gonorrhea,sexually transmitted disease characterized principally byinflammation of themucous membranes of the genital tract andurethra. It is caused by thegonococcus,Neisseria gonorrhoeae—abacterium with apredilection for the type of mucous membranes found in the genitourinary tract andadjacent areas. All gonococcal infections except eye infections in newborn infants (ophthalmia neonatorum), some instances of vulvovaginitis of young girls living in institutions, and occasional accidental eye infections in adults are transmitted by direct sexual contact.

Incidence

Gonorrhea is very common, having been known for centuries by the slang term “the clap.” It is worldwide in distribution, though the precise incidence is unknown because of self-treatment, undiagnosed cases, and defective reporting. TheWorld Health Organization estimates that 82 million people are infected annually worldwide. Increases in gonorrhea infections occur occasionally, as has been the case particularly since the mid-1990s. These increases have beenattributed in part to the rise of drug-resistantN. gonorrhoeae and to inconsistent safe-sex practices. The mortality from gonorrhea is negligible, but its indirect effects on the population by its not infrequentsterilization of both sexes are incalculable.

Course of infection

The incubation period of gonorrhea is usually 3 to 5 days (range 2 to 10 days). The first symptoms in the male are a burning sensation upon urination and a purulent urethral discharge that may be profuse or may be so meagre as to go unnoticed. In the absence of treatment, theinfection usually extends deeper, to involve the upper urethra, the neck of theurinary bladder, and theprostate gland. Urgency and frequency of urination and, occasionally, blood in the urine may follow.Spontaneous recovery may occur within a few months to a year. Particularly among homosexual or bisexual men, rectal gonorrhea may appear with pain in the perianal area and a mucous coating on the stool.

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Symptoms

The initial symptoms in the female are, in most instances, so mild as to go unnoticed. Slight vaginal discharge with burning may occur. Thedisease is not usually suspected by either patient or physician until complications arise or a sexual partner is infected. Abscess of a vulvovaginal (Bartholin) gland occurs rarely as an early complication. Many women recover spontaneously from gonorrheal infections that extend no farther than theuterine cervix (mouth of theuterus). In many cases, however, the infection extends through the uterus to thefallopian tubes andovaries—a condition known aspelvic inflammatory disease. Fever usually accompanies this extension, and lower abdominal pain is a prominent symptom. Pelvic abscess orperitonitis may result. The symptoms can be confused with those ofappendicitis. Healing occurs without resort to surgery in most cases, often with some physical disability and sterility. In immature girls the infection is usually confined to thevagina.

N. gonorrhoeae can sometimes enter the bloodstream, causingdisseminated gonococcal infection (DGI) in virtually any organ system. In both male and female,arthritis is the most commonmanifestation of DGI. The process usually settles in one or two joints and may result in permanent disability in the absence of treatment. Involvement of the tendon sheaths in the region of the affected joint or joints is not uncommon. Other, very rare, complications of gonorrhea are iritis (inflammation of theiris),endocarditis,meningitis, and skin lesions.

Diagnosis and treatment

Diagnosis is established byculture of a sample of urine or discharge. Treatment is withantibiotics. In the past, infection was treated with eitherpenicillin ortetracycline, and one injection usually was sufficient to cure uncomplicated gonorrhea. In the 1970s, however, strains of gonococciresistant to penicillin or tetracycline emerged. Thus,fluoroquinolones such as ciprofloxacin, the aminocyclitol antibioticspectinomycin, andcephalosporins such ascefoxitin became increasingly used asalternatives for eliminatingN. gonorrhoeae. Some strains of the bacteria, however, later developed resistance to fluoroquinolones, and eventually multidrug-resistant strains appeared. In the early 2000s, evidence of cephalosporin-resistantN. gonorrhoeae emerged.

In many places, the recommended approach to treating gonorrhea centres ondual drug therapy. Which drugs are used in dual therapy is determined in part by which drug-resistant strains are prevalent in the geographical region where infection was acquired and in some cases by whether there exists a likelihood of coinfection (such as withChlamydia trachomatis, a bacterium that causes nongonococcalurethritis). An example of a dual therapy that is used in theUnited States is the administration of a cephalosporin, such as cefixime or ceftriaxone, in combination with azithromycin (amacrolide antibiotic) or doxycycline (a tetracycline antibiotic). This approach is used regardless of whether coinfection has been ruled out. Isolates ofN. gonorrhoeae are routinely collected from patients and tested for antibiotic susceptibility, therebyfacilitating the detection of new drug-resistant strains.

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The administration of small doses of antibiotics sufficient to cure gonorrhea may mask the earlymanifestations of coexistingsyphilis and delay its diagnosis. Anintegral part of the treatment of gonorrhea, therefore, is the so-calledserological follow-up—ablood test for syphilis at least once a month for four months.