Gulshan Sethi Neisseria gonorrhoeae is a gram‐negative diplococcus which infects the urethra, cervix, anorectum, and pharynx. Involvement of the vagina is unusual because the stratified squamous epithelium of this organ is relatively resistant to infection. Infection may spread to the paraurethral and Bartholin’s glands, the fallopian tubes, and the endometrium. From the pharynx, infection may disseminate leading to systemic disease. Gonorrhoea is the second most common bacterial sexually transmitted infection (STI) in the United Kingdom.There were 70,936 diagnoses of gonorrhoea reported in 2019 [1]. In the United Kingdom, rates are highest in the 20–24 age group. The incubation period for gonorrhoea is between 2 and 10 days [2–4]. Approximately 50% of women with gonorrhoea are symptomatic [5]. Symptoms may include a vaginal discharge, dysuria, lower abdominal pain and, rarely, intermenstrual bleeding or menorrhagia. Rectal and pharyngeal infections are usually asymptomatic. Examination may be normal or reveal a purulent urethral discharge or mucopurulent cervicitis with or without pelvic tenderness. The gram‐negative diplococci of N. gonorrhoeae may be seen on examination of the cervical or anorectal discharge. In women, the sensitivity of microscopy is between 30% and 50% [6,7]. Culture is 100% specific, but the sensitivity of this technique is variable, depending on collection and transport techniques. In optimal conditions, sensitivity approaches 85–95% [5]. Samples for culture should be plated directly onto specialised culture media or sent to the laboratory in appropriate transport media. Culture, however, is not as good as the newer DNA detection techniques of nucleic acid amplification testing (NAAT) which are being used increasingly in the detection of gonorrhoea [8,9]. NAAT has sensitivities of up to 95% [10–13] and can be performed on urine specimens and self‐taken vulvovaginal swabs. However, it does not allow for antibiotic sensitivity testing. In low‐prevalence settings, the positive predictive value may be less than 80%, so confirmation by culture is necessary [10, 14]. The differential diagnosis includes Chlamydia trachomatis, and differentiation between the two is impossible on clinical grounds. Candidiasis, bacterial vaginosis, trichomoniasis, pelvic inflammatory disease, and herpes simplex can have similar features, and it is possible for gonorrhoea to coexist with these and other infections. Complications of gonorrhoea occur when the infection is left undiagnosed and untreated. This is more likely to occur when the infection is asymptomatic or when there is any barrier to access healthcare. Infection may spread from the urethra to the paraurethral glands and cause oedema of the urethral meatus and sometimes abscess formation. Infection of the Bartholin’s glands causes enlargement and, if untreated, abscess formation (Figure 12.1). Bartholin’s abscesses are easily visible, and treatment may require surgical intervention. Infection may spread from the cervix into the uterus and fallopian tubes, resulting in salpingitis and pelvic inflammatory disease (PID) with the consequent increased risks of tubal infertility, ectopic pregnancy, and chronic pelvic pain. In a study involving nearly 4000 cisgender women attending a sexual health clinic in the United Kingdom, PID was reported in approximately 14% of those with gonorrhoea [15]. Gonococcal infection during pregnancy can result in miscarriage, preterm delivery, and postpartum endometritis. Vertical transmission from mother to child can cause neonatal conjunctivitis and, more rarely, bacterial sepsis.
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Gonorrhoea
Epidemiology
Clinical features
Diagnosis
Differential diagnosis
Complications
Bartholin’s abscesses
Pelvic inflammatory disease
Pregnancy and neonatal infection
Conjunctival infection
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