Gonorrhea

Gonorrhea is a sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. The usual symptoms in men are a burning with urination and discharge from the penis. Women have no symptoms about half the time or have vaginal discharge and pelvic pain. In both men and women, if gonorrhea is left untreated, it may spread locally, causing inflammation of the epididymis in men or pelvic inflammatory disease in women. Gonorrhea can also spread throughout the body and affect joints and heart valves.

Testing all women who are sexually active and less than 25 years of age each year is recommended. This same recommendation applies in men who have sex with men.

Gonorrhea can be prevented with the use of condoms. Treatment is usually with ceftriaxone, as resistance has developed to many previously used antibiotics. Ceftriaxone is typically given in combination with either azithromycin or doxycycline, as gonorrhea infections may occur along with chlamydia. Some strains of gonorrhea have begun showing resistance to this treatment. Retesting is recommended three months after treatment.

An estimated 78 to 88 million cases of gonorrhea occur each year, out of the 448 million new cases of curable STI – which also includes syphilis, chlamydia and trichomoniasis. Infections in women most commonly occur when they are young adults. In 2010, it caused about 900 deaths, down from 1,100 in 1990.

Signs and symptoms
Half of women with gonorrhea do not have symptoms, whereas others have vaginal discharge, lower abdominal pain, or pain with sexual intercourse associated with inflammation of the uterine cervix. Most infected men with symptoms have inflammation of the penile urethra associated with a burning sensation during urination and discharge from the penis. In men, discharge with or without burning occurs in half of all cases and is the most common symptom of the infection. Men and women can acquire gonorrhea of the throat from performing oral sex on an infected partner, usually a male partner. Such infection does not produce symptoms in 90% of cases, and produces a sore throat in the remaining 10%. In advanced cases, gonorrhea may cause a general feeling of tiredness similar to other infections. It is also possible for an individual to have an allergic reaction to the bacteria, in which case any appearing symptoms will be greatly intensified.

The incubation period is 2 to 14 days, with most symptoms appearing between 4 and 6 days after infection. Rarely, gonorrhea may cause skin lesions and joint infection (pain and swelling in the joints) after traveling through the blood stream (see below). Very rarely it may settle in the heart causing endocarditis or in the spinal column causing meningitis (both are more likely among individuals with suppressed immune systems, however).

One case in a man's lifetime is associated with the risk of developing prostate cancer.

Cause
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae.

Spread
The infection is usually spread from one person to another through vaginal, oral, or anal sex. Men have a 20% risk of getting the infection from a single act of vaginal intercourse with an infected woman. The risk for men that have sex with men is higher. Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man. A pregnant women can pass on the infection to her unborn infant.

A mother may transmit gonorrhea to her newborn during childbirth; when affecting the infant's eyes, it is referred to as ophthalmia neonatorum.

Among children it has been noted to spread through methods other than sex such as through contaminated objects. These objects have included baths, clothing, and towels. This however is very uncommon.

Diagnosis
Traditionally, gonorrhea was diagnosed with gram stain and culture; however, newer polymerase chain reaction (PCR)-based testing methods are becoming more common. In those failing initial treatment, culture should be done to determine sensitivity to antibiotics. All people testing positive for gonorrhea should be tested for other sexually transmitted diseases such as chlamydia, syphilis, and human immunodeficiency virus.

Screening
The United States Preventive Services Task Force (USPSTF) recommends screening for gonorrhea in women at increased risk of infection, which includes all sexually active women younger than 25 years. Extragenital gonorrhea and chlamydia are highest in men who have sex with men. Additionally, the USPSTF also recommends routine screening in women who have previously tested positive for gonorrhea or have multiple sexual partners and individuals who use condoms inconsistently, provide sexual favors for money, or have sex while under the influence of alcohol or drugs.

Screening for gonorrhea in women who are (or intend to become) pregnant, and who are found to be at high risk for sexually transmitted diseases, is recommended as part of prenatal care in the United States.

Prevention
As with most sexually transmitted diseases, the risk of infection can be reduced significantly by the correct use of condoms and can be removed almost entirely by limiting sexual activities to a mutually monogamous relationship with an uninfected person.

Those previously infected are encouraged to return for follow up care to make sure that the infection has been eliminated. In addition to the use of phone contact, the use of email and text messaging have been found to improve the re-testing for infection.

Management
As of 2010, injectable ceftriaxone appears to be one of the few effective antibiotics. This is typically given in combination with either azithromycin or doxycycline. Because of increasing rates of antibiotic resistance local susceptibility patterns must be taken into account when deciding on treatment.

Many antibiotics that were once effective including penicillin, tetracycline, and fluoroquinolones are no longer recommended because of high rates of resistance. Resistance to cefixime has reached a level such that it is no longer recommended as a first-line agent in the United States, and if it is used a person should be tested again after a week to determine whether the infection still persists. Cases of resistance to ceftriaxone have been reported but are still rare, though public health officials are concerned that an emerging pattern of resistance may predict a global epidemic.

The UK's Health Protection Agency reported that 2011 saw a slight drop in gonorrhea antibiotic resistance, the first in 5 years.

It is recommended that sexual partners be tested and potentially treated. One option for treating sexual partners of people infected is patient-delivered partner therapy (PDPT), which involves providing prescriptions or medications to the person to take to his/her partner without the healthcare provider's first examining him/her.

The United States' Centers for Disease Control and Prevention (CDC) currently recommend that individuals who have been diagnosed and treated for gonorrhea avoid sexual contact with others until at least one week past the final day of treatment in order to prevent the spread of the bacterium. Also, previous infection does not confer any immunity, and a person who has been infected can easily become infected again by exposure to someone who is a carrier for the bacterium, whether or not that person has any infectious signs or symptoms of their own.

Like the bacteria that cause syphilis, these fragile, "fastidious" bacteria cannot sustain themselves outside the body and will rapidly die within minutes to hours. Soap and water can effectively remove the bacteria from the hands, and washing bedding and clothing is seldom necessary. The chlorine of most swimming pools destroys it immediately.

Prognosis


Gonorrhea if left untreated may last for weeks or months with higher risks of complications. One of the complications of gonorrhea is systemic dissemination resulting in skin pustules or petechia, septic arthritis, meningitis, or endocarditis. This occurs in between 0.6 and 3% of infected women and 0.4 and 0.7% of infected men.

In men, inflammation of the epididymis, prostate gland, and urethra can result from untreated gonorrhea. In women, the most common result of untreated gonorrhea is pelvic inflammatory disease. Other complications include inflammation of the tissue surrounding the liver, a rare complication associated with Fitz-Hugh-Curtis syndrome; septic arthritis in the fingers, wrists, toes, and ankles; septic abortion; chorioamnionitis during pregnancy; neonatal or adult blindness from conjunctivitis; and infertility. Men who have had a gonorrhea infection have an increased risk of getting prostate cancer.

Newborn babies coming through the birth canal are given erythromycin ointment in the eyes to prevent blindness from infection. The underlying gonorrhea should be treated; if this is done then usually a good prognosis will follow. Adults may also have eyes infected with gonorrhoea and require proper personal hygiene and medications.

Among persons in the United States between 14 and 39 years of age, 46% of people with gonorrheal infection also have chlamydial infection.

Epidemiology
Gonorrhoea world map - DALY - WHO2004.svg for gonorrhea per 100, 000 inhabitants.

{{legend|#b3b3b3|no data}} {{legend|#ffff65|<13}} {{legend|#fff200|13–26}} {{legend|#ffdc00|26–39}} {{legend|#ffc600|39–52}} {{legend|#ffb000|52–65}} {{legend|#ff9a00|65–78}}

{{legend|#ff8400|78–91}} {{legend|#ff6e00|91–104}} {{legend|#ff5800|104–117}} {{legend|#ff4200|117–130}} {{legend|#ff2c00|130–143}} {{legend|#cb0000|>143}} ]] The World Health Organization estimates that 88 million cases of gonorrhea occur each year, out of the 448 million new cases of all curable STI each year – that also includes syphilis, chlamydia and trichomoniasis. As of 2010, it caused about 900 deaths down from 1,100 in 1990.

In the United Kingdom, 196 per 100,000 males 20 to 24 years old and 133 per 100,000 females 16 to 19 years old were diagnosed in 2005. In 2013, the CDC estimated that more than 820,000 people in the United States get a new gonorrheal infections each year. Fewer than half of these infections are reported to CDC. In 2011, 321,849 cases of gonorrhea were reported to the CDC. After the implementation of a national gonorrhea control program in the mid-1970s, the national gonorrhea rate declined from 1975 to 1997. After a small increase in 1998, the gonorrhea rate has decreased slightly since 1999. In 2004, the rate of reported gonorrheal infections was 113. 5 per 100,000 persons.

In the US, it is the second-most-common bacterial sexually transmitted infections; chlamydia remains first. According to the CDC, "Overall, African Americans are most affected by gonorrhea. Blacks accounted for 69% of all gonorrhea cases in 2010."

History
Some scholars translate the biblical terms zav (for a male) and zavah (for a female) as gonorrhea.

It has been suggested that mercury was used as a treatment for gonorrhea. Surgeons' tools on board the recovered English warship the Mary Rose included a syringe that, according to some, was used to inject the mercury via the urinary meatus into any unfortunate crewman suffering from gonorrhea. The name "the clap", in reference to the disease, is recorded as early as the sixteenth century.

Silver nitrate was one of the widely used drugs in the 19th century. However, It became replaced by Protargol. Arthur Eichengrün invented this type of colloidal silver, which was marketed by Bayer from 1897 on. The silver-based treatment was used until the first antibiotics came into use in the 1940s.

The exact time of onset of gonorrhea as prevalent disease or epidemic cannot be accurately determined from the historical record. One of the first reliable notations occurs in the Acts of the (English) Parliament. In 1161, this body passed a law to reduce the spread of "...the perilous infirmity of burning". The symptoms described are consistent with, but not diagnostic of, gonorrhea. A similar decree was passed by Louis IX in France in 1256, replacing regulation with banishment. Similar symptoms were noted at the siege of Acre by Crusaders.

Coincidental to, or dependent on, the appearance of a gonorrhea epidemic, several changes occurred in European medieval society. Cities hired public health doctors to treat afflicted patients without right of refusal. Pope Boniface rescinded the requirement that physicians complete studies for the lower orders of the Catholic priesthood.

Medieval public health physicians in the employ of their cities were required to treat prostitutes infected with the "burning", as well as lepers and other epidemic victims. After Pope Boniface completely secularized the practice of medicine, physicians were more willing to treat a sexually transmitted disease.

Human experiments were conducted by the United States in Guatemala from 1946 to 1948 to find a cure for syphilis and gonorrhea. The United States formally apologized to Guatemala in 2010.

Research
A vaccine for gonorrhea has been developed that is effective in mice. It will not be available for human use until further studies have demonstrated that it is both safe and effective in the human population.