OVERVIEW

Gonorrhea (‘clap’ or ‘drip’) is a bacterial infection caused by Neisseria gonorrhoeae. It is a very common sexually transmitted infection (STI), especially among young people between the ages of 15 to 24 yrs. In the US, it is the second-most-common (second to chlamydia) bacterial sexually transmitted infection. It is almost always spread through sexual activity, but can be transmitted by other means. An infected expecting mother can spread the infection to her child during labor. In babies, gonorrhea usually affects the eyes.

Gonorrhea most commonly infects the epithelia (lining) of the cervix, vagina, rectum, urethra, and pharynx (throat). It can also affect the membranes that cover the front part of the eye (conjunctiva and cornea) in which case it is known as gonococcal conjunctivitis.

Gonorrhea in many cases presents no symptoms. Symptoms that may be present most often include pain, discomfort, discharge and lesions on the genitals.

WHY IS IT CALLED CLAP OR DRIP? 

Slang terms for STIs are common because of the social stigma around talking about them. There is no consensus as to why gonorrhea is known as ‘clap’ or ‘drip’ but there are a number of proposals as to why it is called so.

The most popular reference to the “clap” aspect of gonorrhea is also the most disgusting. It was coined from the proposed Medieval era treatment of gonorrhea which involved a male patient having to clap or slap the penis between both hands to get rid of the pus, which was believed to also relieve the infection.

The “drip” isn’t as well known, when compared to the “clap”, but is believed to be a reference to the most common of all gonorrhea symptoms; the dripping of pus from the genitals of victims.

TRANSMISSION

Gonorrhea is usually spread from an infected person through unprotected sexual contact such as; vaginal sex, oral sex, anal sex.

It can also spread from an infected mother to a child during birth. This is possible because the bacteria can spread to the eyes of the fetus during birth, causing conjunctivitis in the newborn (known as gonococcal ophthalmia neonatorum)

Gonococcal conjunctivitis may also be caused by accidental infection from fingers contaminated with the bacteria during childbirth.

EPIDEMIOLOGY

Gonorrhea is a global problem. It is the second most prevalent sexually transmitted infection (STI) reported in the United States of America.

Globally, the precise incidence is difficult to establish because of lack of reporting systems in many parts of the word. The World Health Organization (WHO) estimates the incidence of many STIs among individuals from age 15 to 49 years. This estimation is based on data acquired from regions that have good case-based surveillance systems and good population-based studies.

In 2008, WHO estimated global incidence of 106 million cases of gonorrhea. This represent a 21% increase over the 2005 estimates. Regions with the highest incidence included Western Pacific and Africa. The total number of new cases of gonorrhea globally in 2008 was estimated to be 106.1 million cases. Out of this 36.4 million were adults. Males accounted for more than 50% of the new cases.

Gonorrhea in the African Region

The WHO African region comprises of 46 countries.  Records show an estimated population of about 348.4 million adults between the ages of 15 and 49 with gonorrhea as of 2008.

  • Incidence: about 21.1 million cases of gonorrhea
  • Prevalence: 8.2 million with gonorrhea.

Gonorrhea in the American Region

The WHO African region comprises of 35 countries. Records show an estimated population of about 476.9 million of adults between the ages of 15 and 49 with gonorrhea as of 2008.

  • Incidence: about 11.0 million cases of gonorrhea
  • Prevalence: 3.6 million with gonorrhea.

Gonorrhea in the South-East Asian Region

The WHO South-East Asian Region comprises of 11 countries. Records show an estimated population of about 945.2 million of adults between the ages of 15 and 49 with gonorrhea as of 2008.

  • Incidence: about 25.4 million cases of gonorrhea
  • Prevalence: 9.3 million with gonorrhea.

Gonorrhea in the European Region

The WHO European Region comprises of 53 countries. Records show an estimated population of about 450.8 million of adults between the ages of 15 and 49 with gonorrhea as of 2008.

  • Incidence: about 3.4 million cases of gonorrhea
  • Prevalence: 1.0 million with gonorrhea.

Gonorrhea in the Eastern Mediterranean Region

The WHO Eastern Mediterranean Region comprises of 23 countries. Records show an estimated population of about 309.6 million of adults between the ages of 15 and 49 with gonorrhea as of 2008

  • Incidence: about 3.1 million cases of gonorrhea
  • Prevalence: 1.0 million with gonorrhea.

Gonorrhea in the Western Pacific Region

The WHO Western Pacific Region comprises of 37 countries. Records show an estimated population of about 986.7 million of adults between the ages of 15 and 49 with gonorrhea as of 2008

  • Incidence: about 42.0 million cases of gonorrhea
  • Prevalence: 13.3 million with gonorrhea.

The estimated number of cases are likely to be much higher than the figures provided. This is because there are unreported and undiagnosed infections due to asymptomatic (no obvious symptoms) infections. Also, an increase in population over the years directly increases the number of infected people over the years. For example, a 21% increase in incidence between 2005 and 2008.

SYPMTOMS AND SIGNS

Symptoms usually appear between 2 to 5 days after infection, because the bacteria has an incubation period (the period between exposure to an infection and the appearance of the first symptoms) of 2 to 10 days. Most people are infected without any visible signs or symptoms. Known as carriers, they can spread the disease to other people. Gonorrhea causes symptoms only at the sites of initial infection. In a few cases, the infection can spread through the bloodstream to other parts of the body, especially to the skin and joints.

 In Men:

Symptoms are absent in about 10% of cases in men. Some of the symptoms affecting the genital tract include:

  • Dysuria (Painful, discomfort or burning sensation when urinating)
  • Purulent urethral discharge (white, yellow or green discharge of pus from the tip of the penis)
  • If untreated gonorrhea can also present with inflammation (pain, warmth, redness, or swelling) of the testicles and prostate gland.
  • Frequent urination
  • Urinary urgency (sudden urge to urinate)
  • Dyspareunia (pain during sexual intercourse)

 In Women:

Symptoms are absent in about 80% of cases in women. Women tend to have milder symptoms than men. Most often than not, gonorrhea symptoms are as a result of co-infections like chlamydia and candidiasis.

Some of the symptoms affecting the genital tract include:

  • Dysuria (Painful, discomfort or burning sensation when urinating)
  • Purulent vaginal discharge (white, yellow or green discharge of pus from the vagina)
  • Inter-menstrual bleeding (Vaginal bleeding between periods) which is indicative of PID (pelvic inflammatory disease)
  • Lower abdominal pain (indicative of PID)
  • Frequent urination (the need to urinate more often than usual)
  • Urinary urgency (sudden urge to urinate)
  • Dyspareunia (pain during sexual intercourse)

Some of the symptoms affecting other parts of the body include:

  • RECTUM

Rectal gonorrhea is an infection of the rectum. It is usually asymptomatic in gays but may present with discomfort, discharge or rectal bleeding and proctitis (inflammation of the rectum)

In women, the rectum may also be involved either due to spread from a vaginal site or as a result of anal sex.

  • EYES

Gonococcal conjunctivitis is an uncommon complication. It presents with purulent discharge from the eye(s), inflammation of the conjunctivae and cornea, pain and photophobia (light sensitivity).

Gonococcal ophthalmia neonatorum is a form of conjunctivitis contracted by newborns during delivery. It may result in blindness if not treated early.

  • THROAT

Pharyngeal gonorrhea is usually a result of oral sex. In most cases, it is asymptomatic (without symptoms). Symptoms of a throat infection may include a sore throat and swollen lymph nodes in the neck region.

  • Joints and Skin.

Disseminated gonococcal infection is a rare complication that may arise when the infection spread through the bloodstream to the other parts of the body especially, the joints and the skin. It presents with symptoms such as arthritis (inflammation of the joint), and small red spots on the skin usually on the arm and leg. The spots on the skin are slightly painful and may be purulent.

COMPLICATIONS

Untreated gonorrhea can result in the following complications:

  • Infertility in women: Untreated gonorrhea may ascend up the female reproductive tract and affect the uterus, fallopian tubes, and ovaries. This results in inflammation known as pelvic inflammatory disease (PID). PID can cause severe and chronic pain and damage the female reproductive organs which leads to infertility.
  • Ectopic pregnancy: Damage to the fallopian tube may result in scarring of the tubes and can lead to ectopic pregnancy (pregnancy in which the fertilized egg implants outside the uterus).
  • Peritonitis: Sometimes the gonorrheal infection spreads to the of the lining of the abdominal cavity, known as the peritoneum, causing it to be inflamed. This inflammation of the peritoneum is known as peritonitis, and it may cause severe systemic complications.
  • Infertility in men: Untreated gonorrhea in men can result epididymitis — inflammation of the epididymis (a small, coiled tube in the portion of the testicles where the sperm ducts are located). Epididymitis is treatable, but if treated late may lead to infertility.
  • Prostate cancer: Men who have had gonorrheal infections or its complications are at a higher risk of getting cancer of the prostate.
  • Disseminated gonococcal infection: This is a rare complication that may arise when the gonorrheal infection spreads through the bloodstream to the other parts of the body especially, the joints and the skin. It presents with symptoms such as arthritis (inflammation of the joint), lesions on the skin and fever.
  • Perihepatitis: In some cases, infection in the abdomen may concentrate around the liver causing perihepatitis (Fitz-Hugh-Curtis syndrome). This results in pain in the upper right part of the abdomen in women especially.
  • Blindness in babies: Babies who contract gonorrhea from their mothers during birth have high possibility of developing blindness. In most developed countries, this is prevented since all newborns are treated after delivery with erythromycin eye ointment.

DIAGNOSIS

Symptoms alone cannot confirm an infection with gonorrhea because its presentation is similar to other STIs.

Gonorrheal infection can be confirmed by

  • Gram staining

Gram staining is a method of identifying and categorizing bacteria into two classes known as Gram-positive and Gram-negative bacteria with the help of dyes. These dyes are taken up, or stain different structures of different bacteria depending on what particular variant they are.  Gram-positive bacteria appear purple or blue after staining while the gram-negative variants appear pink or red after staining.

Neisseria gonorrhea is a gram-negative bacterium. If Gram-negative bacteria are visualized with a microscope on direct Gram stain of pus from the penis (male genital infection), gonorrhea can be diagnosed without a further test. It is different in the case of a female infection, because the vagina has Gram-negative bacteria as part of its normal flora (bacteria that are already present and do not usually cause disease). This makes it difficult to distinguish normal flora Gram-negative bacteria from Neisseria gonorrhea in gram staining. Because of the uncertainty with Gram staining, a second method known as bacteria culture is employed to help with diagnosis. 

  • Culture

Culturing involves growing bacteria under ideal conditions for the purpose of multiplication and identification of the organism. A colony of Neisseria gonorrhea bacteria will grow if gonorrhea is present in the sample. Culture is a useful diagnosis of infections of the throat, rectum, eyes, blood, or joints. 

  • Nucleic acid-based testing (NAT) or Nucleic acid amplification tests (NAAT)

Nucleic acid-based testing (NAT) is a test that detects the genetic material (DNA & RNA; which are collectively known as nucleic acids) of the organism involved. Nucleic acid amplification testing (NAAT) uses the same mechanism as NAT, by first amplifying the genetic material through means such as polymerase chain reaction (PCR) and strand displacement assay (SDA).  NAT or NAAT is done by obtaining samples from blood, genital fluids, rectal or oral swabs, and joint fluids. The sample is sent to the laboratory to determine the presence of the unique genetic material of Neisseria gonorrhea.

All people who test positive for gonorrhea should be tested for other sexually transmitted infections such as chlamydia, syphilis, and human immunodeficiency virus. Studies have shown that co-infection with chlamydia is about 46-54% likely in young people with gonorrhea. People infected with gonorrhea have a fivefold increased risk of HIV transmission.

PROGNOSIS

Gonorrhea is curable. If left untreated for a long time, it may result in the complications motioned above. 

SCREENING FOR GONORRHEA

Screening is for people who have characteristics that increase their risk of infection. These include:

  • Sexually active women who are 25 years and below.
  • People who have tested positive for gonorrhea before.
  • Commercial sex workers
  • Pregnant women or women who intend to become pregnant and are found to be at high risk for sexually transmitted infections,
  • Homosexual men who have who have been sexually active within the last year. 

PREVENTION

The following are some of the ways to prevent gonorrhea.

  • Abstinence from sex
  • Regular and correct use of condoms
  • Avoid unsafe sex practices with multiple sex partners or with partners who have other sex partners.
  • Newborn babies coming through the birth canal must be given erythromycin ointment in the eyes to prevent blindness from gonorrheal infection.
  • People who have been diagnosed and treated for gonorrhea should avoid sexual contact with others, until at least one week after treatment in order to prevent the spread of the infection.
  • Getting tested regularly 

TREATMENT

Since gonorrhea is caused by bacteria, its mainstay of treatment is the use of antibiotics. A combination therapy is required in most cases to prevent resistance by the bacteria.

Injectable ceftriaxone is the drug of choice with combination of either azithromycin or doxycycline. As of 2015 and 2016 the Center for Disease Control and the World Health Organization only recommend both ceftriaxone and azithromycin as the first line of treatment.

To avoid late diagnosis, sexual partners of people diagnosed with gonorrhea have to be tested and potentially treated. Sex partners exposed to gonorrhea within the two weeks should be treated for it without waiting for test results.