Gonorrhoea – Epidemiology, Risk Factors, and Prevention.

Introduction

Gonorrhoea is a sexually transmissible infection caused by bacteria known as Neisseria gonorrhoeae. It usually affects the genital area, although the throat or anus (back passage) may also be affected. Gonorrhoea affects both men and women and is easily transmitted during vaginal intercourse. It can also be transmitted during anal or oral sex.

Neisseria gonorrhoeae

Infection in tongue due to oral sex

History

The exact time when gonorrhea started cannot be ascertained. Earliest records of the disease are found from 1611 when the English parliament enacted a law to ensure that the spread of the infection is decreased and curbed.

This was followed by a similar law in 1256 in France during the reign of Louis IX. The symptoms of the infection were observed when the crusaders lay siege of Acre. After the Pope Boniface secularized the practice of medicine, the doctors began to treat common men as well as prostitutes for this infection.

In 1879 Neisser discovered the gonococcus or Neisseria gonorrhoeae and it was soon proven to be the causative agent of gonorrhoea. He demonstrated its presence consistently in patients with symptoms. In addition, when discharge and cultures of gonococci was introduced into the urethra of healthy men, it caused the disease

Gonorrhoea was referred to as the clap. According to some historians the name came about because the infected person would experience a clapping sensation that appeared suddenly when urinating.

History of gonorrhea treatment

The earliest treatment of gonorrhea was with the use of mercury. Earliest findings from an English warship “Mary Rose” show that several special surgical tools were used to inject mercury via the urinary opening.

In the 19th century gonorrhea was treated with the help of silver nitrate. Silver nitrate was soon discontinued and instead protargol was used which a type of colloidal silver was sold by Bayer from the year 1887.

Around 1859 another treatment was popular. These were cubebs, an Indonesian variety of pepper of which the dried powdered unripe fruit was used, and balsam of copaiba (or copaiva), which was extracted from a South American tree. The indication of their effectiveness was cessation of the discharge.

In the 1890s the first vaccine prepared from killed gonococci taken from Neisser’s laboratory. This vaccine was introduced in 1909.

Before antibiotics came into being metals were tried against the infection this included arsenic, antimony, bismuth, gold etc.

The use of other drugs for treatment continued right until the 1940s till antibiotics – notably Penicillin – came into use. Other antibiotics that arose during this time were the sulphur compounds or Sulphanilamide, Sulfapyridine and sulfathiazol.

Penicillins continued to be mainstay of therapy until 1970’s. In 1980 the first gonococcus isolates were identified that were resistant to penicillin. In 1983 a local epidemic caused by a penicillin resistant strain occurred in North Carolina. Patients were successfully treated with spectinomycin.

Epidemiology

The World Health Organization (WHO) has estimated the global incidence of several sexually transmitted infections (STIs) among individuals aged 15 to 49 years based on data from regions that have good case-based surveillance systems as well as data from population-based studies. In 2008, the WHO estimated global incidence of N. gonorrhoeae was 106 million cases, which represented a 21 percent increase over the estimate for 2005.

The highest incidence areas included Africa and the Western Pacific (including China and Australia) regions. In one review of infections during pregnancy in sub-Saharan Africa, the prevalence of sexually transmitted and reproductive tract infections was comparable with that of malaria. The prevalence of N. gonorrhoeae during pregnancy ranged from 1.5 percent in West and Central Africa to 4.9 percent in East and Southern Africa.

Causes of gonorrhea

• Gonorrhea is an infection caused by the bacterium Neisseria gonorrhoeae. It not only affects the reproductive tract, but can also affect the mucous membranes of the mouth, throat, eyes, and rectum.
• The infection is transmitted through sexual contact with an infected person involving the penis, vagina, anus, or mouth. Men do not need to ejaculate to transmit or acquire gonorrhea.
• Gonorrhea can also be passed from an infected mother to her baby during delivery.
• Although all sexually active individuals are at risk for acquiring gonorrhea, the highest rates of infection occur in teenagers, young adults, and African-Americans.
• Babies who display signs of a gonorrhoea infection at birth (such as inflammation of the eyes), or who are at increased risk of infection because the mother has gonorrhoea, will usually be given antibiotics immediately after birth. This is to prevent blindness and other complications developing and does not harm the baby.

Risk factors

Factors that may increase your risk of gonorrhea infection include:

• Younger age
• A new sex partner
• A sex partner who has concurrent partners
• Multiple sex partners
• Previous gonorrhea diagnosis
• Having other sexually transmitted infections

What do gonorrhoea symptoms look like?

Gonorrhoea symptoms normally appear within 10 days of infection but they can occur many months later. Roughly 10% of men and 50% of women will not experience any symptoms at all.

In women, symptoms include:

• Unusual discharge from the vagina that is thick and green or yellow in colour
• Pain when urinating
• Pain in the lower abdomen
• Bleeding between periods and/or heavy periods
• Bleeding after sex – this is rare.

Men may experience:

• Unusual discharge from the tip of the penis that may be white, yellow or green in colour
• Pain when urinating
• Inflammation or swelling of the foreskin
• Pain in the testicles – this is rare.

Infected semen or vaginal fluid in the eyes can cause inflammation of the eye (conjunctivitis). Unprotected anal or oral sex can lead to infection and symptoms in the rectum (discomfort, pain, bleeding or discharge) or throat (normally no symptoms).

Complications of gonorrhoea

If you get treatment for gonorrhoea early, it’s less likely to cause you any further problems. If you don’t get treatment, there’s a risk the infection might spread to other parts of your body and cause complications. Not everyone who gets gonorrhoea will have complications, but the more times you have the infection, the greater your chance of becoming infertile, for example.

• In women, gonorrhoea can lead to pelvic inflammatory disease if the infection spreads to your womb (uterus), fallopian tubes and ovaries. Pelvic inflammatory disease can make you infertile and cause ectopic pregnancy.
• In men, a gonorrhoea infection can spread to your testicles. This may lead to pain and inflammation (swelling) in the tubes that carry sperm. It’s possible this can make you infertile, but this is rare.

The infection can potentially spread to other parts of your body too. You can get symptoms such as:

• A fever
• Pain
• Tiredness
• Pain and swelling in your joints
• A rash
• Your heart and spine can also be affected.

Diagnosis and Testing

Testing for gonorrhoea can be done by:

• Taking a urine sample which is sent to the laboratory for testing (urine testing is preferable in men only)
• Taking a swab from the cervix or vagina in women, or from the urethral opening in men or women (for women who have had a hysterectomy) or from the anus in anyone who has had unprotected anal sex. This is done with a cotton swab or similar device and does not usually hurt
• Taking a swab from the throat of people who have had unprotected oral sex.

Treatment of gonorrhoea

It is important to receive treatment for gonorrhoea as quickly as possible. It is unlikely the infection will go away without treatment and, if you delay treatment, you risk the infection causing complications and more serious health problems. You may also pass the infection onto someone else.

Gonorrhoea is treated with a single dose of antibiotics, usually one of the following:

• Ceftriaxone
• Cefixime
• Spectinomycin

The antibiotics are either given orally (as a pill) or as an injection.

Abstaining from sexual intercourse – until treatment is complete, there is still a risk of complications and spread of infection.

Repeat testing in some cases – it is not always necessary to be tested to make sure the treatment has worked. However, the CDC recommends retesting for some patients, and a doctor will decide if it is necessary. Retesting should be performed 7 days after treatment.

If a woman is pregnant and infected with gonorrhea, the infant will be given an eye ointment to prevent gonorrhea transmission. However, antibiotics may be required if an eye infection develops.

Prevention of gonorrhoea

Gonorrhoea can be successfully prevented by:

• Using condoms (male or female) every time you have vaginal or anal sex.
• Using a condom to cover the penis, or latex or Plastic Square (dam) to cover the female genitals if you have oral sex.
• Not sharing sex toys. If you do share them, wash them and cover them with a new condom before anyone else uses them.
• Taking these precautions can also help to protect you from getting other sexually transmitted infections (STIs), such as genital herpes and chlamydia.
• Having sexual activity with a mutually monogamous, unaffected partner.
• Abstinence from sex.
• Before you have sex with a new partner, you could both consider having a test for gonorrhoea and other STIs.
• You can reduce your chances of getting gonorrhea by practicing safe sex, and by getting regular screenings.
• No sex until antibiotic treatment is completed and your usual sexual partner has completed treatment.
• A follow-up test must be done to make sure that treatment has cleared the infection.
• All sexual partners need to be contacted, tested and treated, if indicated. Even if partners have no symptoms they may be able to transmit infection to other sexual partners.
• Testing to exclude other sexually transmitted infections is advisable.