Clinical and Morphological Diagnosis and Treatment of Sexually Transmitted Diseases - Yakimova T. P. 2007

Gonorrhea. Clinical and Morphological Characteristics of Modern Gonorrhea. Treatment of Gonorrhea

Gonorrhea is a common sexually transmitted infection. In some regions (such as Central Africa and parts of Asia), it has reached epidemic proportions.

The gonococcus was first isolated from cases of gonorrhea and blennorrhea by Neisser in 1879. The disease is transmitted primarily through sexual contact and causes purulent inflammation of the urogenital tract. The source of infection is an infected individual or a carrier with inadequately treated gonorrhea. On personal care items (such as towels and Sponges), the gonococcus can retain its virulence for up to 24 hours, which can also serve as a source of transmission, particularly for eye infections. Gonorrhea can likewise be transmitted via contaminated hands.

The contagiousness of gonococci is such that a single contact with an infected partner leads to transmission in 30% of cases.

Gonorrhea is an infectious disease characterized primarily by damage to the mucous membranes of the urogenital Organs. In addition, gonococcal infections of the oral mucosa—typically occurring after orogenital contact—as well as the rectum, ocular mucosa, synovial membranes, and serous membranes are also observed.

Although gonorrhea is transmitted almost exclusively through sexual contact, non-sexual transmission may occur in certain instances. Examples include young girls whose genitals are washed with sponges contaminated by the secretions of infected mothers; the sharing of chamber pots, bedding, or similar items with infected individuals; and the contamination of the eyes by the patients' own unwashed hands. Newborns can also acquire the infection during childbirth as the fetus passes through the birth canal of an infected mother.

The incubation period of the disease lasts 2 to 3 days, rarely exceeding 3 days. Immunity to gonorrhea does not develop, meaning that reinfection is possible after recovery, sometimes immediately.

In recent years, the epidemiological landscape of gonococcal infection has shifted. Cases have become increasingly common not only in major industrial centers, but also in smaller towns and rural areas.

The incidence rate has risen among young people aged 15–19, with frequent reports of reinfection. Of particular note is the steady increase in the incidence of gonorrhea among young women aged 16–18.

Currently, The ratio of male to female patients with gonorrhea has changed significantly: the incidence rate among men is now 1.5 to 2 times higher than among women. This statistic may be somewhat skewed due to the relative ease of diagnosing gonorrhea in men versus the difficulty of detecting it in women, given that the latter more frequently experience an asymptomatic course of the disease.

Gonococcal urethritis is the primary and most common manifestation of gonococcal infection in men. Gonococcal urethritis is classified into anterior and posterior forms, as well as acute (recent) and chronic stages.

The primary symptoms of anterior gonococcal urethritis are itching and a burning sensation around the external opening of the Urethra. These are followed by Swelling and hyperemia, and when pressure is applied to the urethra, a mucopurulent discharge emerges from the external meatus. After 24 to 48 hours, these symptoms intensify. Occasionally, the Lymphatic vessels in the Skin of the glans Penis become involved in the inflammatory process, leading to The Development of purulent lymphangitis. Patients report pain during urination and painful erections.

Gonorrhea is sometimes complicated by inflammation of the skin of the glans penis (balanitis) and the inner layer of the prepuce (posthitis). Typically, these conditions occur together, presenting clinically as balanoposthitis.

Gonorrhea is sometimes complicated by inflammation of the skin of the glans penis (balanitis) and the inner layer of the prepuce (posthitis). Typically, these conditions occur together, presenting clinically as balanoposthitis.

Initially, patients experience itching, burning, and a sensation of heat in the region of the glans penis. As the inflammatory response intensifies, involvement extends beyond the inner mucosal layer to the entire prepuce. Subsequently, edema of the foreskin increases, resulting in inflammatory phimosis. In some cases, the inflamed and edematous prepuce, when retracted behind the glans, traps it and causes the glans to swell, thereby leading to paraphimosis.

In acute, severe cases of gonococcal urethritis, the pathogen may occasionally invade the lymphatic Vessels of the penis, causing inflammation known as lymphangitis. Clinically, this condition most frequently manifests as firm, swollen cords along the urethral surface of the penis. Gonococcal lymphangitis may be accompanied by fever and chills.

In posterior gonococcal urethritis, the infection is not confined to the spongy portion of the urethra but gradually extends to its prostatic section. Along with the clinical signs typical of anterior urethritis, patients develop inflammation of the bladder neck, Prostate Gland, Seminal Vesicles, and Epididymis. Characteristic symptoms of posterior urethritis include frequent urges to urinate, frequent erections, pollakiuria, and occasionally Blood-tinged semen, known as hemospermia. Pus from the prostatic urethra enters the Urinary Bladder; consequently, pus is also detected in the urine, and dysuric symptoms become more pronounced.

In cases of inadequate Treatment, high pathogen virulence, or Antibiotic Resistance, acute gonococcal urethritis may occasionally progress to a chronic form, in which acute and subacute inflammatory signs subside, while the inflammatory process in the urethra assumes a protracted, torpid, and sluggish character.

Inflammation of the urethral glands and lacunae frequently occurs as a complication of gonococcal infection. The urethral glands are microscopic, cluster-like glands whose bodies reside in the submucosal tissue of the urethra, while their excretory ducts take a somewhat tortuous course through the thickness of the mucous membrane, opening onto its surface via 10–20 ducts emptying into the lacunae.

The lacunae lie within the walls of the spongy portion of the urethra, and isolated lacunae are also found in its prostatic section. Gonococcal lesions induce squamous metaplasia of the columnar epithelium in the prostatic urethra, followed by keratinization and marked thickening.

Chronic gonococcal urethritis may be associated with gonococcal involvement of the urethral glands, prostate gland, and seminal vesicles. Therefore, in all cases of chronic gonorrhea, it is essential to examine the urethral glands, prostate, and seminal vesicles.

Gonococcal urethritc strictures (narrowing) of the urethra are a consequence of chronic gonorrhea and are relatively rare, whereas strictures of the prostatic urethra occur even less frequently. The Diagnosis is established based on patient history, clinical Complaints, instrumental examination of the urethra using bulbous sounds or flexible and metal bougies, as well as urethrography.

Gonococcal inflammation of the preputial glands, located in the subcutaneous tissue on both sides of the frenulum of the prepuce, manifests as hyperemia and infiltration of the surrounding tissue.

Gonococcal inflammation of the bulbourethral (Cowper's) glands is frequently a cause of chronic urethritis and its recurrent flare-ups. The Bulbourethral Glands consist of two small structures located within the urogenital Diaphragm. They are complex tubular glands that produce a mucous secretion, and the orifices of their excretory ducts open at the Base of the urethral bulb.

Abscesses and fistulas are frequent consequences of Bulbourethral gland inflammation. The abscess may rupture into the urethra, or less commonly into the rectum or the perineal region.

Acute inflammation of the bulbourethral glands frequently assumes a chronic course.

Another complication of gonococcal urethritis is the involvement of the paraurethral glands and ducts. Typically, the paraurethral glands become infected concurrently with the urethra, though isolated infection is also possible. They frequently serve as a reservoir of chronic infection and contribute to disease relapses.

Inflammation of the cavernous bodies of the penis (cavernitis) develops when the gonococcal infection spreads beyond the periglandular Connective Tissue of the urethral glands into the corpus cavernosum of the urethra. Cavernitis can be localized or diffuse, and its clinical course may be acute or chronic.

One of the complications of gonococcal infection is colliculitis, which is a gonococcal lesion of the seminal colliculus. Colliculitis is characterized by clinical symptoms typical of posterior urethritis. Frequently, colliculitis is asymptomatic and is diagnosed only during ureteroscopy.

Gonorrheal inflammation of the epididymis (epididymitis) is a frequent occurrence. It arises from the penetration of gonococci into the epididymis from the prostatic urethra via the vas deferens or, bypassing it, through the lymphatic vessels. Gonococcal epididymitis is very often accompanied by concurrent involvement of the prostate gland and seminal vesicles.

Along with the epididymis, the vas deferens is frequently affected. In some cases, the fascia and Muscles of the Spermatic Cord are also involved in the pathological process. When the entire spermatic cord is affected, the gonococcal inflammatory process may extend to the subperitoneal tissue and subcutaneous fat, resulting in Phlegmon of the abdominal wall.

Typically, the gonococcal inflammatory process spreads from the epididymis to the Testis, leading to the development of gonorrheal orchitis.

Gonococcal inflammation of the prostate gland (prostatitis) can occur in acute and chronic forms. Based on The Nature and severity of the lesion, catarrhal, follicular, and parenchymatous prostatitis are distinguished.

Gonococcal inflammation of the seminal vesicles (vesiculitis) generally occurs in combination with prostatitis and epididymitis.

In women, the Introduction of gonococci into the urogenital organs in 60–65% of cases is associated with simultaneous or sequential infection of the urethra, paraurethral ducts, Vestibule of the Vagina, vestibular glands, vagina, cervix, or rectum. Most commonly, both the urethra and the cervical canal are affected simultaneously. Subsequently, other organs are frequently involved—such as the Fallopian tubes, Uterus, and even the Peritoneum, leading to the development of diffuse purulent Peritonitis.

Inflammatory Diseases of the Internal female reproductive organs are frequently accompanied by coinfection with gonococci and chlamydia, Mycoplasmas, Viruses, or other pathogenic microorganisms.

The clinical manifestations of gonococcal infection in women include: gonococcal urethritis, vulvitis (inflammation of the external genitalia), vestibulitis (involvement of the vaginal vestibule), bartholinitis (inflammation of the greater vestibular glands), gonococcal vaginitis, colpitis, cervicitis and Endocervicitis of the cervical canal, gonococcal endometritis (inflammation of the uterine mucosa), salpingitis (inflammation of the Fallopian tubes), salpingo-oophoritis (inflammation of the Fallopian tubes and Ovaries), and Pelvioperitonitis (inflammation of the pelvic serosa).

The invasion of gonococci into the urogenital mucosa and the development of acute and chronic inflammatory processes subsequently promote degenerative tissue changes that progress to atrophy, sclerosis, and ultimately stricture and obliteration of the Fallopian tubes, uterine cavity, and urethra.

The diagnosis of gonococcal infection is based on a comprehensive evaluation of the patient's medical history, complaints, Clinical presentation, and the detection of the causative agent in smears via cytological and bacterioscopic examination, as well as through bacteriological cultures.