HIV/AIDS

Updated 25 June 2014

Gonorrhoea

Gonorrhoea is one of the oldest known and most common sexually transmitted diseases (STDs). It is caused by a bacterium called Neisseria gonorrhoea and is highly contagious.

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Summary

  • Gonorrhoea is a sexually transmitted bacterial disease.
  • Women with gonorrhoea often have no symptoms.
  • Gonorrhoea is extremely contagious.
  • It can be passed on from mother to infant during childbirth.
  • The disease is treated with antibiotics.
  • The highest incidence is in the 15- to 29-year-old age group.
  • Chlamydia occurs in 20 to 40% of people with gonorrhoea.

Description

Gonorrhoea is one of the oldest known and most common sexually transmitted diseases (STDs). It is caused by a bacterium called Neisseria gonorrhoea and is highly contagious. This disease usually first appears in the genital areas but can affect many body parts. In women, it is commonly found in the vagina and more specifically the cervix (the opening to the uterus). It can also exist in the tube that carries urine from the bladder (urethra) of men and women. Unprotected oral sex can lead to infection in the back of the throat, known as gonococcal pharyngitis. Rectal infection (anal gonorrhoea) is also common in women and homosexual men.

Gonorrhoea can also be passed from a mother to her new-born during birth and can lead to pneumonia or an eye infection known as gonococcal conjunctivitis, which can lead to permanent blindness. Adults can also contract gonococcal conjunctivitis if a contaminated hand touches the eyes.

Unfortunately, the disease often goes undetected in women, as up to 50% of women with gonorrhoea are symptom-free. In untreated cases, complications can develop. In women, untreated gonorrhoea may lead to many complications, including pelvic inflammatory disease, an ascending infection that spreads from the vagina and cervix to the uterus and Fallopian tubes. Pelvic inflammatory disease can lead to infertility. The symptoms of this disease include fever, pelvic cramping, abdominal pain or pain during intercourse. In men, symptoms of gonorrhoea can include epididymitis (an inflammation of the scrotal tubes) and prostatitis (infection of the prostrate gland). However, the main symptom in men is a urethral discharge, and often pain on passing urine .

Infection of the joints (gonococcal arthritis) may also develop in one to three percent of men and women with untreated gonorrhoea.

Symptoms

It is possible for people, especially women, not to have any apparent symptoms. Approximately 50% of women and 10 to 15% of men have no symptoms of infection. In both sexes, anal gonorrhoea and gonococcal pharyngitis are usually asymptomatic. Even if there are no symptoms, an infected person is still a carrier and can still transmit the disease to others.

Women who have symptoms may suffer from the following:

  • Painful or frequent urination
  • Pain during intercourse
  • Cloudy, yellowish vaginal discharge, which may have a foul odour
  • Redness and swelling of the genitals
  • Burning or itchy vaginal area
  • Stomach pain
  • Heavy menstrual bleeding
  • In isolated cases, severe sore throat, pain on swallowing (gonococcal pharyngitis)
  • Constant urge to move bowels, anal itching, pain or discharge (anal gonorrhoea)
  • Infection of the eyes (rare)

Men usually develop symptoms within two to 10 days. Symptoms include:

  • Thick discharge from the penis (clear or milky at first and then yellow, creamy, profuse and sometimes blood-tinged)
  • Frequent and painful urination
  • Reddened, irritated tip of penis
  • Pain in the scrotum or testicle
  • In isolated cases, severe throat and pain on swallowing (gonococcal pharyngitis)
  • Constant urge to move bowels, anal itching, pain or discharge (anal gonorrhoea)
  • Infection of the eyes (rare)

Course

The Neisseria gonorrhoea bacterium thrives in warm, moist environments such as the lining of the tubes and cavities inside the body (mucous membranes). Gonorrhoea usually starts as an infection in the cervix in women and in the urethra in male patients. The development of complications depends on how long the disease has been present, the spread of infection and whether a person has had gonorrhoea previously or not.

If left untreated, men may develop epididymitis, urethral strictures (narrowing of the urethra), proctitis (inflamed rectum) and acute prostatitis. Complications in women include pelvic inflammatory disease, bartholinitis (infection of the Bartholin glands, which are located in the vagina) and salpingitis (infection of the Fallopian tubes, the tubes that carry eggs from the ovaries to the womb).

Pregnant women with untreated gonorrhoea can have an increased risk of ectopic pregnancy, miscarriage, premature birth, pre-term labour, premature rupture of the membranes or endometritis (infection of the uterine lining after childbirth).

In approximately two percent of all cases, gonorrhoea spreads to other parts of the body via the bloodstream. This is called disseminated gonococcal infection and is more common in women than men. Disseminated gonococcal infection may cause:

  • Localised infections such as abscesses
  • Skin infections
  • Gonococcal arthritis (an inflammation of the joints, especially the knees, ankles and wrists)
  • Septicaemia (infection of the blood)
  • Endocarditis (infection of the inner lining of the heart and heart valves)
  • Fever
  • Meningitis (infection or inflammation of the membrane covering the brain and spinal cord)

Risk factors

The following people are most at risk:

  • Sexual partners of people with gonorrhoea
  • Sexually active adolescent women
  • People who have unprotected sex with multiple sexual partners
  • People who have a current chlamydia infection
  • Babies born to women with gonorrhoea

As with other STDs, women are more at risk of being infected with gonorrhoea than men. The risk of infection from a single act of unprotected sex with an infected partner is:

  • 60 to 90% for women
  • 20 to 50% for men

When to see a doctor

Gonorrhoea manifests differently in men and women. In certain cases, immediate medical attention is needed.

Women

As gonorrhoea is often asymptomatic in women, sexually active women should be tested for gonorrhoea once a year. If a woman is pregnant or plans to have a child, she should also be tested.

Immediate medical attention is needed in the case of the following:

  • Exposure to or symptoms of gonorrhoea
  • Yellowish, thick or bad-smelling vaginal discharge
  • Unexpected mid-cycle bleeding
  • Bleeding after sexual intercourse or douching
  • Sudden, severe pelvic pain
  • Lower abdominal pain accompanied by a new or different vaginal discharge and fever (38 °C or higher)
  • Painful or frequent urination, or inability to urinate
  • Signs of any possible complications such as chest pain

Men

Men need immediate medical attention if they have any of the following symptoms:

  • Discharge from the penis and fever (38 °C or higher)
  • Pain, swelling or tenderness in the scrotum and fever
  • Painful or frequent urination or inability to urinate
  • Exposure to gonorrhoea with fever and possible complications such as joint inflammation or chest pain

Visit preparation

  • Be prepared to answer any questions about recent sexual activity.
  • Make a note of any symptoms that may be present.
  • Inform your health care professional if you are allergic to penicillin.
  • Avoid all sexual contact while waiting for a medical examination.

Diagnosis

Gonorrhoea has to be differentiated from other diseases with similar symptoms. In some cases gonorrhoea can be diagnosed during a gynaecological or genital examination. If there is any suspicion of gonorrhoea or other STDs, the doctor will take a culture of discharge from the infected area (cervix, urethra, throat or rectum) for examination under a microscope. Pregnant women who are at risk for gonorrhoea should be screened at their first prenatal visit and again during the third trimester. Sexual partners should be tested and treated simultaneously if infected.

New tests for the diagnosis of gonorrhoea are being developed, and some are in use. As with the test for Chlamydia trachomatis, these tests detect the DNA of the organism in urine or genital specimens, rather than relying on growth of the organism. This sort of test is often more sensitive than routine culture (i.e. it will detect cases that might be missed by culture). However, the test is also more expensive than a standard culture, and should probably only be used in certain cases. Many patients will be treated for gonorrhoea just on the basis of symptoms, it does not therefore make any sense to perform this test on these patients.

Approximately 15 to 25% of heterosexual men with gonorrhoea and 30 to 50% of women with gonnorrhoea also have another STD, chlamydia. People should therefore also be tested for chlamydia.

Treatment

Medication

Gonorrhoea is highly contagious and can lead to serious complications. It should therefore be treated immediately. As chlamydia is often found in people with gonorrhoea, both infections should be treated. Unfortunately new strains of gonorrhoea have become resistant to various antibiotics and are therefore more difficult to treat. Treatment usually consists of antibiotics to kill the bacteria and analgesics to relieve pain. The most commonly used antibiotics are ciprofloxacin or ofloxacin. Pharyngeal gonococcal infection is usually treated with ciprofloxacin. Eye infections (gonococcal ophthalmia) are usually treated with ceftriaxone and a saline solution. The common medication prescribed to pregnant women is ceftriaxone or spectinomycin. New-borns are automatically treated with silver nitrate eye ointment to prevent eye infections.

Once the treatment is complete, it is important to be re-tested to ensure that the infection is cured. It is important to abstain from sexual activity until gonorrhoea has cleared up. Reinfection with gonorrhoea is common. It is therefore important for all sexual partners to be treated.

Hospitalisation

If disseminated gonococcal infection has developed, a person may be hospitalised. Abscesses, which sometimes form as a result of untreated gonorrhoea, may have to be removed surgically.

Prevention

Gonorrhoea is one of the easiest STDs to prevent because the bacteria can survive only under certain conditions. Preventative measures include the following:

  • Always use condoms during vaginal, anal and oral sex. Female condoms, which are now available in South Africa, can also help to reduce the risk of transmission. Use of condoms will also help to prevent the spread of other STDs, including herpes, chlamydia and HIV.
  • Do not share towels that may be contaminated with the bacteria.
  • Ask to be tested for gonorrhoea during all routine visits.
  • If you are pregnant or planning to become pregnant, have yourself tested for gonorrhoea.

Reviewed by Dr Andrew Whitelaw, MBBCh (Witwatersrand), MSc (UCT), FCPath (Micro) (SA) Senior registrar, Department of Microbiology, University of Cape Town and Groote Schuur Hospital

 

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Dr Sindisiwe van Zyl qualified at the University of Pretoria before working for an HIV/AIDS NPO in Soweto for many years. She was named one of the Mail & Guardian's Top 200 Young South Africans in 2012.
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