By:

Shazleen Farhana
Anggun Lestary
Advisor:
dr. Diana Muchsin
Supervisor:
dr. Asnawi Madjid, Sp.KK, MARS

Gonorrhea
A sexually transmitted infection (STI), also termed
venereal disease that is caused by Neiserria
gonorrheae.
Affects the mucosa and the transitional
epithelium; typically leading to urethritis in men
and to an often asymptomatic cervitis in women.
Epidemiology
Disease rates are unknown for most countries but
it is widely thought that rates of the disease and its
complications are very much higher in the
developing countries of Africa, Asia and Latin
America.
The highest rates of infection occur in young
people, especially in teenage women and men in
their early twenties.
Etiology
Gonorrhea is caused by Neiserria gonorrhea, the gram-
negative, aerobic coccus-shaped bacterium found in
pairs.
N. gonorrhea principally infects the columnar
epithelium. Outside the human host the organism is
delicate, but within the body it has a large capability to
effect antigenic variation that helps it evade the host
immune response and to develop antimicrobial
resistance.
Pathogenesis
Gonorrhea is acquired through sexual contact, or,
less commonly, as a result of poor hygiene or
medical use of urine.
It can also be transmitted vertically from mother to
child during birth.
Attachment to columnar epithelial cells via
pili or fimbriae.
Outer membrane proteins, PilC and Opa,
on the bacteria aid in attachment and local
invasion.
Once inside the cell, the organism
undergoes replication and can grow in
both aerobic and anaerobic environments.
After cell invasion, the organism replicates
and proliferates locally, inducing an
inflammatory response.
Clinical Features
N. gonorrhea infection tends to involve mucous
membranes consisting of columnar epithelial cells.
The urethra, cervix, pharynx, and conjunctiva are
the areas most commonly involved.
The incubation period is short and symptoms
typically have their onset 15 days after sexual
contact with an infective person.
Localized disease in men
The incubation period for the bacteria in men
ranges from 2 to 8 days, with most infections being
symptomatic after 2 weeks.
Only 10% of infections are asymptomatic in men.
The most common being urethritis, followed by
proctitis, and a rarer pharyngitis.
Urethritis
The most common manifestation of gonococcal
infection in men is urethritis, characterized by
cloudy or purulent discharge from the penile
meatus.
Mucosal membrane inflammation in the anterior
urethra leads to painful urination and surrounding
redness and swelling.
Testicular pain and swelling may indicate
epididymitis or orchitis and may be the only
presenting symptom.
Gonococcal urethritis in men
Proctitis
Another manifestation of gonococcal infection
with symptoms including rectal mucopurulent
discharge, pain on defecation, constipation and
tenesmus.
Usually occurs in individuals who engage in
anoreceptive intercourse and more commonly in
homosexual men.
Proctitis in a patient
with gonorrhea
Localized disease in women
50% of women infected N. gonorrhea are
asymptomatic.
The endocervix is a common site of local infection
and invasion by organisms.
Manifestations in women include cervicitis,
urethritis and bartholin ducts.
Cervicitis
Endocervical infection may appear as a
nonspecific, pale-yellow vaginal discharge, but in
many cases this is not detected or is accepted as
being a normal variation.
The cervix may appear normal, or it may show
marked inflammatory changes with cervical
erosions and pus exuding from the os. Skene's
glands, which lie on either side of the urinary
meatus, exude pus if infected.
Cervitis in a patient
with gonorrhea
Urethritis
Begins with frequency and dysuria after a 3- to 5-
day incubation period. These symptoms are of
variable intensity.
Other symptoms may include mucopurulent
discharge and vaginal pruritus.
Pus may be seen exuding from the red external
urinary meatus or after the urethra is milked
with a finger in the vagina.
Bartholin ducts
The Bartholin ducts, which open on the inner
surfaces of the labia minora at the junction of their
middle and posterior thirds near the vaginal
opening, may, if infected, show a drop of pus at the
gland orifice.
After occlusion of the infected duct, the patient
complains of swelling and discomfort while
walking or sitting.

Newborns and children
Gonococcal conjunctivitis is more often associated
with newborn babies as ophthalmia neonatorum,
which usually occurs in the first week after birth.

Diagnosis
Bacterial culture has been the gold standard
diagnostic test for years.
In men, culture and Grams stain are performed on
secretions or urethral swabs.
Endocervical and endourethral specimens for
culture and Grams stain have yielded more
accurate results than testing vaginal secretions in
women.
Culture can be performed on modified Thayer-
Martin medium.
Diagnostic Gram-stained smear of
urethral discharge of a man with acute
gonorrhea. Gonococci (red) with a
polymorphonuclear leucocyte.
Differential Diagnosis
Urethritis Non
Gonorrhoea
Serous
urethral
secretion
Meatal
erythema
Trichomoniasis
Purulent
vaginal
secretion
Vaginal
mucosa
erythema
Candidiasis
Vulvovaginalis
Vulva pruritus
Cloudy
vaginal
secretion
Bacterial
Vaginosis
Foul odor
Homogenous
vaginal
secretion
Differential Diagnosis
Urethritis Non Gonorrhoea
Trichomoniasis
Differential Diagnosis
Candidiasis Vulvovaginalis
Bacterial Vaginosis
Management
Uncomplicated anogenital infection in adults
Ceftriaxone 250 mg i.m. as a single dose
Cefi xime 400 mg orally as a single dose
Spectinomycin 2 g i.m. as a single dose

Pregnancy and breastfeeding
The above regimens are suitable for pregnant women
In addition, where regional prevalence of penicillin-
resistant N. gonorrhoeae is 5%
Amoxycillin 3 g plus probenecid 1 g orally as a single dose
Ampicillin 2 g plus probenecid 1 g orally as a single dose
Complications
May occur as a result of local abscess formation, from
ascending infections and from haematogenous spread.
Periurethral abscess may occur in either sex and lead
to fistula formation and subsequent urethral stricture.
Ascending infection in men causes acute prostatitis,
with symptoms of urinary frequency and stranguria.
In women, ascending infections cause PID. There may
be a marked adnexal and cervical motion tenderness
on bimanual pelvic examination.