Gonorrhea
Gonorrhea is a common acute or chronic sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae (the gonococcus). The gonococcus has a particular affinity for the columnar and transitional epithelium lining the genital tract, anus, throat and the conjunctiva of the eye.
Unlike STIs that progress silently, N. gonorrhoeae in men usually triggers a vigorous inflammatory reaction, with urethritis producing thick yellow or green pus and intense burning. In women, by contrast, the infection is often hidden (more than 50–70% have no obvious symptoms), which leads to a high risk of serious complications such as pelvic inflammatory disease (PID), ectopic pregnancy and infertility from blocked fallopian tubes. The global rise of multidrug-resistant strains ("superbug gonorrhea") makes early diagnosis and correct treatment a top priority.
At Haute-Derma, gonorrhea is managed under a strict infection-control protocol: direct Gram-stain microscopy, real-time PCR molecular testing (NAAT), culture with antibiotic susceptibility testing, and high-dose intramuscular ceftriaxone with treatment for Chlamydia co-infection in line with the latest CDC and WHO recommendations.
How Neisseria gonorrhoeae Causes Disease
Surface Structures and Immune Evasion
- Neisseria gonorrhoeae is a Gram-negative diplococcus: coffee-bean-shaped bacteria that sit side by side in pairs.
- The bacteria use pili (fimbriae) and Opa (opacity-associated) proteins to latch firmly onto CD66/CEACAM receptors on the surface of mucosal epithelial cells.
- The gonococcus secretes IgA1 protease, which breaks down the secretory IgA antibodies of the mucosa, and it constantly changes the antigenic structure of its pili and LOS (lipo-oligosaccharide), a process called antigenic variation. As a result, the host cannot develop lasting immunity.
Cell Invasion and the Inflammatory Surge That Produces Pus
- Once attached, the bacteria trigger endocytosis to pass through the epithelial cells into the connective tissue below (the submucosa).
- LOS and peptidoglycan prompt local cells to release a flood of inflammatory cytokines (TNF-alpha, IL-1beta, IL-8), drawing large numbers of neutrophils (PMNs) into the infected site. The breakdown and incomplete phagocytosis of millions of neutrophils produce the typical thick, yellow-green pus.
Clinical Forms and Complications
Gonococcal Urethritis in Men:
- Incubation period: Very short, 2–5 days after unprotected sex.
- Symptoms: The urethral opening is red, swollen and slightly narrowed, with heavy discharge of thick dark-yellow or green pus (either spontaneously or when the urethra is milked). Patients have painful, frequent urination and describe a sensation like "broken glass" in the urethra every time they pass urine.
- Complications: Epididymitis (painful swelling on one side of the scrotum), seminal vesiculitis, prostatitis and fibrotic urethral stricture.
Gonococcal Cervicitis and Urethritis in Women:
- Key feature: More than 50–70% of cases have no symptoms, or symptoms so mild they are easily overlooked.
- Symptoms: Unusually heavy vaginal discharge (pale yellow or gray, with a bad odor), a red, congested cervix with mucopurulent discharge, pain during sex (dyspareunia), painful urination or light bleeding between periods.
- Complications: Pelvic inflammatory disease (PID), leading to tubal adhesions and blockage, a 7–10-fold higher risk of ectopic pregnancy and permanent infertility.
Extragenital Gonorrhea:
- Pharyngeal gonorrhea: Spread through oral sex. More than 90% have no symptoms; a few have a sore throat, a red, swollen throat lining and enlarged neck lymph nodes.
- Anorectal gonorrhea: Anal pain and burning, tenesmus, and pus or blood from the rectum.
- Disseminated gonococcal infection (DGI): The bacteria enter the bloodstream, causing fever, inflammation of several small joints (wrists, ankles) and scattered necrotic pustules on a red base on the hands and feet.
Differential Diagnosis of Urethral Discharge and Urethritis
| Gonorrhea (N. gonorrhoeae) | Chlamydia (C. trachomatis) | Mycoplasma genitalium |
|---|---|---|
| Thick, heavy, yellow/green pus | Scant clear or cloudy-white mucus | Slightly cloudy, persistent mucus |
| Very severe (like broken glass) | Mild to moderate, itching and burning | Mild burning, often recurrent |
| Incubation 2–5 days | Incubation 1–3 weeks | Incubation 1–3 weeks |
| Gram stain: Gram-negative diplococci inside white cells | Gram stain: no bacteria seen (intracellular) | Gram stain: no bacteria seen (no cell wall) |
How We Diagnose Gonorrhea at Haute-Derma
Direct Gram-Stain Microscopy:
- A sample of pus is taken from the urethra (men) or cervix (women).
- Diagnostic finding: Many coffee-bean-shaped Gram-negative diplococci (staining red/pink) inside neutrophils (intracellular Gram-negative diplococci). Sensitivity and specificity exceed 95% in men with urethral discharge.
NAAT / Real-Time PCR (Gold Standard): Multiplex real-time PCR detects gene sequences specific to N. gonorrhoeae in swabs from the urethra, cervix, throat or rectum, or in first-catch urine. Sensitivity exceeds 98%, and it is required for women, men without symptoms and extragenital infection.
Culture and Antibiotic Susceptibility Testing:
- Thayer–Martin agar, incubated in a CO2-enriched atmosphere.
- Required when treatment fails, when infection recurs, or when the gonococcus's resistance to ceftriaxone, ciprofloxacin or azithromycin needs to be assessed.
Treatment and Management of Drug Resistance at Haute-Derma
Antibiotic Regimens (CDC 2021 / WHO Guidelines)
Because gonococcal resistance to fluoroquinolones (ciprofloxacin) and penicillin is now widespread worldwide, first-line treatment is based on third-generation cephalosporins:
- Urethral, cervical, rectal or pharyngeal gonorrhea (preferred regimen): ceftriaxone 500 mg as a single deep intramuscular (IM) injection (for patients weighing > 150 kg, ceftriaxone 1 g IM).
- Mandatory co-treatment for Chlamydia (if Chlamydia has not been ruled out): add doxycycline 100 mg orally twice daily for 7 consecutive days (or azithromycin 1 g orally as a single dose in pregnancy).
- Severe cephalosporin / penicillin allergy: gentamicin 240 mg IM as a single dose PLUS azithromycin 2 g orally as a single dose.
Partner Management and Follow-Up (Test of Cure)
- Partner management: All sexual partners from the 60 days before symptoms began should be notified, examined and treated with the same gonorrhea/chlamydia regimen, even if they have no symptoms.
- Test of cure (TOC):
- Patients with pharyngeal or recurrent gonorrhea should have a repeat real-time PCR test 14 days after finishing treatment to confirm the infection has been fully cleared.
- Patients are advised to avoid all sexual contact for 7 days after the injection and until their partners have also completed treatment.
