Organism Gonorrhoea is a bacterial disease caused by Neisseria gonorrhoeae (the gono-coccus).

Clinical features In the male, infection commences as a mucoid urethral secretion, which soon changes to a profuse, purulent discharge (as opposed to NGU where it is scanty, white, mucoid or serous). The discharge is best seen first thing in the morning (dew drop) and a smear should be made from this before the patient urinates. The main symptom is pain on micturition, but the degree of discomfort is very variable. In the female, the infection generally passes unnoticed, but may present with urethritis or acute salpingitis. It is this latter presentation of the disease that can lead, in an acute or chronic form of pelvic inflammatory disease, to sterility in the female. This is a serious problem in the unmarried woman and a cause of divorce in the married. In the male, untreated or improperly treated infection can result in urethral stricture, while generalized symptoms of arthritis, dermatitis or meningitis can rarely occur in either sex. In the pregnant woman, there is a danger of the newborn infant developing gonococcal conjunctivitis at the time of delivery. The discovery of this infection in the newborn infant may be the manner in which the infection is found in the woman.

Box 14.1 The control of sexually transmitted infections (STIs).

There has been a considerable increase in STI with new STIs appearing or their relative importance changing. Some of the reasons for these changes are:

• increasing world population, especially of younger age groups;

• urbanization and migrant labour;

• increasing travel and mixing of populations;

• alteration of social values and increasing promiscuity;

• development of contraceptive practice;

• ignorance of STI and lack of sex education;

• vulnerability of women biologically, culturally and socio-economically;

• inadequate treatment and development of resistant organisms.

International travel has allowed a mixing of cultural groups that would otherwise have remained isolated, potentiating the spread of different types and strains of STI. The development of resistant strains has posed a problem of imported cases to the developed world, but has left the developing world with an intolerable situation that they are economically unable to deal with.

STIs are more prevalent in young people, yet with an increasing world population, it is predominantly these younger age groups that are expanding at a more rapid rate than others. This increase in the youth of the world has thrown a greater strain on the education services so that health education, especially of STIs, is neglected.

Change has occurred in the social structure whereby traditional values and the monogamous married couple are no longer regarded as the norm. The development of contraceptives has freed the woman from the risk of unwanted pregnancy, but at the same time, increased the opportunity for developing an STI. Married women are particularly vulnerable when they are abandoned or their husbands have to find work away from the confines of the family. STIs are often asymptomatic in women so they do not seek treatment, putting their lives and those of any future children at greater risk.

Generally, the risk of developing an STI is more recognized, rather than the shock that previously led to concealment or recourse to treatment from a medical quack. Also contraceptive practice should not be discouraged for it is the problem of the rapidly expanding young population that is a major contributory factor. The key is health education with a combined approach of contraceptive advice and STI information. If this is to succeed there must be a considerable increase in treatment facilities, especially in urban areas. Standard treatment regimes should be decided by specialists and administered by primary healthcare workers. Improved treatment facilities, contact tracing, training of health workers and more effective drugs will not only reduce the prevalence and seriousness of STIs, but also of HIV infection.

Diagnosis Due to the similarity in presentation of gonococcal and non-gonocococcal urithritis, the emphasis is on making a diagnosis syndromically of a urethral discharge. A smear should be made and stained with Gram stain, the finding of Gram-negative intracellular diplococci indicating gonococ-cal infection. Where facilities permit, the discharge should be cultured, but as the organism is very sensitive, it must be inoculated on to a culture plate or placed in transport medium (less satisfactory) as soon as possible.

Transmission is by sexual intercourse or with contact of the infected mucous exud ate. N. gonorrhoeae is unable to penetrate stratified epithelium, but has a predilection for mucous membranes where it produces an accumulation of polymorphonuclear leucocytes and outpouring of serum to give the characteristic discharge.

Important factors in the transmission of gonorrhoea are:

• the short incubation period;

• the often asymptomatic disease in women (estimated to be 80%);

• promiscuous sexual intercourse;

• urbanization and changing social values;

• use of contraceptives;

• inadequate treatment.

The combination of a short incubation period and promiscuous sexual activity means that a large number of people can become infected in rapid succession. Since women are often largely unaware of their infection they serve as a continuous reservoir of the disease. Urbanization changes the social balance that occurs in the village, traditional values and taboos are lost and promiscuity develops. Contraceptives allow increased opportunity for sexual intercourse although the condom provides limited protection. The contraceptive pill by reducing the acidity of genital secretions removes some of the natural defences, while the intra-uterine contraceptive device encourages mechanical spread of infection to the uterus and tubes. Improper treatment both by doctors and quacks, usually with grossly inadequate doses of antibiotics, has led to chronic infections and the development of resistant organisms.

Incubation period 2-7 days (average 3 days).

Period of communicability can be months in untreated cases, especially hidden infections in women.

Occurrence and distribution The number of cases of gonorrhoea in the world today is estimated to be some 62 million. Underreporting, illegal treatment and the protection of contacts make any standard methods of case treatment and contact tracing quite inadequate in most developing countries. Gonorrhoea is not so much found as a reservoir in commercial sex workers as more widely distributed amongst the promiscuous under-25-year-olds.

Control and prevention Where possible, cases presenting at STI clinics should be encouraged to bring their partners (or provide information so that they can be traced) for counselling and treatment. Alternatively, contact cards can be sent anonymously to all contacts of a case, recommending them to present at a clinic. Condoms can be given out at the same time as a person presents at a clinic. Health education concentrating on the dangers of STIs is the main preventive action (see also under syphilis above and Box 14.1). The eyes of babies as they are being born should be wiped and a 1% aqueous solution of silver nitrate instilled (Section 7.7).

Treatment which used to be a simple matter with penicillin, is now fraught with problems of resistance not only to this antibiotic, but to many others that have subsequently been tried. Any recommended treatment regime may be ineffective in certain parts of the world and local expertise must be consulted to develop routines that are compatible with the resistance patterns and available resources. Recommended regimens are:

• ciprofloxacin 500 mg as a single oral dose (but not in pregnant women or children), or

• azithromycin 2 g orally as a single dose, or

• ceftriaxone 125 mg by single intramuscular injection, or

• cefixine 400 mg as a single oral dose, or

• spectinomycin 2 g by single intramuscular injection.

Patients diagnosed with gonorrhoea often have Chlamydia infection as well, so treatment for this condition should be combined as a routine (see below).

Surveillance Strains of the gonococcus resistant to the standard treatment regime in the country are likely to be imported from time to time, so sensitivity should be regularly tested and the treatment regime modified accordingly.

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