Gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae that is transmitted through sexual contact. It is estimated that 98 million new cases occur annually worldwide. Common symptoms include abnormal discharge, burning during urination, and pelvic pain. Diagnosis involves testing samples from the affected area. Treatment consists of a single dose of ceftriaxone and azithromycin. Left untreated, gonorrhea can cause pelvic inflammatory disease and increase risk of infertility.

1. Gonorrhea
A bacterial infection that is transmitted by sexual contact caused by the
Neisseria gonorrhoeae bacteria.
Epidemiology
An estimated 98 million new cases of gonorrhea occur annually.
(according to World Health Organization,2018, sep o7)
Cause
Neisseria gonorrhoeae bacteria.
Risk factors
• Sexual exposure to an infected partner without barrier protection (eg,
failure to use a condom or condom failure) [13]
• Multiple sex partners
• Male homosexuality
• Low socioeconomic status
• Minority status - Blacks, Hispanics, and Native Americans have the
highest rates in the United States
• History of concurrent or past STDs
• Exchange of sex for drugs or money
• Use of crack cocaine
• Early age of onset of sexual activity
• Pelvic inflammatory disease (PID) - Use of an intrauterine device
(IUD)
Sign and symptoms
50% of patients are asymptomatic and nonspecific
i. Local
ii. Distant or metastatic
iii. PID

2. I) Local
Symptoms
a. Urinary symptoms such as dysuria or frequent micturition
(25%)
b. Excessive irritant vaginal discharge (50%)
c. Acute unilateral pain and swelling over the labia due to
involvement of Bartholin’s gland
d. Rectal discomfort due to associated proctitis from genital
contamination
e. Others: pharyngeal infection, intermenstrual bleeding
Signs
a) Inflamed labia
b) Mucopurulent vaginal discharge
c) Burning or itching vaginal area
d) Bartholin gland may be palpably enlarged, tender with
fluctuation, suggestive of formation of abscess
e) Speculum examination reveals congested ectocervix with
increased mucopurulent cervical secretions escaping out
through the external os
II) Distant or metastatic
• There may be features of perihepatitis and septicemia
• Septicemia is characterized by
i. Low grade fever
ii. Polyarthralgia
iii. Tenosynovitis

3. iv. Septic arthritis
v. Meningitis
vi. Endocarditis
vii. Skin rash
III) PID
• Occurs in 10%-40% of cases
i. Fever
ii. Pelvic cramping
iii. Abdominal pain
iv. Dyspareunia
v. May leads to infertility and miscarriage
Diagnosis
a. History taking:
• Present history: sign and symptoms like rashes, chancre,
genital ulcers
• Sexual history: number of sexual partners, duration of sexual
relationship
• 5 p’s (partners, practices, prevention from pregnancy,
protection from STDs and past history of STDs)
• Exposure to infected person
b. Examinations
• Bimanual examination
Inspection of vagina, cervix, anus
Cervical inspection through speculum to check edema,
ectopy, friability
Per vaginal examination to check the discharge,
soreness, edema
c. Urine test. This can help identify bacteria in your urethra.

4. d. Swab of affected area. A swab of your throat, urethra, vagina or
rectum can collect bacteria that can be identified in a lab.
e. Nucleic acid amplification test (NAAT) assay: is the test of
choice and is very sensitive and specific (95%)
f. Culture gram stain test: for N gonorrhoeae on endocervical,
urethral, pharyngeal, or rectal discharge
g. DNA and PCR Test
h. Culture of discharge is Thayer-Martin medium is done for the
confirmation of the diagnosis. Drug sensitivity test helps to select
the antibiotics that are best for disease
i. In all cases, serologic tests for syphilis and rapid diagnostic test
for C. Trachomatis-monoclonal antibody and enzyme linked
immunosorbent assay (ELISA) are performed to detect
gonococcus.
Treatments
Uncomplicated Gonococcal Infections of the Cervix, Urethra, and
Rectum
• Ceftriaxone 250 mg IM in a single dose
PLUS
• Azithromycin 1g orally in a single dose
Alternative Regimens
If ceftriaxone is not available:
• Cefixime 400 mg orally in a single dose
PLUS
• Azithromycin 1 g orally in a single dose

5. Follow-Up
Men and women who have been treated for gonorrhea should be
retested approximately 3 months after treatment, regardless of
whether they believe that their sex partners were treated.
If retesting at 3 months is not possible, clinicians should retest
whenever persons next present for medical care in the 12-month
period following initial treatment.
Management of Sex Partners
Sex partners should be referred for evaluation, testing, and
presumptive treatment if they had sexual contact with the partner
during the 60 days preceding the patient’s onset of symptoms or
chlamydia diagnosis.
To avoid reinfection, sex partners should be instructed to abstain
from sexual intercourse until they and their sex partners have been
adequately treated (i.e., for 7 days after a single-dose regimen or
after completion of a 7-day regimen) and have resolved any
symptoms.
Gonococcal conjunctivitis
Recommended Regimen
• Ceftriaxone 1 g IM in a single dose
PLUS
• Azithromycin 1 g orally in a single dose

6. Complications
a) Pelvic inflammatory disease
Ten to twenty percent of patients diagnosed with cervical
gonorrhea may develop PID.
Females with recurrent PID have high rates of ectopic pregnancy
and infertility.
b) Epididymitis and orchitis
c) Arthritis
d) Endocarditis
1%-2% of cases
e) Additional complications
• Corneal scarring after ocular gonococcal infections
• Destruction of cardiac valves in gonococcal endocarditis
• Death from congestive heart failure related to endocarditis
• Central nervous system (CNS) complications of gonococcal
meningitis

7. References
Dutta, D.C.,Konar, H.(2018). Textbook of Gynecology.(9th
Edition). Jaypee Brothers Medical Private Ltd.
Subedi, D.,Gautam, S.(2012). Gynecology Nursing.(1st
Edition).
Medhavi Publications.
Tamrakar, A.(2014). Textbook of Gynecology.(1stEdition). Jaypee
Brothers Medical Private Ltd.
Retrieved from https://www.cdc.gov/std/bv/default.htm
Retrieved from https://www.who.int/news-room/fact-
sheets/detail/sexually-transmitted-infections-(stis)
Retrieved from
https://www.medicalnewstoday.com/articles/184622