P>2 involvement in females and vas deferens involvement in males. e# 2uring birth from an infected mother, the child0s eyes may become infected, causing blindness (opthalmia neonatorum#. This is prevented by adding 1= *g)9! or penicillin to eyes of newborns.

F ig !. Pathogenesis gonorrhea Ha itat and Portal of Entry Genitourinary tract and the eyes of infected persons Mode of !rans"ission Gonorrhea is spread through contact with the penis, vagina, mouth, or anus. $5aculation does not have to occur for gonorrhea to be transmitted or ac.uired. Gonorrhea can also be spread from mother to baby during delivery (through passage of fetus in the infected genital tract#. How does Gonorrhea affect a pregnant woman and her baby? If a pregnant woman has gonorrhea, she may give the infection to her baby as the baby passes through the birth canal during delivery. This can cause blindness, joint infection, or a life-threatening blood infection in the baby. Treatment of gonorrhea as soon as it is detected in pregnant women will reduce the ris of these complications. !regnant women should consult a health care provider for appropriate e"amination, testing, and treatment, as necessary. People who have had gonorrhea and received treatment may get infected again if they have se-ual contact with a person infected with gonorrhea. Host Defenses >nfection stimulates inflammation and a local immune (>g*# response. >nflammation focuses the host defenses but also becomes the pathology of the disease. >t is not 6nown whether the secretory immune response is protective. 1erum antibodies also appear, and >gG and complement may be components of the inflammatory e-udates. ?ut whether the immune defenses provide much protection against reinfection has not been clearly shown. >n any case, immunity is e-pected to be strain specific so that reinfection may occur. )ot everyone e-posed to ). gonorrhoeae ac.uires the disease. This may be due to variations in the si@e or virulence of the inoculum, to natural resistance, or to specific immunity. * "= infective dose (>2 "# of about 1,""" bacteria has been determined based on e-perimental urethral inoculation of male volunteers. )o data is available for females. )onspecific factors have been implicated in natural resistance to gonococcal infection. >n women, changes in the genital p& and hormones may increase resistance to infection at certain times of the menstrual cycle. :rine contains bactericidal and bacteriostatic components against ). gonorrhoeae. Factors in urine that may be important are p&, osmolarity, and the concentration of urea. The variability in the susceptibility of gonococcal strains to the bactericidal and bacteriostatic properties of urine is thought to be one of the reasons some males apparently do not develop a gonorrhea infection when e-posed. Aost uninfected individuals have serum antibodies that react with gonococcal antigens. These antibodies probably result from coloni@ation or infection by various Gram3negative bacteria that possess cross3reactive antigens. 1uch "natural

antibodies" may be important in individual natural resistance or susceptibility to infection, but this has not been clearly demonstrated. >nfection with ). gonorrhoeae stimulates both mucosal and systemic antibodies to a variety of gonococcal antigens. Aucosal antibodies are primarily >g* and >gG. >n genital secretions, antibodies have been identified that react with Por, 9pa, Bmp and 891. ;accine trials have suggested that specific antifimbrial antibodies inhibit the fimbrial3 mediated attachment of the homologous gonococcal strain. >n general, the >g* response is brief and declines rapidly after treatmentC >gG levels decline more slowly. *nti Por antibodies apparently are bactericidal for the gonococcus. >gG that reacts with Bmp bloc6s the bactericidal activity of antibodies directed against Por and 891. Genital infection with ). gonorrhoeae stimulates a serum antibody response against the 891 of the infecting strain. 2isseminated gonococcal infection results in much higher levels of anti3891 antibody than do genital infections. 1trains that cause uncomplicated genital infections usually are 6illed by normal human serum and are termed seru" sensiti#e. This bactericidal activity is mediated by >gA and >gG antibodies that recogni@e sites on the 891. 1trains that cause disseminated infections are not 6illed by most normal human serum and are referred to as seru" resistant. Besistance is mediated, in part, by >g* that bloc6s the >gG3mediated bactericidal activity of the serum. 1erum from convalescent patients with disseminating infections contains bactericidal >gG to the 891 of the infecting strain. >ndividuals with inherited complement deficiencies have a mar6edly increased ris6 of ac.uiring systemic neisserial infections and are sub5ect to recurring episodes of systemic gonococcal and meningococcal infections, indicating that the complement system is important in host defense. Gonococci activate complement by both the classic and alternative pathways. <omplement activation by gonococci leads to the formation of the < b3, comple- (membrane attac6 comple-# on the outer membrane. >n normal human serum, similar numbers of < b3 , comple-es are deposited on serum3sensitive and serumresistant organisms, but the membrane attac6 comple- is not functional on serum3resistant organisms. Signs and Sy"pto"s *lthough many men with gonorrhea may have no symptoms at all, some men have some signs or symptoms that appear two to five days after infectionC symptoms can ta6e as long as !" days to appear. 1ymptoms and signs include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. 1ometimes men with gonorrhea get painful or swollen testicles. Aales :rethritis (pain during and fre.uency of urination# :rethral 2ischarge >n women, the symptoms of gonorrhea are often mild, but most women who are infected have no symptoms. $ven when a woman has symptoms, they can be so non3specific as to be mista6en for a bladder or vaginal infection. The initial symptoms and signs in women include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods. Domen with gonorrhea are at ris6 of developing serious complications from the infection, regardless of the presence or severity of symptoms.

Females :rinary Tract >nfection ?artholinEs Glands may become inflamed and painful >ncreased ;aginal 2ischarge (slight yellowishF thic6 greenish yellow# 1ymptoms of $-treme >nflammation 1ymptoms of rectal infection in both men and women may include discharge, anal itching, soreness, bleeding, or painful bowel movements. Bectal infection also may cause no symptoms. >nfections in the throat may cause a sore throat but usually causes no symptoms. Assess"ent and Diagnostic $indings 1. *ssess for feverC urethral, vaginal and rectal dischargeC and for signs of arthritis. 7. 1pecimen <ulture :rine G for gonococcal bacillus ;aginal on all children with vulvovaginitis :rethral or urethral discharge Dhere to obtain specimensH >n malesI :rethra, anal canal, and pharyn>n femalesI $ndocervi-, anal canal and pharyn2iagnosisI a# Presence of Gram negative diplococci in e-uded pus. b# Transfer pus specimen to plates of Thayer3Aartin agar (selective for ). gonorrhoeae# 9bserve for growth of ). gonorrhoeae. c# Gono@yme test 3 $8>1* test for *g in urethral samplings (does not detect *g very well in rectal or pharyngeal forms of the disease#. %o"plications :ntreated gonorrhea can cause serious and permanent health problems in both women and men. >n women, gonorrhea is a common cause of pelvic inflammatory disease (P>2#. Domen with P>2 do not necessarily have symptoms. Dhen symptoms are present, they can be very severe and can include abdominal pain and fever. P>2 can lead to internal abscesses (pus3filled Jpoc6etsK that are hard to cure# and long3lasting, chronic pelvic pain. P>2 can damage the fallopian tubes enough to cause infertility or increase the ris6 of ectopic pregnancy. $ctopic pregnancy is a life3threatening condition in which a fertili@ed egg grows outside the uterus, usually in a fallopian tube. >n men, gonorrhea can cause epididymitis, a painful condition of the testicles that can lead to infertility if left untreated. Gonorrhea can spread to the blood or 5oints. This condition can be life threatening. >n addition, people with gonorrhea can more

easily contract &>;, the virus that causes *>21. &>;3infected people with gonorrhea are more li6ely to transmit &>; to someone else. Medical Manage"ent The recommended treatment for uncomplicated infections is a thirdgeneration cephalosporin or a fluoro.uinolone plus an antibiotic (e.g., do-ycycline or erythromycin# effective against possible coinfection with <hlamydia trachomatis. 1e- partners should be referred and treated. The current <2< Treatment Guidelines recommend treatment of all gonococcal infections with antibiotic regimens effective against resistant strains. The recommended antimicrobial agents are ceftria-one, cefi-ime, ciproflo-acin, or ofla-acin. 1. *dministration of ceftria-one (Bocephine# (or cefi-ime L1upra-M ciproflo-acin L<iproM#, or oflo-acin LFlo-inM# along with do-icycline 7. )oteI >f the patient is pregnant, give amo-icillin. !. 1erologic Testing for syphilis and &>; Nursing Manage"ent 1. 9btain patientEs history 7. $ncourage treatment and follow up care !. >dentify patientEs se-ual contacts Pre#ention and %ontrol There is no effective vaccine to prevent gonorrhea. <andidate vaccines consisting of PilE protein or Por are of little benefit. The development of an effective vaccine has been hampered by the lac6 of a suitable animal model and the fact that an effective immune response has never been demonstrated. The surest way to avoid transmission of se-ually transmitted diseases is to abstain from se-ual intercourse, or to be in a long3term mutually monogamous relationship with a partner who has been tested and is 6nown to be uninfected. 8ate- condoms, when used consistently and correctly, can reduce the ris6 of transmission of gonorrhea. The evolution of antimicrobial resistance in ). gonorrhoeae may ultimately affect the control of gonorrhea. 1trains with multiple chromosomal resistance to penicillin, tetracycline, erythromycin, and cefo-itin have been identified in the :nited 1tates and most other parts of the world. 1poradic high3level resistance to spectinomycin and fluoro.uinolones has been reported. Penicillinase producing strains of ). gonorrhoeae were first described in 1,'(. Five related Nlactamase plasmids of different si@es have been identified. Their prevalence penicillin3resistant strains has increased dramatically in the :nited 1tates since 1,+O. Plasmid3mediated resistance of ). gonorrhoeae to tetracycline was first described in 1,+( and has now been reported in most parts of the world. This resistance is due to the presence of the streptococcal tetA determinant on a gonococcal con5ugative plasmid. *ny genital symptoms such as discharge or burning during urination or unusual sore or rash should be a signal to stop having se- and to see a doctor immediately. >f a person has been diagnosed and treated for gonorrhea, he or she should notify all recent se- partners so they can see a

health care provider and be treated. This will reduce the ris6 that the se- partners will develop serious complications from gonorrhea and will also reduce the personEs ris6 of becoming re3infected. The person and all of his or her separtners must avoid se- until they have completed their treatment for gonorrhea. *lsoI Bapid treatment Facilities for early diagnosis and treatment &ealth and se- education 1uppression of commerciali@ed prostitution <redeEs prophyla-is for newborn

Pictures Penile