General Medical Information

Gonorrhea

Wilberto Nieves-Neira
Bhagirath Majmudar
Ira R. Horowitz

The vulva is covered by stratified squamous epithelium, which is not directly infected by the gonococcus, because the latter primarily invades nonsquamous mucus membrane. The thin premenarchal vaginal epithelium is cuboidal and, therefore, infected by the gonococcus. The associated vaginal discharge commonly results in vulvar skin irritation. Generalized vulvar skin erythema and vaginal discharge are the most common findings. Gonorrhea infection may be the result of sexual abuse, but nonvenereal transmission also has been reported. A positive gram stain is helpful but not diagnostic, as other Neisseria species may be present in the vagina. It is important to obtain cultures and sensitivity results for gonococcus before the patient is treated with penicillin. Because of the increased prevalence of resistance to penicillin, the use of a third-generation cephalosporin is recommended. A single intramuscular dose of 125 mg of ceftriaxone is adequate treatment. This treatment also may be effective for syphilis, but not for chlamydia trachomatis. A single intramuscular dose of spectinomycin (40 mg/kg for children weighing less than 45 kg, otherwise 2 g) is a safe and efficacious regimen for uncomplicated gonococcal infection in prepubertal children who are penicillin allergic. One approach used in the past was the use of intravaginal estrogen suppositories to induce squamous change in the vaginal mucosa. It was observed that gonorrhea can resolve spontaneously at the time of menarche. Thickening of the vaginal epithelium may eliminate the infection and thus the resulting dermatitis. However, it is recommended that a gonorrheal infection, even when silent, should be completely treated with antibiotics because of its potential for pelvic and distant spread. Local vulvar irritation may be treated by cool sitz baths with or without aluminum acetate (Domeboro) powders. The Domeboro powder reduces swelling associated with the infection. The urethra may be irritated. It may be infected directly or through the infection of the urethral mucus glands. In either case, the patient will complain of pain on voiding. The gonococcus rarely produces cystitis and conjunctivitis. Local treatments usually are effective in relieving the discomfort. Distant organ involvement of PID (pelvic inflammatory disease), arthritis, endocarditis, and septicemia should be considered.