Gonorrhea, also called Gonorrhoea, is a sexually transmitted infection (STI), caused by a bacteria called Neisseria gonorrhoeae. It affects both males and females and is one of the most common STIs globally. More than half of the infected patients belong to the age group of < 25 years. Any form of unprotected sexual contact with an infected individual can transmit the disease. The bacteria primarily infects the reproductive organs, rectum, and the oropharynx.
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What is the cause of Gonorrhea?
Gonorrhea is caused by a bacteria Neisseria gonorrhoeae. Microbiologically, Neisseria gonorrhoeae is a Gram-negative diplococcus bacteria. This means that the bacteria is round shaped, occurs in pairs, and stains negative on the gram stain. The symptoms usually start appearing after 2 to 8 days of contracting the infection.
This bacteria is transmitted by unprotected intimate sexual contact with an infected partner. Any form of sexual contact – vagina, oral, or anal can transmit the infection. Infected mothers can also transmit the disease to their newborn babies during childbirth.
Transmission of Gonorrhea
Gonorrhea can spread by:
- Sexual contact: Unprotected intimate sexual contact with an infected partner is the main source of transmission of gonorrhea. Contact with any infected body fluid of an infected partner, whether it is the vaginal secretions, semen, or blood, can transmit the infection. This means that all forms of sexual intercourse – vaginal, anal, or oral sex, can transmit the bacteria and cause gonorrhea.
- Vertical transmission: Newborn babies can get the infection from their infected mother during the delivery process. This can lead to a serious neonatal eye infection called Neonatal Conjunctivitis.
The disease is not transmitted by casual contact like hugging, kissing, or holding hands or by sharing the same household, bed, toilet, utensils, etc.
Risk factors for Gonorrhea
Since gonorrhea is a sexually transmitted infection and many infected individuals are asymptomatic, all sexually active people who practice unprotected sex, are at risk. The risk of transmission is higher if:
- You are aged 25 years and younger.
- You have more than one sexual partner.
- You have only one sexual partner only but your partner has other sexual partners.
- You practice unprotected sexual intercourse (without the use of condoms).
- If you have sexual contact with someone infected with other STIs like syphilis or chlamydia. This is important as gonococcal infection is commonly seen as a coinfection in individuals who have syphilis or chlamydia.
Symptoms of Gonorrhea
Gonorrhea remains asymptomatic in many people. Even when the symptoms are present, they can be very vague and nonspecific. The genital symptoms are the most common symptoms in symptomatic people.
SYMPTOMS IN MEN
- Painful or burning sensation during urination (dysuria) is one of the initial symptoms in men.
- Purulent (pus-like) or mucopurulent discharge from the penis due to infection of the urethra.
- Purulent discharge from the rectum, with pain and irritation due to rectal infection.
- Painful, red, swollen testis due to infection of epididymis in the testis.
- Difficulty in swallowing, sore throat, and enlarged neck lymph nodes when the throat is infected.
- Untreated infection can cause infection and extensive inflammation of the prostate, epididymis, and urethra, leading to long-term problems like prostatitis, epididymitis, and urethral strictures.
SYMPTOMS IN WOMEN
- Painful or burning sensation during urination (dysuria), with increased urinary frequency.
- Purulent (pus-like) or mucopurulent discharge in the urine due to infection of the urethra.
- Purulent, or greenish-yellow vaginal discharge due to infection of the cervix and the uterus.
- Pelvic pain or a feeling of deep-seated dragging feel in the pelvis.
- Pain during sexual intercourse (dyspareunia).
- Intermenstrual bleeding: This means that vaginal bleeding may occur in between periods.
- Swelling and pain over the labia: due to infection of the Bartholin’s glands present on the inner side of the labia (Bartholinitis).
Diagnosis
The diagnosis of gonorrhea is based on your symptoms, physical examination, and certain laboratory tests ordered by your healthcare provider. In addition, your healthcare provider may also get you tested for chlamydia and syphilis which frequently occur as co-infections with gonorrhea.
- History: Your doctor will take a detailed history of your symptoms, especially your sexual history. This may include:
- your current symptoms
- how many sexual partners you have
- whether you practice protected or unprotected sex (use of condoms)
- any known intimate sexual contact to a partner with a sexually transmitted disease
- whether you have been diagnosed with a sexually transmitted infection before
- Physical examination: Your healthcare provider may do a pelvic, rectal or throat exam. Findings suggestive of gonorrhea may include a mucopurulent or purulent discharge from the vagina or penis, enlarged lymph nodes near the site of infection, inflamed and swollen labia, inflamed rectum, inflamed pharynx, etc.
- Laboratory tests: For laboratory confirmation of the diagnosis, morning first urine sample and swab samples obtained from the affected areas like the cervix, penis, rectum, or throat are sent for the following tests:
- Nucleic acid amplification test (NAAT): NAAT is the test of choice as it is an extremely sensitive and specific test for the diagnosis of gonorrhea.
- Gram stain: Gram staining of samples from affected areas show Gram negative, diplococci.
- Culture: Samples are also sent for culture to identify the bacteria and to test various antibiotics for their sensitivity or resistance to the isolated organism.
Complications
- Pelvic inflammatory disease (PID): Infection of the upper reproductive organs like the uterus, fallopian tubes, and ovaries in females is called Pelvic Inflammatory Disease. This can cause symptoms such as fever, abnormal vaginal discharge, abnormal vaginal bleeding, pelvic pain, painful urination (dysuria), or painful sexual intercourse (dyspareunia). Untreated acute PID can progress to Chronic PID, leading to complications like chronic pelvic pain, infertility, or ectopic pregnancy.
- Infertility: Infection of the uterus and fallopian tubes by Neisseria gonorrhoeae can lead to infertility in women by causing adhesions in the uterus and scarring of the fallopian tubes. Infection and inflammation of the epididymis in the testis can lead to infertility in men.
- Prostatitis and epididymitis in men: Untreated gonococcal infection can infect the prostate causing Prostatitis and epididymis in the testis causing epididymitis. This leads to pelvic inflammatory pain, abnormal purulent discharge and infertility in men.
- Disseminated gonococcal infection (DGI): Sometimes the gonococcal infection may travel through the blood to other parts of the body. It may affect the joints causing Localized Septic Arthritis in joints like wrists, ankles or elbows, or cause Tenosynovitis of multiple joints with joint pains. It can also produce systemic symptoms like fever and rash. Rarely it may affect the brain causing meningitis or the heart causing endocarditis.
- More than 50% of the infected individuals are asymptomatic. This means that many infected individuals do not have any symptoms and are unaware of their infection. So they can unknowingly transmit the infection to their partners during unprotected sexual intercourse. This makes the disease transmission difficult to prevent and makes the use of barrier methods like condoms extremely important during sexual intercourse, especially if you have more than one partner and if you are currently not planning to get pregnant.
- Coinfection: Gonorrhea is frequently seen in association with other sexually transmitted infections like syphilis, chlamydia, HIV, etc. So both partners and their other sexual partners should be screened for other STIs like syphilis, chlamydia, and HIV, in addition to gonorrhea.
Prevention
Strategies that can help your chances of contracting gonorrhea and any other sexually transmitted infection in general, are as follows:
- A strictly mutual monogamous relationship: Short of total abstinence of sexual activity, a strictly mutual monogamous relationship between two noninfected partners, is the best way to prevent gonorrhea. This means that even if you have only one sexual partner, you can still get gonorrhea if your partner has other sexual partners. So both partners should have no other sexual partners, except each other.
- Limiting the number of sexual partners: If you have more than one sexual partner, you should try to limit the number of your sexual partners and use barrier contraception.
- Avoid sexual partners who have gonorrhea or any other sexually transmitted infection.
- Use condoms: Use of condoms (see Barrier methods of contraception) during any form of sexual activity, significantly reduces the transmission of gonorrhea.
- Regular gonorrhea screening: Since most people with gonorrhea are asymptomatic, people who have more number of sexual partners or practice unprotected sex, should regular screening for gonorrhea and other STIs. This can help in the early detection of asymptomatic cases, thereby preventing transmission to others.
- Partner notification: If you have been diagnosed with gonorrhea, you should notify your partners to get tested, so that they can also be treated at the same time as you. This prevents reinfection from each other again and again
Treatment
Since gonorrhea is caused by a bacteria, it is treated with antibiotics. The main principles of treatment are:
- Earlier, a single dose of intramuscular ceftriaxone was used for treatment.
- Nowadays, due to increasing antibiotic resistance, intramuscular ceftriaxone in higher doses is used, along with an oral antibiotic called azithromycin. Another antibiotic called doxycycline may be used, in case of coinfections or allergy to any of the above medicines. The exact dose, frequency, and duration of treatment for you will be decided by your healthcare provider.
- For disseminated gonococcal infection, the same antibiotics are used, but in much higher doses and for longer periods.
- If a person is diagnosed with gonorrhea, then treatment should be started as soon as possible as untreated gonorrhea leads to long-term symptoms and complications.
- Both sexual partners and their other sexual partners must be treated for gonorrhea at the same time, so as to prevent reinfection from each other.
- After completion of treatment, both partners should get tested to ensure that they are cured completely and no traces of infection is left.
- Both partners should abstain from any kind of sexual activity till the treatment is complete and follow-up tests indicate that the infection has been completely cured.
- Once cured, you can get gonorrhea again, as infection with gonorrhea does not offer future immunity. So safe sexual practices are very important and should be strictly followed.
Carry home message
Gonorrhea is very common sexually transmitted disease. It is caused by a bacteria Neisseria gonorrhoeae and affects both men and women. It gets transmitted by unprotected sexual intercourse with an infected partner. All forms of sexual contact – vaginal, anal or oral can transmit the bacteria.
It is treatable with antibiotics, but treatment should be started as soon as possible as untreated gonococcal infection leads to many long-term complications like infertility. It may also spread through the bloodstream to other organs like joints, brain, heart and the damage caused may be impossible to revert back.
It is even more easily preventable by staying committed to one sexual partner (monogamous relationship), or having fewer sexual partners, and using condoms during intercourse. Stay safe and stay healthy!
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