Gonorrhea

Gonorrhoea (gonorrhea in American English), slang term "the clap", is among the most common curable sexually transmitted diseases in the world and is caused by the Gram-negative bacterium called Neisseria gonorrhoeae.

Infection with gonorrhoea increases the risk of becoming infected with HIV (human immunodeficiency virus, the virus that causes AIDS). This is likely due to weakening of the mucosal surface secondary to the gonorrhoea infection. Note, however, that this effect is by no means limited to gonorrhoea and there is increased risk of HIV transmission with co-infection of most sexually transmitted infections (STIs - Sexually Transmitted Infections).

The first place this bacterium infects is usually the columnar epithelium of the urethra and endocervix. Non-genital sites in which it thrives are the rectum, the oropharynx and the conjunctivae (eyes). The vulva and vagina in women are usually spared because they are lined by stratified epithelial cells -- in women the cervix is the usual first site of infection.

Gonorrhoea spreads during sexual intercourse. Infected women also can pass gonorrhoea to their newborn infants during delivery, causing eye infections in their babies. This complication is now rare because newborn babies receive eye medicine to prevent infection. When the infection occurs in the genital tract, mouth, or rectum of a child, it is most commonly due to sexual abuse.

Epidemiology
In 2000, 358,995 cases of gonorrhoea were reported to the U.S. Centers for Disease Control and Prevention (CDC). In the United States, approximately 75 percent of all reported cases of gonorrhoea are found in younger persons aged 15 to 29 years. The highest rates of infection are usually found in 15- to 19-year old women and 20- to 24-year-old men. Health economists estimate that the annual cost of gonorrhoea and its complications is close to $1.1 billion.

The disease can spread into the uterus and Fallopian tubes, resulting in pelvic inflammatory disease (PID). PID affects more than 1 million women in the United States every year and can cause infertility in as many as 10 percent of infected women and tubal (ectopic).

Symptoms of gonorrhoea
The incubation period varies from 2 to 14 days with most symptoms occurring between days 2 and 5 after being infected from an infected partner. A small number of people may be asymptomatic for several months.

Men
In male patients dysuria accompanied by thick, copious, purulent (condensed milk-like) urethral discharge is the most common presentation. Examination show a reddened external urethral meatus. This urethral inflammation accompanied by discharge, and sometimes the discharge itself, are occasionally called "leet." Without effective treatment, ascending infection could extend to the epididymis, testes or prostate causing symptoms such as scrotal pain or swelling.

Men and women with rectal gonorrhea may present with anal discharge, perianal pruritus, tenesmus and rectal bleeding. Proctoscopy shows inflamed mucous membrane with little mucous.

The fact sheet from the Center for Disease Control (CDC) states, "Many men with gonorrhea may have no symptoms at all, some men have some signs or symptoms that appear two to five days after infection; symptoms can take as long as 30 days to appear. Symptoms and signs include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. Sometimes men with gonorrhea get painful or swollen testicles."

Women
Between 30-60% of women with gonorrhoea are asymptomatic or subclinical. The patient may complain of a vaginal discharge, dysuria, intermenstrual bleeding or postcoital bleeding. The cervix may appear anywhere from normal to the extreme of marked cervicitis with a mucopurulent exudate. Involvement of the urethra causes little dysuria, purulent secretion and frequency. The combination of urethritis and cervicitis on examination is very suggestive of the diagnosis as both sites are infected in most patients.

More advanced symptoms, which may indicate development of pelvic inflammatory disease (PID), include cramps and pain, bleeding between menstrual periods, vomiting, or fever.

Complications
In men, epididymitis, prostatitis and urethral stricture can result from untreated gonorrhoea.

In women, Bartholinitis and abscess formation (causing trouble walking), pelvic inflammatory disease (PID) and Fitz-Hugh-Curtis syndrome can occur.

The most common result of untreated gonorrhoea is PID, a serious infection of the female reproductive tract. PID causes scarring of the fallopian tubes which leads to increased risks of causing an ectopic pregnancy as a fertilized egg may not be able to pass through the narrowed, scarred fallopian tube. Ectopic pregnancies are serious conditions which are potentially life-threatening to the mother.

In both sexes, disseminated gonococcal infection (DGI) can occur, leading to multiple distant sites of infection which can include the brain, heart and joints.

Diagnosis of gonorrhoea
Doctors or other health care workers usually use three laboratory techniques to diagnose gonorrhoea: staining samples directly for the bacterium, detection of bacterial genes or DNA in urine, and growing the bacteria in laboratory cultures. Many doctors prefer to use more than one test to increase the chance of an accurate diagnosis.

The staining test involves placing a smear of the discharge from the penis or the cervix on a slide and staining the smear with a dye. Then the doctor uses a microscope to look for bacteria on the slide. You usually can get the test results while in the office or clinic. This test is quite accurate for men but is not good in women. Only one in two women with gonorrhoea have a positive stain.

More often, doctors use urine or cervical swabs for a new test that detects the genes of the bacteria. These tests are as accurate or more so than culturing the bacteria, and many doctors use them.

The culture test involves placing a sample of the discharge onto a culture plate and incubating it up to 2 days to allow the bacteria to grow. The sensitivity of this test depends on the site from which the sample is taken. Cultures of cervical samples detect infection approximately 90 percent of the time. The doctor also can take a culture to detect gonorrhoea in the throat. Culture allows testing for drug-resistant bacteria.

Treatment
The mainstay of treatment is the appropriate use of antibiotics. An increase in antibiotic resistance has led to the decline in use of penicillin for treating gonorrhoea. Nowadays, a third generation cephalosporin such as ceftriaxone is recommended for treating gonorrhoea.

Doctors usually prescribe a single dose of one of the following antibiotics to treat gonorrhoea:


 * Cefixime 400 mg orally in a single dose, or
 * Ceftriaxone 125 mg intramuscular injection in a single dose, or
 * Ciprofloxacin 500 mg orally in a single dose, or
 * Ofloxacin 400 mg orally in a single dose, or
 * Levofloxacin 250 mg orally in a single dose

As co-infection with chlamydia is common, doctors often prescribe a combination of antibiotics, such as ceftriaxone and doxycycline or azithromycin, which will treat both diseases.

Follow up treatment is needed to ensure the organism has been eradicated. Sexual contacts should also be screened and treated if necessary.

Vertical transmission
Pregnant mothers infected with gonorrhoea, can transmit the disease to their babies during childbirth.

Gonococcal conjunctivitis is a major preventable cause of blindness in newborns so if there is a known risk of transmitting gonorrhoea, prophylactic silver nitrate or other medications may be applied to the baby's eyes immediately after birth.

Because of the risks of vertical transmission, doctors recommend that pregnant women have at least one test for gonorrhoea during pregnancy.

Protecting against gonorrhea
As gonorrhea is a STD, proper use of barrier contraceptives such as the latex condoms will significantly reduce the risk of getting gonorrhea and its complications. However, this does not eliminate risk. According to the Centers for Disease Control and Prevention, the only ways to eliminate risks is abstinence, or sex with a monogamous partner who has been previously tested.

Slang term "the clap"
Gonorrhoea is also commonly known by the slang term "the clap". One suggested etymology is from the Old French word "clapier", meaning "brothel". Another suggested source for the term is from a notorious 18th century keeper of a brothel, Margaret Clap (better known as "Mother Clap"), though perhaps her name itself was derived from the slang term. It could also refer to the painful sting in the male urethra, which feels like the sting of a clap when infected with the disease. Yet another suggested source refers to a traditional treatment used to clear the blockage in the urethra from gonorrhoea pus, where the penis would be "clapped" on both sides simultaneously. 

This term has, in recent years, come to be used by extension to refer to any unspecified sexually transmitted disease.