Diagnosis, complications and treatment of gonorrhea

**gonorrhea**

Gonorrhea is a sexually transmitted disease caused by Neisseria gonorrhoeae, resulting in infection of the mucous membranes of the urogenital system. Besides direct transmission through sexual contact, it can occasionally be transmitted indirectly through contaminated clothing, towels, toilet seats, bathtubs, and hands. There are reports abroad of pharyngeal gonococcal infection through oral sex and rectal gonococcal infection through anal sex. Delivery of a pregnant woman with gonorrhea can directly infect the newborn's eyes with gonococci, causing conjunctivitis, keratitis, corneal ulcers and perforation, and even blindness. Therefore, various sexually transmitted diseases, including gonorrhea, can seriously endanger the health of the population and future generations, and their transmission and spread must be controlled. my country declared the eradication of sexually transmitted diseases in 1964, but in recent years, the number of patients has been on the rise, with gonococcal urethritis in men being particularly prominent, causing serious harm and impact.

Diagnosing acute gonococcal urethritis is not difficult. Based on a history of unprotected sexual contact and typical symptoms, combined with laboratory tests such as the presence of Gram-negative Neisseria gonorrhoeae inside and outside polymorphonuclear leukocytes in urethral smears, the diagnosis can be confirmed. Diagnosing chronic gonococcal urethritis is more challenging, often requiring repeated examinations or urethral dilation and irrigation for confirmation. Sometimes, a definitive bacteriological diagnosis cannot be obtained at all. The gonococcal complement fixation test can be used as a reference.

Gonococcal urethritis needs to be differentiated from non-gonococcal urethritis. Non-gonococcal urethritis is the most common sexually transmitted infection (STI), primarily caused by Chlamydia trachomatis and Ureaplasma urealyticum. Statistics show that approximately 80% of cases are caused by these two pathogens, each accounting for 40%; the remaining 20% ​​are caused by Trichomonas vaginalis, Candida albicans, herpes simplex virus, hepatitis virus, and Eustachian tuberculosis. All specific urethritis not caused by Neisseria gonorrhoeae is collectively referred to as non-gonococcal urethritis. This type of urethritis is mainly transmitted through contact with infected individuals after unprotected sex. Onset typically occurs 1-3 weeks after infection, and the clinical manifestations are similar to gonococcal urethritis, but the symptoms are milder.

Typical symptoms include urethral itching accompanied by urinary frequency, urgency, dysuria, and a small amount of watery mucous discharge from the urethra. Sometimes, it may only manifest as a crust sealing the urethra or soiling the groin, which is easily washed away by the urine flow if not carefully observed. The symptoms are most pronounced before the first urination in the morning. In men, Chlamydia trachomatis infection can invade the epididymis, causing acute epididymitis, which can lead to male infertility.

**I. Complications of Gonorrhea**

1. Balanitis/balanoposthitis is a common complication in men with phimosis, paraphimosis, or redundant foreskin, especially during acute gonococcal urethritis due to the irritation from pus. Clinical manifestations include itching, burning, and pain in the glans penis; redness, swelling, and moistness of the foreskin, coronal sulcus, and glans; and the possibility of paraphimosis. If the foreskin can be retracted, clean the area with saline solution and promptly restore the foreskin to its original position to prevent paraphimosis. In cases of phimosis, a dorsal slit should be made during the acute phase, and circumcision should be performed after the inflammation is controlled.

2. Clinical manifestations of gonococcal prostatitis include urinary frequency, dysuria, perineal distension, and rectal examination revealing prostate swelling and significant tenderness. In severe cases, chills, high fever, dysuria, and even urinary retention may occur. Continued deterioration can lead to prostate abscess formation. Chronic gonococcal posterior urethritis often co-occurs with prostatitis; its symptoms and treatment are the same as for nonspecific chronic prostatitis. Due to the spread of the lesion to the reproductive system, the duration of drug treatment for gonorrhea must be appropriately extended.

3. Gonococcal seminal vesiculitis results from posterior urethritis spreading to the seminal vesiculitis. Symptoms are similar to prostatitis, including hematospermia. Treatment is the same as for prostatitis.

4. Gonococcal epididymitis and spermatic cord inflammation are caused by retrograde infection. Predisposing factors include alcohol consumption, excessive sexual intercourse, strenuous exercise, and iatrogenic causes such as insertion of urethral instruments or instillation of medications. Epididymitis and spermatic cord inflammation are usually unilateral. Early clinical manifestations include a local pulling sensation and mild pain, followed by fever, epididymal pain, swelling, or abscess formation. The inflammation can involve the testis, causing acute hydrocele. The affected scrotum is red and swollen, with a significant feeling of heaviness, and significant systemic symptoms. With antibiotic treatment, the inflammation can subside, but induration may remain in the epididymis. If both epididymis are involved, it often leads to azoospermia, causing male infertility. Treatment is the same as for acute epididymitis and orchitis.

5. Gonococcal cystitis: Acute gonococcal posterior urethritis can spread to the bladder if it continues to develop, and clinical manifestations include urinary frequency, terminal dysuria, and residual urinary sensation.

6. Urethral Stricture: Urethral stricture is caused by chronic gonococcal urethritis. Gonococcal urethral stricture usually involves the entire anterior urethra, unlike traumatic urethral stricture which is limited to a segment of the urethra (such as the bulbar portion). Clinical manifestations include chronic urethritis and difficulty urinating. Treatment primarily involves regular, gradual dilation of the urethra, along with anti-inflammatory drugs. In some cases, incision of the urethral meatus may be performed. For extensive anterior urethral stricture, endoscopic transurethral resection may be used.

**II. Treatment of Gonorrhea**

During the acute phase of gonorrhea, it is essential to rest, increase fluid intake, and avoid alcohol and spicy foods; sexual intercourse is strictly prohibited until recovery; the affected area must be kept clean to prevent the spread of pus.

Drug treatment primarily involves antibiotics. Erythromycin, tetracyclines, and cephalosporins are all effective, and these are commonly used treatment methods.

1. Cephalosporins: Ceftriaxone 3.0g, IV drip; Cefotaxime sodium 4.0g, IV drip.

2. Spectinomycin, also known as Linbizhi, 2g, once intramuscular injection, some also advocate 4g, once intramuscular injection for women.

3. Quinolone drugs: Ofloxacin, also known as norfloxacin, 600mg, orally once, or 200mg, intravenously. Note: Quinolone drugs are contraindicated in pregnant women and children.

4. Combination therapy of β-lactamase inhibitors and penicillins: Sutacillin is a combination of penicillin sulfone and ampicillin, 1.5g, once intramuscularly; Piperacillin sodium plus sulbactam sodium, 3.0g, once intramuscularly or intravenously. Because some gonorrhea patients also have chlamydia infection, we commonly use ceftriaxone sodium 3.0g intravenously, along with oral azithromycin or roxithromycin 250mg twice daily.

Cure criteria: Disappearance of subjective symptoms, absence of urethral discharge, and three negative urethral smears and bacterial cultures performed one week after treatment. Two to three weeks after symptom disappearance, three negative prostate massage smears and bacterial cultures are performed.