Gonorrhea is a sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, characterized primarily by purulent infections of the genitourinary system. It may also involve the eyes, pharynx, rectum, or manifest as disseminated gonococcal infection (DGI). It has a short incubation period, is highly contagious, and can lead to various complications and sequelae.
Factors Associated with Onset
Neisseria gonorrhoeae (commonly referred to as gonococci) are Gram-negative cocci lacking flagella and spores. Humans are their only natural host. Gonococci primarily invade the mucous membranes of the genitourinary tract, causing lysis and rupture of mucosal cells, resulting in congestion, edema, and purulence. If timely diagnosis and treatment are not provided, the infection can progress to a chronic stage.
Modes of Transmission
The primary mode of transmission is through sexual contact. In rare cases, transmission can occur via contact with secretions containing gonococci or contaminated clothing or objects. Pregnant women with gonococcal infection can transmit the bacteria to the fetus in utero through involvement of the chorion and amnion. During childbirth, neonates passing through an infected mother's birth canal may contract gonococcal conjunctivitis (ophthalmia neonatorum).
Effects on Mother and Infant
Gonococcal infection during pregnancy negatively impacts pregnancy outcomes across all trimesters. Gonococcal cervicitis in early pregnancy can cause infectious miscarriage and post-miscarriage infections. In late pregnancy, the infection may increase membrane fragility, leading to chorioamnionitis, intrauterine infection, fetal distress, restricted fetal growth, stillbirth, premature rupture of membranes, and preterm birth.
Postpartum, reduced maternal immunity can result in dissemination of gonorrhea, causing puerperal infections such as endometritis or salpingitis. Severe cases may lead to disseminated gonorrhea. Approximately one-third of neonates born to untreated mothers contract Neisseria gonorrhoeae through vaginal delivery, potentially leading to neonatal gonococcal conjunctivitis, pneumonia, or even sepsis, increasing perinatal mortality rates.
Clinical Manifestations
Uncomplicated Gonorrhea
The infection primarily affects the lower genitourinary tract. Gonococcal cervicitis is the most common presentation, characterized by increased vaginal mucopurulent discharge, vulvar itching, or a burning sensation. Gynecological examination may reveal cervical edema, congestion, and purulent discharge. Other possible manifestations include urethritis, paraurethral gland inflammation, or Bartholin's gland inflammation.
Complicated Gonorrhea
About 10–20% of patients develop complicated gonorrhea. During the acute phase, symptoms may include abdominal pain, dyspareunia, abnormal vaginal bleeding, and fever. Gynecological examinations may reveal signs of typical pelvic inflammatory disease (PID). Improper or incomplete treatment can lead to recurrent infections, infertility, tubal pregnancy, or chronic pelvic pain. Disseminated gonorrhea, caused by hematogenous spread, may present with fever, chills, and arthritis-dermatitis syndrome, though such cases are relatively rare.
Diagnosis and Differential Diagnosis
Diagnosis is established based on medical history, clinical manifestations, and laboratory tests. Laboratory investigations include:
- Nucleic Acid Amplification Test (NAAT): Highly sensitive and suitable for a variety of genitourinary samples.
- Culture: Highly specific but less sensitive compared to NAAT. This method is particularly useful for cases with treatment failure or suspected drug-resistant strains.
- Gram Staining: Not the primary diagnostic method, as other nonpathogenic Gram-negative cocci may be present in cervical secretions.
- Antigen Testing: Uses enzyme immunoassay (EIA) to detect gonococcal antigens in cervical swabs or urine samples; however, this approach is not widely adopted.
Differential diagnoses include infections caused by other sexually transmitted pathogens, such as Chlamydia trachomatis, herpes simplex virus, Treponema pallidum, as well as conditions like trichomoniasis, vulvovaginal candidiasis, and non-gonococcal urethritis.
Treatment
The treatment principle involves prompt administration of adequate, standardized antimicrobial therapy.
Treatment for Uncomplicated Gonorrhea
This includes:
- Recommended regimens: A single dose of ceftriaxone 0.5g or 1g by intramuscular or intravenous injection; or spectinomycin 2g (4g for cervicitis) via a single intramuscular injection.
- Alternative regimens: A single intramuscular injection of cefotaxime 1g, or other third-generation cephalosporins with demonstrated efficacy. If Chlamydia trachomatis coinfection cannot be excluded, anti-chlamydial agents should also be administered.
Treatment for Complicated Gonorrhea
This includes:
- Ceftriaxone 1g by intramuscular or intravenous injection once daily for 10 days, in combination with doxycycline 0.1g orally twice daily for 14 days.
- For gonococcal pelvic inflammatory disease, also combine metronidazole 0.4g orally twice daily for 14 days.
Treatment During Pregnancy
Pregnant women with gonorrhea should follow the appropriate treatment regimens for non-pregnant patients according to the infection type. For pregnant women with suspected Chlamydia coinfection, azithromycin or erythromycin is recommended.
Management During Labor and Delivery
Gonorrhea during pregnancy is not an indication for cesarean delivery. Treatment can be administered during labor and postpartum for both the mother and the newborn. Post-delivery, neonates should promptly receive 0.5% erythromycin eye ointment to prevent gonococcal conjunctivitis. Prophylactic ceftriaxone at 20–50 mg/kg (maximum dose not exceeding 250 mg) via a single intramuscular or intravenous injection is also recommended. The possibility of neonatal disseminated gonorrhea should be closely monitored, as delayed treatment may result in neonatal mortality.
Follow-Up
All patients, including pregnant women, should undergo follow-up 2 weeks to 3 months after treatment. Pregnant women at continued high risk for gonorrhea should undergo reevaluation in late pregnancy.