Gonorrhea

Gonorrhea Infections: An Overview

Gonorrhea is one of the most common sexually transmitted diseases in the United States due to the ease of its transmissibility and the ever-so-growing stigma surrounding the issue of sexually transmitted infections. It is caused by Neisseria gonorrhoeae, a bacterial species that specifically target the mucus membranes of the reproductive tract which may include the cervix, uterus, and fallopian tubes in women, and the urethra in all sexes. Apart from this, the pathogenicity of N. gonorrhoeae is also not restricted to the mucus membranes of the reproductive tract. It could also attack the mucus membranes of the mouth, throat, eyes, and rectum to cause a similar infection within non-reproductive organs as well.

Considering that it belongs under the category of STDs, it is commonly transmitted through sexual contact (including vaginal, anal, or oral sex), but it can also undergo vertical transmission wherein the infected patient could pass on the infection to their unborn child during childbirth. Fortunately, apart from the various preventive measures that you could perform to protect you and your partner from sexually transmitted infections, the disease in itself is treatable with the right course of antibiotic therapy. However, do note that self-medication is highly discouraged when dealing with antibiotics as this might cause antimicrobial resistance – a growing concern in the medical industry nowadays that is slowly crippling the capabilities of the available medications in the market. If you feel that you are at risk of contracting the infection, consult your doctor as to what you should do for your next plan of action, or you could also request routine testing especially if you are sexually active on top of being susceptible to its various risk factors.

Pathogenicity and Prevalence

According to the Centers for Disease Control and Prevention, they were able to record 616, 392 cases of gonorrheal infections in 2019 – ranking second among the list of the most common notifiable conditions in the United States that year. Based on their data, this amount has also been shown to be a result of a 92% increase in the total number of cases of gonorrheal infections in the country since 2009. From 2018 to 2019, there has also been an observed increase of around 5.7% in the number of cases to show once more that there has been an observed increase in the number of cases among both males and females, in all the regions of United States, and among all the racial or ethnic groups present in the country.

In their data records for the year 2018 to 2019, it was also found that the reported gonorrhea cases are mainly influenced by the increased prevalence of the disease in men. In contrast to the women’s increase rate of 5.1% during the same period, the number of cases in males increased by 5.9% - implying that there may either be an increased transmission of the disease within the community, an increased number of cases confirmed and properly diagnosed, or both. In addition to that, the relatively parallel increase in the number of cases in women is likewise indicative of mainly heterosexual transmission of the disease, an increased screening or confirmation among women, or both.

Who should look out for such infections?

Do take note that despite the increasing number of gonorrhea infections in the United States, most cases do remain asymptomatic for the duration of the infection – making it harder to rule out whether you are infected or not without proper testing. Considering this, if you are a sexually active person, you are already susceptible to the infection and you should talk and be honest with your doctor about the options that you could do to ensure that you will not contract or that you will be able to manage the condition early on if you ever tested positive for the condition. The CDC recommends that all sexually active women younger than 25 years, older women with risk factors such as new or multiple sex partners, and those who have a sexual partner who recently tested positive for an STD be tested for gonorrhea at least once annually.

What treatment options are available?

Much like what was mentioned earlier, bacterial infections such as Gonorrhea should be managed with an empiric antimicrobial therapy consisting of various antimicrobials that work against the causative organism of the disease. It is important, however, to emphasize once more, that antimicrobials should not be taken without a proper prescription and assessment from a physician. Various strains of N. gonorrhoeae are now developing resistance against antimicrobials – making it hard and harder to select among the barely viable drugs the best option for you, your condition, and your circumstances.

When is sexual activity allowed once again?

The problem with STDs is that they are easily transmitted through contact with bodily fluids. For the sake of yourself and your partner, do abstain from any sexual contact – penetrative or otherwise – until your physician has cleared you from any suspicions and possibilities for transmission. It may take several days for your symptoms to subside, but you should always consider the possibility of re-infection after a few months. It takes patience to get through this dilemma, indeed.

Gonorrhea: Target Sites and Its Transmission

Gonorrhea is an infection caused by the pathogenic microbe known as Neisseria gonorrhoeae. Due to its natural properties and characteristics, it mainly targets mucus membranes enclosed within warm, moist areas of the body. This includes the following areas:

• Urethra
• Eyes
• Throat
• Vagina
• Cervix
• Fallopian Tube
• Anus
• Uterus

Considering that it can stay within the indicated areas, contact within these infected regions could likewise transmit the condition to another person. This would generally include any type of sexual contact such as oral, anal, or vaginal sex, especially when the individuals are not using any protective measure such as a condom. In addition to that, it is also possible to contract the condition when a mother is infected with the microorganism during pregnancy – transmitting the disease through perinatal means during childbirth. Do note, however, that although it is a common misconception among the general public that ejaculation is the main source of transmission of STDs, it is not the case with gonorrhea at all. Ejaculation is not a must to transmit the disease, making it still apparent and ever so evident that individuals participating in sexual intercourse with new or multiple partners should wear protection or at least consider having themselves tested beforehand. Prevention is always the priority.

It might also be worth noting that individuals who have already been infected and have been successfully treated for gonorrhea could still be re-infected when exposed to the causative organism again. Although resistance and immunity are possible in the case of the bacteria with antibiotics, immunity against the bacteria due to a previous infection is not at all plausible.

Signs and Symptoms of Gonorrhea

Many cases of gonorrhea infection remain asymptomatic for the entire duration of its cycle – making it harder to gauge whether you would have to be tested or treated for an infection that is not manifesting in any way. As such, it is important to not only look for viable signs and symptoms but also for other tell-tale signs, including risk factors that may have increased your susceptibility to contracting the disease.

Gonorrhea in Men

Most men would simply shrug off the possibility of infection due to the poor incidence of symptomatic cases among this demographic group. It may take several weeks, but it could always end up being completely asymptomatic and self-limiting without opting for empirical antimicrobial therapy.

In cases where a symptomatic infection is the area of concern, the symptoms would usually begin around a week after transmission – beginning with a noticeable burning or painful sensation while urinating. This could also be coupled with “dysuria” or a condition wherein there is a white, yellow, or green urethral discharge that usually appears after 1-2 weeks since the initial exposure. It could even develop further symptoms that may include, but is not limited to:

• Increased urinary frequency
• Dysuria or a pus-like discharge (also known as “drip”)
• Swelling and redness at the tip of the penis or the exact opening of the urethra
• Swelling and pain in the testicles (commonly associated with a complication in males)
• A persistent sore throat when your throat mucus membranes are likewise infected

In males, the greatest concern is the development of a complication known as epididymitis. This would result in a painful sensation in the testicles, and in rare cases, infertility due to the extreme progression of the disease within the testes. It is also worthwhile to note that apart from the pain being able to radiate even to the rectal area, all the symptoms listed could also persist for a few more weeks even after the beginning of treatment. Simply make sure that you are in constant communication with your physician to ensure that your treatment regimen is still suitable for the N. gonorrhoeae strain that is causing your condition.

Gonorrhea in Women

Much like the case in males, gonorrheal infections in women are likewise mainly asymptomatic. In cases where they do present some symptoms, it is often construed as mild and nonspecific that it is then confused with other bladder or vaginal infections – making it likewise harder to manage therapeutically. The problem with women, however, is that no matter how severe the symptoms are, the risk of the disease progressing to develop more severe complications is ever so evident nonetheless – making it dangerous to ignore the tell-tale signs of infection.

The initial signs and symptoms in women are similar to yeast infections. This may include dysuria, increased vaginal discharge, and vaginal bleeding between periods. They may also experience the following signs and symptoms:

• Watery, creamy, or slightly green vaginal discharge
• Increased urinary frequency
• Bloody stool
• Heavier periods or “spotting”
• Sore throat
• A painful sensation when having sex
• High-intensity pain in the lower abdomen
• May develop a fever
• Itching within the genitalia or anal region

Despite this extensive list of signs and symptoms to look out for, also do note that women have a higher risk of developing complications. Consult your doctor immediately once you feel a little discomfort in your reproductive area to ensure that you are tested and diagnosed with clarity.

Gonorrhea During Pregnancy

Pregnant women infected with gonorrhea may experience severe complications such as an increased risk of miscarriage, preterm birth, or a premature “water breaking” due to the damage caused by the microorganism to the structures in the female genitalia.

Furthermore, the infection may be passed to the baby during labor – resulting in a cascade of symptoms such as blindness, infection within the joints, and a systemic infection.

Other Gonorrhea Infections

Considering that Gonorrhea can infect other mucus membranes such as those present in the rectum, eyes, and the throat, you should likewise take note of the symptoms that might manifest if those areas are affected. For rectal infections in both men and women, it could be asymptomatic, but in symptomatic cases, it may cause discharge, anal itching, soreness, bleeding, and painful bowel movements. On the other hand, pharyngeal infections could manifest as a persistent sore throat, but this is less likely to manifest as such cases are usually asymptomatic.

Gonorrhea Complications

Much like with any other infection, Gonorrhea, when left untreated and not properly managed could continuously progress to cause a whole new spectrum of complications that will not only make the treatment process more difficult but also decrease the chances of recovering from the condition without any significant long-term damage.

Pelvic Inflammatory Disease

In women, once the bacteria spread to the uterus and fallopian tubes, a condition known as Pelvic Inflammatory Disease could develop. It is usually an infection caused by a complication of another STD such as Chlamydia or Gonorrhea, but other non-STD infections could also result in such a level of damage. There are no current tests for PID, but a diagnosis could be developed through a complete assessment of your medical records, risk factors, signs and symptoms, and physical exam.

When a gonorrhea infection in women results in PID, the symptoms could sometimes manifest as mild signs, but it could also cause severe conditions on top of abdominal pain and fever. Apart from that, PID has also been found to cause internal abscesses and chronic pelvic pain due to the proliferation of the bacteria within the internal structure of your reproductive tract. The following symptoms could likewise be experienced by someone suffering from PID:

• Fever
• Unusual discharge with an unpleasant odor
• Pain during sex or bleeding
• Dysuria
• Bleeding between periods

With sufficient damage and lack of appropriate management, PID could also cause more complications such as:

• Scar tissues that block the fallopian tube
• Ectopic pregnancy or pregnancy outside the womb
• Infertility
• Chronic and Long-term pelvic/abdominal pain

When diagnosed early, PID is completely treatable but it will not be able to heal the damages that it has caused to your internal structures. Always make sure to gauge your status to prevent the development of such complications that would certainly be a long-term issue rather than one that could be dealt with in one hospital visit.

Epididymitis

Epididymitis, much like PID, is a complication that is caused by a previous infection resulting from either Chlamydia or Gonorrhea. It usually presents as a painful sensation along the epididymis coupled with swelling and inflammation. In certain cases, it could also be observed that the testes are sometimes involved – now resulting in another condition known as “epididymo-orchitis.”

The following signs and symptoms are the most common ones associated with an acute onset of epididymitis in men who have previous predisposing infections that may have caused such a development:

• Unilateral testicular pain and tenderness
• Palpable swelling of the epididymis
• Tender and swollen spermatic cord

Such a condition must be monitored and managed by a physician immediately since testicular torsion is a surgical emergency. With the increased pressure being applied to the testes of the patient, there is a possibility that its viability might be compromised, especially when the condition is allowed to progress without any type of management. If such an instance is allowed to occur, it could, unfortunately, lead to a decreased fertility, or in worst cases, complete sterility.

Do take note, however, that epididymitis is still treatable, especially when a presumptive therapy is provided to combat the underlying causative organism of the condition. Treatments are usually performed on an outpatient basis, but if testicular torsion or abscess development is evident, hospitalization might be necessary.

Other Complications

Apart from the conditions mentioned previously regarding untreated Gonorrhea infections, your condition could likewise increase your susceptibility to other infections such as HIV – the causative agent of AIDS or Acquired Immunodeficiency Syndrome. Due to your strained immune system, your resistance against other pathogens is relatively constricted, making it easier for other opportunistic microbes to target you and trigger another condition within your system.

It is also worthwhile to note that there is a rare instance wherein the causative agent of your Gonorrhea infection migrates to your bloodstream. If such a condition occurs, it would usually cause arthritis, heart valve damage, and inflammation of your brain and spinal cord lining. It remains a critical condition nonetheless as this signifies that your infection is now systematic instead of being localized to a specific area.

Treatment Options for Gonorrhea

Due to the changing susceptibility trends of various N. gonorrhoeae strains as well as the imperative need for an immediate treatment regimen, the drugs of choice for Gonorrhea are constantly being updated by the Centers for Disease Control and Prevention. Changes are being applied to ensure that the following are met:

• The drug will be effective against the causative agent
• The drug will be able to halt the progression of the disease
• The drug will be able to provide the appropriate therapeutic effect without compromising its safety aspects

As such, based on the latest update of the CDC on the 28^th of December, 2020, the following are the treatment recommendations that they are putting forward:

For Uncomplicated Urogenital, Rectal, or Pharyngeal Gonorrhea

For these three classifications of Gonorrhea, the CDC recommends that the patient must take a single 500 mg dose of Ceftriaxone intramuscularly. In addition to that, in cases where the patient’s weight is more than or equal to 150 kilograms or approximately 300 pounds, the dose should then be adjusted to a single 1g dose of Ceftriaxone IM.

In cases, on the other hand, where the patient is sensitive or allergic to cephalosporins (the drug class of Ceftriaxone), a single 240 mg dose of Gentamicin plus a single 2 g dose of Azithromycin is another viable option that the patient could consider. Do take note, however, that with this treatment regimen, gastrointestinal symptoms such as vomiting could be observed within the first hour of administration in approximately 3-4% of people taking the medication.

It could also be noted that if the patient could not be administered with IM Ceftriaxone (procurement problems), a single 800 mg oral dose of Cefixime is likewise a viable option that you or your physician could explore. However, it must be considered that Cefixime, unlike Ceftriaxone, is not able to consistently maintain its therapeutic levels within the body be as effective as the previous cephalosporin of choice. This might have specific impacts, especially when dealing with other Gonorrhea variations such as Pharyngeal Gonorrhea.

For Resistant Gonorrhea Strains

Due to the widespread yet improper use of antibiotics all over the country, resistance rates are continuously shooting up – affecting the resistance of certain N. gonorrhoeae strains to cephalosporins, the drug of choice as per the recommendation of the CDC in its latest gonococcal treatment guidelines. In such cases where there is a possibility of cephalosporin resistance or rather, a failure of the cephalosporin therapy upon actual administration, you may consult your physician for them to be able to procure a sample and perform an antimicrobial susceptibility test. Such tests are performed to countercheck against all viable antibiotics and determine the one that would provide the best bactericidal effect against the bacteria present in your body. The case must also be reported to CDC through state or public local health authorities within 24 hours to properly document the resistant strain and avoid the administration of cephalosporins in resistant cases.

Test-of-Cure

A test-of-cure is a process performed to validate and conclusively declare that the microbe is no longer present in your body in sufficient amounts to cause an infection. In short, it is a confirmatory test performed to determine whether a re-infection is imminent or is already present in the same or on a different area. However, according to the 2020 CDC Guidelines, a test-of-cure is no longer necessary for patients who were experiencing uncomplicated urogenital or rectal gonorrhea and were treated with one of the recommended or alternative treatment options presented previously. However, in cases where the patient presents with pharyngeal gonorrhea, a test-of-cure is recommended 7 to 14 days after the start of the initial treatment, regardless of the treatment regimen that was selected.

Considering that re-infection is likewise a legitimate concern in many patients, it might also be ideal to be retested 3 months after treatment no matter the risk factors that may predispose them to have a re-infection. However, if the patient would not be able to comply with the 3-month testing recommendation, the patient can opt for retesting 12 months after treatment under, of course, the supervision of their physician.

Treatment of Partners

If you are diagnosed with a Gonorrhea infection, you should always determine your recent sexual partners so as for the physician to be able to prescribe them with the appropriate medication before the condition progresses into a more serious complication. An infected person as well as their recent partners should likewise abstain from intercourse until their treatment regimen has been completed. This is simply a safety precaution that will effectively contain the infection and prevent the unfortunate transmission of the bacteria to other unknowing individuals.

Essentially, all of your sexual partners 60 days before your confirmed diagnosis should be tested for gonorrhea and treated with the empirical therapy of 500 mg Ceftriaxone IM, or be prescribed with another alternative regimen depending on the recommendations of the physician. In addition to that, if a gonococcal expedited partner therapy or the provision of medications for your partner without prior examination is legal and permissible within your State, the CDC’s recommendation is a single 800 mg oral dose of Cefixime in cases where a Chlamydia infection has been confirmed to be absent. Otherwise, an 800 mg oral dose of Cefixime plus oral Doxycycline 100 mg twice daily for 7 days is recommended instead.

A Reminder on the Use of Antimicrobials

To reiterate the reminder that is constantly being highlighted in any treatment regimen, DO NOT SELF MEDICATE. We repeat, DO NOT SELF MEDICATE. Antimicrobials are scarce enough as it is due to the rising resistance of various microorganisms to the first-line drugs of modern medicine. By self-medicating, a therapeutic dose is sometimes not achieved and is instead used by the microorganisms to adapt to the medication’s mechanism. As such, this removes the number of viable treatment options until the disease becomes nearly impossible to manage pharmaceutically. Always consult your doctor before taking any medications, inquire about possible side effects, and clarify any issues regarding dosing and regimen duration. To reiterate, DO NOT SELF MEDICATE.

Preventive Measures against Gonorrhea

Much like with any sexually transmitted disease, the core aspect that should always be considered when attempting to prevent the contraction of such a condition is the observance of your sexual habits.

Gonorrhea is easily transmitted through contact between infected mucus membranes in the reproductive tract, the anus and rectum, and even in the mouth and throat. The infection is easily transmissible, but the great thing about this condition is that its mechanism is clearly understood. With a clear understanding of how can confer its pathogenicity, the ways to prevent its spread is likewise clearer and more evident.

The following list identifies some of the most effective ways to stop the infection before it even starts to proliferate. For better recall, you may call it “the ABCs to preventing STDs.”

Abstinence

While this might seem like a cliché that has been overly used by Sex Education professors or medical professionals, its efficacy is evident in the way that it follows a simple logic: if you do not participate in intercourse, you could not contract a disease that is transmitted sexually. Removing yourself from the source of the infection itself guaranteed protection and is perhaps the most effective way in making sure that your susceptibility is minimized greatly. In a sense, no intercourse, no contact, no infection.

Be Sexually Monogamous

Monogamy is sometimes construed as a political topic, but this could likewise have medical implications, especially when dealing with sexually transmitted infections. By being able to monitor the condition of your partner and simply having one partner to consult when you do experience symptoms, you could easily decrease the risk of having undetected asymptomatic gonorrhea as you are confident that you did not take an unnecessary risk with another individual.

Condoms (in vaginal, oral, or anal sex)

Condoms are probably the second-best protective measure that you could access that will prevent any direct contact between your partner’s genitalia and yours – ensuring that whatever infection you or your partner might have is restricted in its original location. While this might not seem as foolproof as abstinence due to the fact that contact could still occur in some way, it still minimizes the risk that is otherwise glaring when participating in unprotected sex.

What to Prepare when you have a Suspected Infection

STDs or Sexually Transmitted Diseases are often jarring, especially when the symptoms begin to manifest. As such, even in this case, you should be able to know what actions you could take if you are symptoms are aligned with those that characterize such as condition.

If you are already experiencing symptoms but are still unsure as to whether it is gonorrhea or not, the first thing that you should immediately do is halt any sexual activity for the meantime. Following that, you should then contact your doctor for an appointment and prepare the answers to the following questions that will help your doctor determine your condition, its extent, and who else to treat in case your results come back positive.

• The complete details of your signs and symptoms (duration, intensity, time of manifestation).
• Discuss your complete sexual history. If possible, bring your partner during the consultation so that they may be checked as well.
• Provide the contact information of your sexual partners if they are still not aware yet of your condition.
• Medical history (allergies, past STDs, etc.)
• Medications you are currently taking

You would then need to consult your doctor again after a few days to verify that the medication is working for you. Re-testing after 3 or 12 months is also recommended by the CDC to rule out any cases of re-infection.

Frequently Asked Questions

If side effects are evident, is it okay to stop the treatment?

Ideally, no, especially if you are deciding without the knowledge of your physician. Stopping an antimicrobial regimen halfway is a risk factor for the development of antimicrobial resistance. To avoid the development of resistance in various strains, as much as possible, antibiotic therapies are continued, nonetheless. Consult your doctor beforehand as they may prescribe you a new medication that you could tolerate better.

What is usually the first sign of gonorrhea?

It is commonly signified by a burning or painful sensation when urinating, but this could also be attributed to other diseases. Diagnosis, after all, does not only depend on one symptom but instead, relies on a myriad of test results and diagnostic tools.

Does gonorrhea naturally subside?

Unfortunately, it does not, which makes it even more important to have it treated immediately. Untreated Gonorrhea results in complications such as PID and Epididymitis that are considered to be more severe and more difficult to manage.

Can you get gonorrhea from kissing?

Gonorrhea is only spread through vaginal, anal, and oral sex as this is usually associated with bodily fluids like semen, vaginal discharge, etc. Kissing, hugging, holding hands, or any other means of casual contact are not suitable transmission pathways for Gonorrhea.

How is gonorrhea diagnosed?

Diagnosis is usually performed using lab tests that may require urine, vulvovaginal samples, cervical samples, and even urethral swabs. Lab tests performed for the diagnosis of gonorrhea infections may include gram staining, culture testing, and polymerase (PCR) chain reaction tests.

• Gram Stain and Culture. This type of testing requires a swab sample from the infected site. The samples gathered from the swab are cultured in a laboratory and the bacteria and its genetic composition are identified. This type of testing is more traditional and is highly dependent on the sampled area. However, it is possible that the sampled area may have minimal or no bacterial content – resulting in certain false negative results.

• Polymerase Chain Reaction. This type of testing requires either a urine sample, or a vaginal or urethral swab to perform. However, unlike gram and stain culture, small amounts of the bacteria are sufficient as the DNA is copied using an enzyme called “polymerase” and, therefore amplified. This type of test, on the one hand, is more expensive but provides faster and more accurate results.

Considering how the accessibility to such tests is poor in certain areas, an examination of symptomatic manifestations as well as risk factors is sometimes performed instead.

How do I tell my partner that I have Gonorrhea?

Breaking news that is as crucial as this to your partner could be physically and mentally taxing. As such, you must take your time and allow both you and your partner enough time to digest this information before making any huge decisions. In addition to that, you may also refer to this site which contains tips on how to talk to your partner about STD testing: http://www.gytnow.org/talking-to-your-partner

What happens if my baby gets infected with Gonorrhea?

When infants are infected with STDs, they usually develop eye infections that could be harmful to them when left untreated. As such, immediately after birth, they are usually provided with tetracycline or erythromycin ointments for their eyes as a prophylactic procedure against Gonorrhea.

Can you treat Gonorrhea with Antivirals?

Unfortunately, no. Neisseria gonorrhoeae is a bacteria and should therefore be treated with antibacterials. With the difference in the mechanism of antivirals and antibacterials, antivirals would exhibit no therapeutic effect when used on a bacterial infection.

Should I take a little antibiotic before going to the doctor especially if it hurts too much?

To reiterate, DO NOT SELF MEDICATE. Always consult your doctor first before consuming any medication.

I have been diagnosed with Gonorrhea, is it possible to be infected again?

Yes. Being diagnosed and treated from Gonorrhea does not exempt you from getting infected again. You can get it again if you are exposed to a person infected and it is a possibility that there will be no symptoms presented. It is highly encouraged to return for a follow-up checkup or consultation with healthcare personnel to do a re-testing.