Gonorrhea is a sexually transmitted infection caused by Neisseria gonorrhoeae. It is second only to chlamydial infection (discussed later) among reportable communicable diseases in the United States. With an estimated 350,000 cases reported in 2014, it remains a major public health problem. Coinfection with other STDs is common, particularly Chlamydia trachomatis, which is found in 30% of males with gonorrhea. The gravity of gonococcal infections has increased with the emergence of strains of N. gonorrhoeae that are resistant to multiple antibiotics.
Humans are the only natural reservoir for N. gonorrhoeae. The organism is highly fastidious, and spread of infection requires direct contact with the mucosa of an infected individual, usually during sexual activity. The bacteria initially attach to mucosal epithelium, particularly of the columnar or transitional type, using a variety of membrane-associated adhesion molecules and structures termed pili (Chapter 9). Such attachment prevents the organism from being unceremoniously flushed away by body fluids such as urine or endocervical mucus. The organism then penetrates through the epithelial cells to invade the deeper tissues of the host.
MORPHOLOGYN. gonorrhoeae provokesanintense,suppurativeinflammatoryreaction.Inmales,thismanifestsmostoftenasapurulenturethraldischarge,associatedwithanedematous,congestedurethralmeatus.Gram-negativediplococci,manywithinthecytoplasmofneutrophils,arereadilyidentifiedinGramstainsofthepurulentexudate(
Fig.18.21 ).Ascendinginfectionmayresultinthedevelopmentofacuteprostatitis,epididymitis(
Fig.18.22 ),ororchitis.Abscessesmaycomplicateseverecases.Urethralandendocervicalexudatestendtobelessconspicuousinfemales,althoughacuteinflammationofadjacentstructures,suchastheBartholinglands,isfairlycommon.Ascendinginfectioninvolvingtheuterus,fallopiantubes,andovariesresultsinacutesalpingitis,sometimescomplicatedbytuboovarianabscesses.Theacuteinflammatoryprocessisfollowedbythedevelopmentofgranulationtissueandscarring,withresultantstricturesandotherpermanentdeformitiesoftheinvolvedstructures,givingrisetopelvic inflammatory disease (Chapter19).
Fig. 18.21 Neisseria gonorrhoeae. Gramstainofurethraldischargedemon-stratescharacteristicgram-negative,intracellulardiplococci(arrow). (Courtesy of Dr. Rita Gander, Department of Pathology, University of Texas Southwestern Medical School, Dallas,Texas.)
Fig. 18.22 Acuteepididymitiscausedbygonococcalinfection.Theepididy-misisinvolvedbyanabscess.Normaltestisisseenontheright.
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In most infected males, gonorrhea is manifested by the presence of dysuria, urinary frequency, and a mucopurulent urethral exudate within 2 to 14 days of the time of initial infection. However, urethral gonococcal infection can be detected in 40% of asymptomatic male contacts of women with symptomatic gonorrhea. Treatment with appropriate anti-microbial therapy results in eradication of the organism and prompt resolution of symptoms. Untreated infections may ascend to involve the prostate, seminal vesicles, epididymis, and testis. Neglected cases may be complicated by chronic urethral stricture and, in more advanced cases, by permanent sterility. Untreated men also may become chronic carriers of N. gonorrhoeae.