Gonorrhea

Gonorrhea is an infectious disease caused by an infectious causative agent of the gonococcus, transmitted predominantly through sexual intercourse and characterized mainly by damage to the mucous membranes of the urogenital organs. There is also a gonococcal lesion of the oral and rectal mucosa that is revealed mainly after orogenital or homosexual contacts. In the spread of infection in the pathological process, epididymis and prostate gland in men, endometrium and pelvic organs in women may be involved. There may also be a hematogenous spread of infection from the mucous membrane, although this phenomenon is rare.

Anatomico-physiological characteristics of male, female and child organisms, some specificity in the spread of infection, clinical manifestations, the course of gonorrhea, the development of complications and the difference in the treatment of these patients are the basis for the isolation of male, female and child gonorrhea.

[1], [2], [3], [4], [5], [6]

Causes of gonorrhea

The source of infection is mainly patients with chronic gonorrhea, mostly women, because they have a chronic process that is almost imperceptible, longer, more difficult to diagnose. This leads to complications such as pelvic inflammatory disease (PID). PID regardless of the presence or absence of symptoms can lead to disruption of patency of the fallopian tubes, which, in turn, can lead to reproductive disorders, including infertility, ectopic pregnancy, etc.

In some cases, out-of-the-box contamination through linen, sponges, towels on which the dried gonorrhea pus is retained can occur. Infection of the newborn can occur during childbirth when the fetus passes through the birth canal of the sick mother.

Depending on the intensity, the body's reaction to the introduction of gonococci, the duration of the course and the clinical picture, the following forms of gonorrhea are distinguished:

• fresh (acute, subacute, torpid), when no more than 2 months have elapsed since the moment of the disease;
• Chronic if the time of the disease is unknown or after the beginning of treatment of the disease has passed more than 2 months;
• latent, or gonokokonositsylstvo when patients do not have clinical signs of the disease, but the causative agents of the disease are found.

It is necessary to distinguish gonococcal infection, first occurred in a patient, from recurring (reinfection) and relapse of the disease. In some patients gonorrhea occurs without complications, in others - with complications. Isolation of uncomplicated and complicated forms of gonorrhea is mandatory. Also distinguish extragenital and disseminated forms of gonorrhea.

[7], [8], [9], [10]

Acute gonorrhea

Clinical symptoms of gonorrhea in men are characterized by secretions from the urethra, and also by itching and burning when urinating. With an objective examination, the urethra sponges are sharply hyperemic, edematous, the urethra itself is infiltrated, palpation is marked by soreness. From the urethra free abundant purulent discharge of yellowish-green color, which often macerates the inner leaf of the prepuce. With late treatment, you can observe flushing and swelling of the skin of the glans penis and foreskin. On the head of the penis, surface erosion can form. With rectal infection, there are discharge from the anus or pain in the perineum. In men younger than 40 years. As well as in individuals with reduced resistance, epididymitis results from the penetration of gonococci into the appendage from the prostatic part of the urethra through the vas deferens. The disease begins suddenly with pain in the epididymis and in the groin. In patients, there is an increase in body temperature to 39-40 ° C, chills, headache, weakness. When palpation the appendage is enlarged, dense and painful. Skin of the scrotum is tense, hyperemic, skin folding absent. Gonococcal lesions of the appendages lead to the formation of scars in the ducts of the epididymis. As a result, azoospermia and infertility occur. Asymptomatic flow can be observed in 10% of cases with urethral involvement, 85% in case of rectal involvement, 90% in case of lesion of the pharynx. Disseminated gonococcal infection (DGI) is most often manifested by an increase in body temperature. Defeat of joints (one or several) and skin. The manifestation of gonococcal dermatitis is accompanied by the formation of necrotic pustules on the erythematous base, and erythematous and hemorrhagic spots, papulo- pustules, and blisters can also be observed. The most frequent localization of the rashes is the distal parts of the extremities or near the affected joints. Also affected are the vagina of the tendons, mainly the brushes and feet (tenosipovitis). DGI is more common in women than in men. The risk of developing GHI increases during pregnancy and in the premenstrual period. Manifestation of gonococcal infection in the form of meningitis or endocarditis is very rare.

Clinical symptoms of gonorrhea in women are almost asymptomatic, which leads to late detection of the disease and the development of complications. The primary localization of the lesion is the cervical canal, with inflammatory changes developing both in the integument epithelium and in the stroma of the uterine mucosa. The defeat of the urethra (urethritis) is observed in 70 90% of patients, and the lesion of the vulva and the vagina usually develops again. When examined, the discharge is muco-purulent, contact bleeding may occur. The lesions of the basal layer of the endometrium are caused by the penetration of gonococci into the uterine cavity during menstruation or after childbirth and abortion. Penetration of gonococci from the endometrium into the muscular layer of the uterus (endometritis) is observed after abortion and childbirth. Characteristic for ascending gonorrhea is the rapid spread of infection from the uterus to the fallopian tubes, ovaries, peritoneum. When the suppurative process spreads into the cavity of the gas peritoneum, pelvic eruptitis occurs, the fibrin-rich transudate causes the formation of adhesions and fusions of the fallopian tube and ovary with adjacent organs. This is accompanied by acute pain in the lower abdomen and painful palpation, an increase in body temperature to 39 ° C.

In 50% of cases with lesions of the cervix, 85% of cases - rectum and 90% - pharynx, asymptomatic infection is observed.

Infection often occurs as a mixed (gonorrhea-trichomonas, gonorrhea-chlamydial, etc.). As a rule, several organs are infected (multifocal lesion).

[11], [12], [13], [14], [15], [16], [17], [18], [19], [20]

Gonococcal conjunctivitis in newborns

Affection of the conjunctiva of the eyes in newborns occurs during passage through the birth canal of a patient with gonorrhea of the mother and is accompanied by redness, swelling, gluing of the eyelids. From under their edges or the inner corner of the eye pus emerges, the conjunctiva of the eye becomes hyperemic, swells. If the appropriate treatment is not begun in a timely manner, corneal ulceration is possible up to its perforation, which can lead to complete blindness in the future. Gonococcal lesions of the eyes in adults can be the result of gonococcal sepsis or, most often, direct infection by hand, "dirty secretions from the genitourinary organs. With inflammation of the conjunctiva, there is a purulent discharge, partial or even complete destruction of the conjunctiva.

Indications for testing

• symptoms or signs of discharge from the urethra;
• mucopurulent cervicitis;
• the presence of a sexually transmitted infection (STI) or PID;
• Screening for STIs at the request of the patient or with the recent appearance of a new sexual partner;
• vaginal discharge in the presence of risk factors for STIs (under 25 years of age, recently appeared sexual partner);
• acute orchoepidimitis in men younger than 40 years;
• acute PID;
• casual sexual intercourse without means of protection;
• purulent conjunctivitis in newborns.

Laboratory diagnostics

Verification of the diagnosis of gonorrhea is based on the detection of Neisseria gonorrhea in materials from the genitals, rectum. Pharynx, eyes using one of the methods.

A quick diagnostic test (microscopy of Gram-stained methylene blue smears from the urethra, cervix or rectum) allows rapid identification of typical gram-negative diplococci.

All samples should be examined with the help of culture method and amplification methods of antigen determination (amplification of nucleic acids).

Additional research

• staging a complex of serological reactions to syphilis;
• the definition of antibodies to HIV, hepatitis B and C;
• clinical analysis of blood, urine;
• Ultrasound of the pelvic organs;
• uretroscopy, colposcopy;
• cytological examination of the mucous membrane of the cervix;
• Thompson's 2-glass sample;
• study of the secretion of the prostate.

The expediency of provocation is decided individually by the attending physician. Indication, volume and frequency of additional studies are determined by the nature and severity of the clinical manifestations of gonococcal infection.

Multiplicity of serological studies: before treatment, again - after 3 months (with an unidentified source of infection) for syphilis and after 3-6-9 months for HIV, hepatitis B and C.

[21], [22], [23], [24], [25], [26], [27], [28], [29]

Treatment of gonorrhea

CDC (Centers for Disease Control and Prevention) for uncomplicated gonorrhea cervicitis, urethritis and proctatitis recommends the following antibiotics (recommended regimens): ceftriaxone 250 mg once or tsumixime 400 mg orally, single or ciprofloxacin (sispres) 500 mg orally , once, or ofloxacin 400 mg orally, once, or cefuroxime (megasef) 750 mg IM every 8 hours.

In the absence of the above antibiotics, alternative regimens are prescribed: spectinomycin, 2 g once / once, or once-only regimens for cephalosporins (ceftizoxime 500 mg IM once, or cefoxitine 2 g once with probenecid 1 g orally).

With gonococcal conjunctivitis, ceftriaxone is recommended for 1 g of IM once.

For ophthalmia of newborns caused by N. Gonorrhoeae, ceftriaxone is recommended for 25-50 mg / kg IV or IM once, not more than 125 mg.