Clinical and Morphological Diagnosis and Treatment of Sexually Transmitted Infections - Yakymova T. P. 2007

Gonorrhea. Clinical and morphological characteristics of modern gonorrhea. Treatment of gonorrhea.
Specifics of sample collection for the diagnosis of gonorrhea depending on sex and the nature of the pathological process

COLLECTING SPECIMENS FOR GONOCOCCUS TESTING

To confirm infection in women, three smears are simultaneously collected and examined: from the Urethra, Vagina, and cervix. At the same time, some authors consider examining vaginal contents for gonococci to be impractical due to the presence of an abundant mixed microflora in pathological conditions. Smears are prepared by spreading the biological material in a thin layer on a Glass slide and labeled with the letters U (urethra), V (vagina), and C (cervix). If rectal smears are also taken, they are labeled with the letter R (rectum). Typically, 2–3 smears are made on a single glass slide. When clinically indicated, secretions from Bartholin's glands and the rectum are also collected and examined. Rectal examinations are performed 3–4 hours after bowel movement. For this purpose, saline washings of the rectal mucosa are used. The washings are placed in test tubes, centrifuged, and the sediment is used for analysis. In addition, rectal smears can be obtained using a cotton swab.

For the Diagnosis of Gonorrhea and the preparation of smears in men, discharge is collected from the urethra in the morning before the first urination; prostate fluid is obtained after prostate massage, along with urine collected after prostate massage. If prostate massage is not performed, the first portion of morning urine is examined. Following prostate massage, the first drops of prostatic fluid are collected for bacterioscopic examination, placed on a Microscope slide, and thin smears are prepared. If urine is examined to detect gonococcal infection, 10–15 ml of freshly voided morning urine is delivered to the laboratory. The urine is centrifuged, and native preparations as well as stained smears are prepared from the sediment—which contains shed epithelium, pus, and urethral threads—followed by bacterioscopic examination. Urethral threads are found in the urine during chronic urethritis, most commonly of gonococcal origin. The length of these threads can range from a few millimeters to a centimeter. Urethral threads consist of mucus enclosing Cells (predominantly stratified squamous urethral epithelium) and leukocytes. The ratio of leukocytes to epithelial cells varies, resulting in The formation of either mucous or mucopurulent threads.

Microscopic examination of mucous threads reveals predominantly urethral epithelium in the form of large clusters and a small number of leukocytes, also embedded in fibrous mucus.

Mucopurulent threads contain numerous neutrophil granulocytes and a minor amount of urethral epithelium. Occasional red Blood Cells may also be present.

In chronic gonorrhea, urethral discharge is generally absent; therefore, it is easier to detect gonococci in urethral threads than in urine sediment.

Of particular interest in The Study of urine sediment are individual purulent clumps originating from suppurative foci in the urogenital tract. Purulent-bloody clumps and blood clots may also be identified. Smears must likewise be prepared from all these urinary formations and stained using standardized Methods. It should be noted that detecting gonococcal infection in urine is quite challenging, as the pathogen may become deformed in a liquid medium with varying pH. However, in cases of acute gonorrhea with a high concentration and virulence of the pathogen, this method can be effective.

In girls, three smears are prepared: from the urethra, vagina, and rectal washings. The infection in this group primarily manifests as vulvovaginitis. The biological material is collected by a clinician. Smears are made on at least 2 glass slides. Thin smears are prepared from all types of biological material and air-dried. The smears are stained with methylene blue, Gram stain, eosin, brilliant green, and Romanowsky-Giemsa stain. Gram staining is mandatory for confirming gonorrhea and is performed after diplococci are identified in one of the preliminary smears. Poorly prepared smears containing insufficient biological material are uninformative, and rendering a Conclusion based on them is not recommended. If acute gonorrhea is clinically suspected but no diplococci are found in the specimen, the smear collection is repeated for 3 consecutive days, provided that the pathogen was not detected in the first two tests and clinical suspicion persists. The smear must be thin, uniform, and free of thick deposits that hinder examination. When absolutely necessary, smears should not be collected within the first few hours following therapeutic manipulations. All types of biological specimens must be collected before, rather than after, therapeutic Procedures.

During routine preventive check-ups, material is collected on a single slide. If the physician suspects gonorrhea, the specimen is collected on two slides: one for methylene blue staining or another method, and the second for Gram staining if diplococci are detected.

A smear that has yielded a positive result for gonococcal diplococci must be stored in the laboratory for at least 6 months.

In recent years, cases of gonococcal infection of the Oral Cavity, eyes, and Pharynx (otorhinopharyngeal gonorrhea) have become more frequent. However, the oral cavity harbors a diplococcus that is difficult to distinguish from the gonococcus by bacterioscopy alone, necessitating bacteriological and biochemical testing. The bacterioscopic method is not a mere check of Cell/15.html">Microscopy data, but a complementary method that increases diagnostic reliability. This is necessary due to the Variability of the pathogen's microscopic and staining properties, as well as shifts in the clinical course of the disease, particularly in chronic gonorrhea. Acute gonorrhea typically lasts up to 2 months, whereas chronic gonorrhea lasts longer than 2 months.

MORPHOLOGICAL DIAGNOSIS OF GONORRHEA

The CAUSATIVE AGENT OF gonorrhea is Neisseria gonorrhoeae, discovered by Neisser in 1879. It is a gram-negative, non-motile diplococcus shaped like coffee beans with their concave sides facing inward, measuring 1.25 µm in length and 0.7 µm in width. It is an aerobe or facultative anaerobe. Gonococci possess a well-defined three-layered scalloped outer wall and a cytoplasmic membrane enclosing the Cytoplasm, which contains suspended Ribosomes, a nuclear vacuole, and is permeated by DNA strands.

Studies of gonococci stained by the Giemsa method have shown that 38.3% of strains possess a polysaccharide capsule, with encapsulated forms of gonococci occurring in nearly 60% of patients with chronic gonorrhea and 15% of those with acute gonorrhea.

The portals of entry for the gonococcus are mucous membranes lined with either squamous or columnar epithelium. Consequently, the most frequent localization of the process is urogenital gonorrhea involving the urethra in both men and women. The infection may subsequently spread via an ascending route to the Kidneys, cervix, cervical canal, fallopian tubes, and Ovaries in women, and to the Prostate Gland and Testes in men. Rarely, the gonococcus acts as the causative agent of purulent Conjunctivitis (blennorrhea). Even less frequently, the infection spreads to the Abdominal cavity, causing purulent Peritonitis, affects the joints and Heart Valves, and may even lead to gonococcal Sepsis. With inadequate therapy, especially self-Treatment, acute gonorrhea transitions into a chronic form.

Bacterioscopic examination is the most common laboratory method for diagnosing gonorrhea. In smears prepared from biological material, gonococci stain well with aniline Dyes and are easily identified in acute gonorrhea. A 1% aqueous solution of methylene blue is most frequently used for staining. With methylene blue staining in purulent material, intensely stained gonococci are particularly prominent against the Background of leukocytes and epithelial cells, whose cytoplasm stains pale blue and nuclei stain dark blue (color insert, Fig. 1). For the microscopic diagnosis of gonorrhea, this staining method is of orientational value only, as all cocci stain blue. Other dyes are also used to stain gonococci, such as brilliant green (color insert, Fig. 3), Romanowsky azure-eosin (color insert, Fig. 2), and Pappenheim's stain (color insert, Fig. 5).

Gram staining is a mandatory component of the bacterioscopic diagnosis of gonorrhea. It is based on the property of the gonococcal Cell wall to be decolorized by alcohol. In Gram staining, gonococci stain red, indicating a gram-negative reaction.

Materials for examination include discharge from the urethra, vagina, cervix, eye conjunctiva, rectum, prostate fluid, semen, and urine. When inflammatory exudate is present, it is preferable to use discharge from the lesions and prostate fluid (if available) rather than urine for diagnostic purposes. Urine is examined only when no other discharge from the urogenital tract is available. Prostatic fluid is examined after prostatic massage.

Discharge from various PARTS OF THE Urogenital System is collected using a spatula, brush, or cotton swab. Thin, uniform smears are prepared over a small area of a microscope slide and labeled to indicate the Water/144.html">Origin of the sample: U (urethra), C (cervix), V (vagina), etc. When an adequate amount of biological material is available, multiple smears are prepared for staining with methylene blue, Gram stain, or other methods.

When examining urine and prostatic fluid, they are first collected into centrifuge tubes. After centrifugation (for 5–6 minutes), smears are prepared from the sediment and stained. In chronic gonorrhea, urethral threads form, consisting of mucus, leukocytes, and stratified squamous epithelial cells. Their composition often varies: some are dominated by epithelial cells, while others are rich in inflammatory elements. If urethral threads or tissue fragments are present in the urine, they are collected separately for microscopic and bacterioscopic examination, spread evenly across a slide to form a smear, fixed, and stained.

Prostatic fluid and semen are poured into a Petri dish, thoroughly mixed to ensure an even distribution of cellular elements, and spread over three-quarters of the length of a microscope slide to prepare smears. The smears are air-dried, fixed, and stained. If material is abundant, separate micropreparations are prepared for native (unstained) examination. If material is scarce, a drop of semen or prostatic fluid is first placed on a microscope slide, covered with a coverslip, and examined microscopically. After examining the native preparation, the coverslip is gently slid to the side; if any biological particles remain on it, they are transferred to the slide. The preparation is then air-dried, and if the native preparation reveals purulent content and diplococci, it is stained using the Gram method. If no diplococci are observed in the native preparation, the smear is stained with methylene blue.

In acute cases, Gram-stained smears reveal A large number of gonococci against a purulent background, located both intracellularly within leukocytes and extracellularly (color insert, Fig. 4). In later Stages of the disease, when urogenital discharge becomes scant and contains fewer leukocytes, gonococci are often detected with difficulty (color insert, Fig. 6). They may be located not only within leukocytes but also inside epithelial cells and Protozoa (such as Trichomonas) in cases of mixed infection, while remaining viable. During the acute phase, the gonococcus is found in pure culture without extraneous microflora, suppressing the growth and viability of other microorganisms.

The direct immunofluorescence assay is used for the rapid detection of Neisseria species, including gonococci, in urogenital discharge. This method allows for the easy Differentiation of the gonococcus not only in cultures but also directly in urogenital secretions. Occasionally, differentiation is complicated by the uniform fluorescence of all members of the genus Neisseria.

To achieve earlier detection of gonococci in discharge from various sections of the urogenital tract in gonorrhea patients—particularly women—a delayed immunofluorescence method is employed. This method enables earlier identification of gonococci, especially in cases where the pathogen is not yet present as a monoculture in the test material, but rather in association with other microorganisms.

The morphological diagnosis of chronic gonorrhea is often fraught with great difficulty due to the fact that smears prepared from various biological specimens contain not only gonococci but also other microflora that obstruct the search for the pathogen. A second characteristic feature of specimens in chronic gonorrhea is the reduction in the number of gonococci compared to acute cases, accompanied by changes in their morphological and staining properties. Thus, the size of the diplococci may significantly increase or decrease. The bean-like shape may shift to a spherical one. However, it should be noted that despite the change from bean-shaped to spherical, gonococci remain diplococci. Such forms are most frequently located extracellularly. Upon Gram staining, they may alter their staining reaction, appearing dark blue (gram-positive) rather than red (gram-negative), which does not occur in acute gonorrhea (color insert, Fig. 4).

As noted above, smears are examined using stained and native preparations, provided The amount of biological material is sufficient. Stained smears are viewed under a microscope using an immersion objective (x90).

In acute gonorrhea, smears reveal a purulent inflammatory exudate with leukocytes covering the entire microscopic field. Gonococci occur in pairs. They resemble coffee beans with their concave surfaces facing each other, leaving a narrow cleft between them. In acute gonorrhea, other microflora are suppressed, and smears reveal gonococci exclusively as a pure culture.

In scrapings and discharges, gonococci are found among leukocytes within purulent masses, located both extracellularly and intracellularly in a staggered or "bee-swarm" pattern. In acute gonorrhea, laboratory physicians most commonly identify the pathogen inside neutrophil granulocytes within the purulent exudate, whereas in chronic gonorrhea, they are predominantly found extracellularly (col. insert, Figs. 1–6). At the same time, in the Cytology/cytology/16.html">Early stages of the disease, discharges may be mucous in nature, and gonococci can be found freely floating, extracellularly, or adhering to epithelial cells.

In chronic gonorrhea, discharges from the affected Organs may be absent.

In chronic gonorrhea, gonococci alter their staining properties, Morphology, and function. They become polymorphic, varying greatly in size from very large to very small, with rounded forms predominating over bean-shaped ones. Pathological Aschoff forms appear, which are degenerative in nature. These can present as micro- or macro-forms, losing their characteristic bean shape to become spherical diplococci. Occasionally, they diminish to dot-like dimensions.

As is well-known, the treatment of gonorrhea invariably involves Antibiotics. Within 10–12 hours after initiating treatment, gonococci can no longer be detected in smears. However, if treatment efficacy is insufficient, any microflora may be absent in the smears while the smear remains purulent, corresponding to a vaginal cleanliness grade of zero in women.

In latently progressing chronic gonorrhea, numerous neutrophil granulocytes are detected in smears, but gonococci and other microflora may be absent. In such cases, to prompt the appearance of the pathogen in the smears, a provocation is performed by parenterally administering gonovaccine or specific food products, which exacerbates the disease course and alters the microscopic COMPOSITION OF THE biological material. Additionally, a Bacteriological examination is mandatory.

During recovery following effective antibiotic therapy, a large number of degeneratively altered, partially disintegrated neutrophil granulocytes appear in the smears, along with other conventional microflora.

Upon complete recovery, neutrophil granulocytes and conventional microflora completely disappear from the smears, and in women, Döderlein's bacilli reappear.

TREATMENT OF GONORRHEA

The success of treating gonococcal infection depends on the rational USE OF ANTIMICROBIAL therapy combined with immunotherapy, local treatment, and physiotherapeutic procedures.

Simultaneous treatment of sexual partners and sources of infection is mandatory. For fresh, acute, uncomplicated gonorrhea, management is limited to antibiotics, whereas fresh protracted, complicated, and chronic forms require comprehensive combination therapy.

Fresh, acute, uncomplicated gonorrhea is treated on an outpatient basis. Hospitalization is carried out only according to specific indications. In the absence of contraindications, penicillin-group drugs serve as the primary antibiotics. As a result of administering these medications, inflammatory symptoms sharply decrease within 5–7 days, discharges become scanty, and gonococci are no longer found in them. In cases of successful treatment, 7–10 days after the cessation of antibiotic administration, procedures to determine cure are initiated.

If inflammatory symptoms persist 10–12 days after treatment and the exclusion of gonococci following provocation, these conditions are diagnosed as post-gonorrheal. Patients undergo additional evaluation and receive treatment in accordance with the etiological and topical diagnosis. In cases of early disease relapse—3 to 5 days, or sometimes a month, after completing antibiotic therapy—discharges and dysuric symptoms reappear, and examination reveals gonococci. In such instances, an acute uncomplicated relapse is possible. Treatment utilizes an alternative antibiotic from the tetracycline, macrolide, or aminoglycoside groups, among others. For patients with a sluggish, paucisymptomatic relapse, administering a combination of immunotherapy and local treatment prior to antibiotic therapy is recommended, preferably in an inpatient Setting.

For sluggish (torpid) and chronic forms of gonorrhea, a combined approach utilizing multiple therapeutic factors is especially necessary, preferably within a hospital setting. The administration of antibiotics is preceded by a comprehensive course of immunotherapy and local treatment. In cases of outpatient management, to prevent the spread of infection, antibiotics are prescribed concurrently with immunotherapy and topical agents.

Regarding sources of infection and sexual partners, treatment according to chronic gonorrhea therapeutic regimens must be carried out even if gonococci are not detected.

Etiological treatment. Antibiotics of the penicillin group are most frequently used: benzylpenicillin (sodium and potassium salts), bicillin, bicillin-3, bicillin-5, ampicillin, methicillin, oxacillin, ampiox (active against penicillinase-producing strains); carfecillin, augmentin, amoxicillin, sulfacillin. Tetracycline-series antibiotics—tetracycline, chlortetracycline, oxytetracycline, metacycline (rondomycin), doxycycline—are employed when penicillin derivatives cannot be used.

Chloramphenicol and macrolides—erythromycin, macropen, erythricycline, oletetrin—are convenient and can be administered orally. In addition to the aforementioned drugs, azalides such as azithromycin (sumamed) and roxithromycin (medecamycin), as well as Aminoglycosides like monomycin, gentamicin, kanamycin, and netilmicin (which, like ampiox, is active against penicillinase-producing strains), are widely utilized. Currently, foreign broad-spectrum Cephalosporins and quinolones, which exhibit a high degree of antigonococcal activity, are actively employed in the treatment of gonorrhea. To cure fresh acute uncomplicated gonorrhea, 1–2 doses of these drugs are sufficient.

These include cephalosporin antibiotics: cefaperazone, ceftriaxone, cefotaxime, cefaclor, cefobid, and cefuroxime. Ceftriaxone and cefotaxime are active against penicillinase-producing strains of gonococci. Belonging to this same active new Class of antibiotics are fluorinated quinolones, which are contraindicated in pregnant women and children under 14 years of age: Ciprobay (ciprofloxacin, enoxacin), Tarivid (ofloxacin), norfloxacin, Abaktal (pefloxacin), and Maxaquin. Also active against penicillinase-producing gonococci is a new antibiotic of the aminocyclitol group, spectinomycin (trobicin), and a semi-synthetic broad-spectrum antibiotic from the rifampicin group, rifampicin (though the latter is contraindicated in Pregnancy).

In cases of drug intolerance or antibiotic ineffectiveness, long-acting sulfonamide preparations combined with trimethoprim—such as Biseptol, Bactrim, Septrin, or Sulfatone—or long-acting sulfonamide agents alone, such as sulfamonomethoxine or sulfadimethoxine, are prescribed. Currently, for the treatment of fresh gonorrhea, single-dose preparations that ensure complete recovery with a single administration are particularly effective. Such properties are exhibited by Rocephin (ceftriaxone, administered intramuscularly as a single 250 mg dose); pefloxacin (abaktal) at a dose of 800 mg orally as a single dose; enoxacin (gyramid) 400 mg once daily; ciprofloxacin (ciprobay); the aminoglycoside netilmicin at a single intramuscular dose of 300 mg; and spectinomycin (trobicin) as a single intramuscular dose of 2 g for men and 4 g for women.

Combined sulfonamide preparations (Biseptol, Bactrim, Septrin) contain 0.4 g of sulfamethoxazole and 0.008 g of trimethoprim. Due to the synergistic action of their components, these agents exert an intensive bacteriostatic and bactericidal effect on gonococci, including antibiotic-resistant strains. Patients with fresh, acute, and subacute forms of gonorrhea are prescribed these medications orally at 4 tablets every 6 hours, for a total course of 16 tablets (7.68 g), whereas for other forms, the course is 20 tablets (9.6 g).

REGIMENS FOR THE TREATMENT OF GONORRHEA

Penicillin-group antibiotics: benzylpenicillin sodium and potassium salts. The initial dose is 60,000 IU intramuscularly, followed by 300,000 IU every 3 hours; the total course for fresh, acute, and subacute forms is 3,400,000 IU, while for fresh complicated, torpid, and chronic forms, it ranges from 4,200,000 IU to 6,800,000 IU depending on the severity of the condition.

Bicillin-1, bicillin-3, and bicillin-5 at 6,000,000 IU every 24 hours (administered in two simultaneous intramuscular injections); the total course is 3,600,000 IU for fresh forms, and 4,200,000 IU to 6,000,000 IU for torpid and chronic forms.

Ampicillin—0.5 g every 4 hours orally, total course from 3 g to 8 g depending on the stage of gonorrhea treatment; ampiox—0.6 g every 4 hours orally for 4–5 days or 5–7 days. Oxacillin—0.5 g orally 5 times daily, for a total course of 10–14 g.

Carfecillin – 0.5 g 3 times a day – 5–8 g.

Augmentin – 0.375 g orally every 8 hours for 5 days for acute forms, and for other forms – 0.750 mg every 8 hours for 3 days, followed by 0.375 g every 8 hours for the next 2 days – total course dose ranging from 5.625 to 9 g.

Sulcillin – 1.5 g every 8 hours, total course 6 to 9 g.

Amoxicillin (ampicillin trihydrate) – for acute gonorrhea, 3 g as a single dose with simultaneous oral administration of 1 g of probenecid to inhibit renal excretion of penicillin and maintain its therapeutic concentration in the blood; tetracycline antibiotics – tetracycline (chlortetracycline, oxytetracycline) – 0.3 g orally 5 times a day for 3 days, then 0.2 g 5 times a day for 2 days. Total course dose from 5 to 10 g.

Metacycline (rondomycin) – 0.6 g orally as a starting dose, then 0.3–0.4 g 3–4 times a day for another 2 days; total course dose from 2.4 to 4.8 g.

Doxycycline 0.2 g orally as a starting dose, then 0.1 g every 12 hours for 4 days – total course dose from 1.1 g to 1.5 g.

Levomycetin is prescribed at 0.5 g 6 times a day before meals, with an 8-hour nighttime break for 2–3 days; total course dose from 6 g to 10 g.

Macrolide antibiotics. Erythromycin – 0.05 g 6 times a day for 2 days and 0.4 g 5 times a day for 3 days; total course dose from 8.8 to 12 g.

Macropen – 0.4 g orally 6 times a day for 2 days, followed by 0.4 g 5 times a day up to a total course dose of 8.8 g to 12.8 g.

Erycycline – 0.250 g orally 5 times a day; total course dose up to 3–6 g.

Oletetrin 0.5 g as a starting dose, followed by 0.250 g 3 times later that day, and 0.250 g every 6 hours for the next 4 days; total course dose from 4 g to 7.5 g.

Azolide antibiotics – azithromycin (sumamed) 2 g as a single oral dose; roxithromycin (midecamycin or josamycin) 1 g as a single oral dose for all forms.

Aminoglycoside antibiotics – kanamycin – 1,000,000 IU intramuscularly every 12 hours or as a single daily dose for 2–3 days; total course dose from 2 to 6 million IU.

Netromicin – 200 mg intramuscularly twice daily for 3 days, then 200 mg once daily for 4 days; total course dose – 2 g.

Cephalosporin antibiotics – ceclor 0.5 g orally 4 times a day for 2 days, then 0.25 g 4 times a day for 1 day; total course dose from 5 to 7 g.

Cefobid 1 g intramuscularly once daily; total course dose 3–5 g.

Ceftriaxone 250 mg intramuscularly as a single dose, cefotaxime (claforan) 2 g intramuscularly as a single dose, cefuroxime 1.5 g intramuscularly as a single dose. Course doses for this group of antibiotics have not yet been established.

Fluorinated quinolones – Ciprobay (ciprofloxacin) – 500 mg orally (initial dose), then 250 mg every 12 hours for 3 days; total course dose of 1.25 g for acute gonorrhea.

Tarivid (ofloxacin) 400 mg orally (initial dose), then 200 mg twice daily up to a total course dose of 1.6 g for acute forms.

Abactal (pefloxacin) 600 mg orally once daily for 4 days as a single course; total course dose of 2.4 g for all forms of gonorrhea.

Maxaquin – 600 mg orally once daily for 4 days – total course dose of 2.4 g for all forms of gonorrhea.

Spectinomycin (trobicin) – a single intramuscular dose of 2 g for men, 4 g for women (2 g in each buttock), and for children according to age at 40 mg/kg (maximum dose – 2 g).

Rifampicin (contraindicated in pregnancy) – 0.3 g orally 30 minutes before meals, every 6 hours; total course dose from 1.5 to 6 g.

Immunotherapy. Some patients, particularly those with acute complicated, subacute torpid, or chronic gonorrhea, require combination therapy that primarily includes immune preparations. Specific immunotherapy using gonococcal vaccine takes precedence. The gonococcal vaccine is administered intramuscularly. Vaccine therapy is not prescribed for children under 3 years of age. In older children, the initial dose of the gonococcal vaccine should not exceed 50–100 million microbial bodies, and the maximum single dose for adolescents up to 15–16 years of age is 500 million microbial bodies. For adults, the gonococcal vaccine is initiated at 300–400 million microbial bodies, with a course of 6–8–10 injections. The maximum dose is 2 billion microbial bodies. Nonspecific immunotherapy includes: autohemotherapy, lactotherapy, pyrogenal, prodigiosan, methyluracil, myslopid, glycyram, T-activin, thymalin, and thymactine. Proteolytic Enzymes (Trypsin, Chymotrypsin, avelysin, streptokinase, lidase, Ribonuclease) exhibit anti-inflammatory and antibacterial-enhancing effects. They are used in standard doses.

Local treatment in men. For acute, torpid, and chronic urethritis – urethral irrigation with potassium permanganate solution (1:6000–1:1000), mercuric oxycyanide (1:8000), or chlorhexidine (1:5000) daily for 2–4 weeks.

For mild infiltrate, instillation of a 0.25–0.5% silver nitrate solution or a 2% protargol solution in a 50% dimethyl sulfoxide (DMSO) solution, or a 1% collargol solution every other day, with a course of 6–8–10 procedures.

For hard infiltrate, Vashkevich tamponade with a 2% protargol solution in glycerin or Kalanchoe juice in a 0.5% novocaine solution (1:1), or the insertion of metal bougies every 1–2 days, with a course of 6–8 procedures.

For granulation urethritis, instillations of a 0.5% silver solution or a 2–5% protargol solution in glycerin every other day, for a course of 6–8 procedures.

For persistent granulations, they are cauterized with a 10–20% silver nitrate solution 1–2 times a week.

For desquamative urethritis, daily instillations of 1% zinc sulfate or a mixture of a 0.5% zinc sulfate solution and lead acetate for 10–12 instillations.

For Skin lesions, warm baths with potassium permanganate (1:10000), rivanol (1:1000), or furatsilin (1:5000) are used, along with dusting powders containing dermatol or streptocide, streptocide liniment, and ointments such as hyoxysone, oxycort, celestoderm, etc.

Catarrhal colliculitis is treated with urethral bougienage every other day, 5–7 procedures per course. Additionally, the seminal colliculus is smeared with a 10–20% silver nitrate solution 1–2 times a week (5–7 procedures), along with physical therapy (diathermy, inductothermy, etc.).

For atrophic colliculitis, treatment includes bougienage, diathermy, and instillations into the posterior urethra of a 1:1 mixture of Kalanchoe juice and a 0.5% novocaine solution. Urethral strictures are an indication for bougienage and instillations of lidase, hydrocortisone, or 30–40% DMSO.

Cure is assessed 7–10 days after the completion of treatment. On the first day, the procedures include a physical examination, bacterioscopic examination of urethral discharge, a two-glass urine test, Palpation of the prostate gland and Seminal Vesicles with microscopic and bacteriological analysis of their secretions, and anterior ureteroscopy. The difficulty of detecting gonococci via bacterioscopic and BACTERIOLOGICAL EXAMINATION OF discharges has necessitated The Use of various provocation methods, which are based on tissue irritation in order to reveal infection in encapsulated or hidden foci.

The following provocation methods are used: chemical (in men, urethral instillation of a 0.25–0.5% silver nitrate solution; in women, swabbing of the urethra and the cervical canal with a 2–5% silver nitrate solution or Lugol's solution in glycerin).

The mechanical method in men involves bougienage of the urethra with a straight bougie for 10 minutes or anterior ureteroscopy.

The biological, alimentary, and thermal provocation methods are the same for both men and women. The biological method involves the intramuscular injection of gonovaccine or pyrogenal. The alimentary method involves consuming salty and spicy foods, and the thermal method involves warming the genitalia with inductothermic currents. For women, There is a physiological method: taking smears during menstruation. Combined provocation methods are the most effective. In men, 24, 48, and 72 hours after provocation, urethral discharge is collected for bacterioscopic examination; if no discharge is present, threads from the urine or a scrape from the urethral mucosa are used.

Bacteriological examination is necessary when gram-negative diplococci suspicious for gonococci are found in smears, in the presence of a history suggestive of gonorrhea with unclear clinical symptoms and negative bacterioscopic analysis results for gonorrhea. However, bacteriological examination is especially crucial when confirming the cure of gonorrhea in adults when inflammatory phenomena persist despite the absence of gonococci, as well as in children and pregnant women due to the impossibility of performing full-scale provocation. Inoculation is performed during combined provocation using chemical exposure at 48 and 72 hours, as well as during menstruation.

An important circumstance in the antibiotic treatment of gonorrhea is the fact that antibiotics possess varying degrees of treponemicidal action, which also affects cases of dual infection (gonorrhea and Syphilis). The incubation period and manifestations of syphilis are prolonged, accompanied by altered clinical symptoms. To ensure the timely diagnosis of syphilis in patients treated for gonorrhea who lack traceable sources of infection for dispensary observation, follow-up must be conducted for at least 6 months, during which repeated serological tests for syphilis should be performed.

Confirmation of cure in men following combined provocation, favorable bacterioscopic and bacteriological analyses, and a repeated clinical examination—including ureteroscopy and serological control for syphilis—is achieved 1–1.5 months after treatment.

If inflammatory signs persist despite the persistent absence of gonococci, a detailed clinical and Laboratory examination should be performed to detect post-gonorrheal inflammatory changes. The post-gonorrheal inflammatory process is most commonly sustained by vaginal trichomonads, chlamydia, ureasplasmas, Gardnerella, Candida Fungi, L-forms of Bacteria, and occasionally Herpes simplex virus type 2 and other microorganisms. It is mandatory to screen every gonorrhea patient for vaginal or urethral trichomonads, Candida fungi, chlamydia, and ureaplasmas. The principles and methods of treating patients with post-gonorrheal conditions do not differ from those used for Inflammatory Diseases of gonorrheal Etiology. When prescribing antibiotics and other chemotherapeutic agents, it is essential to consider the CHARACTERISTICS OF THE infectious agent and its sensitivity to the drugs used. For post-gonorrheal inflammatory processes caused by chlamydia, Mycoplasmas, Tetracyclines and quinolones, as well as the antibiotic azithromycin (sumamed), are the most effective.

Treatment of gonorrhea in women. Etiotropic agents, immunotherapy, and enzyme therapy are the same as those used in the treatment of male patients with corresponding forms of gonorrhea. In outpatient treatment, taking into account epidemiological vigilance, antibiotics, immunotherapy, and local treatment are prescribed simultaneously. Women with torpid and chronic gonorrhea require a gynecologist's consultation for both general treatment and rational local therapy in order to correct disorders in the hormonal regulation links that lead to Menstrual cycle irregularities and, consequently, impaired reproductive function.

Treatment for women wishing to preserve pregnancy should be carried out in a hospital setting. Benzylpenicillin is indicated at any stage of pregnancy, but in cases of individual intolerance, erythromycin, levomycetin, or sulfonamides are used. In the second half of pregnancy, course doses of benzylpenicillin are increased by 1.5–2 times. Among immunotherapeutic agents, gonovaccine is prescribed (starting from the II trimester of pregnancy) at a dose of 100–150 million microbial bodies for chronic gonorrhea and relapses. Local Treatment of the cervical canal, rectum, and urethra can be performed at all stages of pregnancy. No drugs are introduced into the cervical canal; only vaginal baths are permissible. The cure of gonorrhea in women is established 7–10 days after the end of treatment. A clinical examination is performed, including a bacterioscopic examination of discharge from the urethra, cervix, and lower rectum. This is followed by combined provocation (an injection of gonovaccine of 150–200 million microbial bodies, swabbing the vagina and vulva with Lugol's solution in glycerin, instilling 2–3 drops of a 0.5–1% silver nitrate solution into the urethra, and swabbing the lower rectum with Lugol's solution), followed by a bacterioscopic examination of the specified foci after 24, 48, and 72 hours, and a bacteriological examination after 2 or 3 days. A second control examination is mandatory during the nearest menstruation: smears are examined bacterioscopically three times at 24-hour intervals from the aforementioned foci. The third control examination is performed after the end of menstruation. Combined provocation is repeated, followed by bacterioscopy 1–3 days later and bacteriological analyses 2 or 3 days after provocation. If the results of the control clinical and laboratory examination are favorable, patients are discharged from medical registry.

Treatment of pregnant women is carried out in a hospital setting at any stage of gestation using antibacterial drugs that do not affect the fetus.

The drugs of choice during pregnancy are certain cephalosporins, macrolides, spectinomycin, and benzylpenicillin. Tetracyclines, fluoroquinolones, and aminoglycosides are contraindicated.

The use of immunomodulatory and biostimulating drugs in gonococcal infection must be strictly justified.

Assessment of the cure criteria for gonorrhea begins 7–20 days after the completion of the treatment course. The criteria for cure are: the absence of subjective and objective symptoms of the disease, and negative results from microscopic and culture studies. In the presence of clinical and laboratory data indicating the persistence of the inflammatory process, a re-examination with mandatory culture testing and the exclusion of co-infections is recommended.

Gonococci detected after completed treatment are most frequently the result of reinfection. When a gonorrhea relapse is established, a culture study with determination of gonococcal antibiotic sensitivity must be performed.

Prior to prescribing antibacterial drugs for gonorrhea, a serological screening for syphilis should be performed. Given the national epidemiological situation regarding syphilis incidence, if serological screening for syphilis cannot be performed on sexual partners, a repeat serological examination of the gonorrhea patient is conducted after 3 months.

When treating gonorrhea with an unknown source of infection, preference should be given to drugs that also possess activity against Treponema pallidum, i.e., exerting a preventive anti-syphilitic effect (ceftriaxone, azithromycin).

Sexual partners of patients with gonorrhea must undergo examination and treatment if sexual contact occurred within 30 days prior to the onset of the patient's symptoms. In cases of a subjectively asymptomatic course of gonorrhea, sexual partners who had sexual contact within 60 days before the diagnosis of gonorrhea was established are subject to examination and treatment.

Children must be examined if gonorrhea is detected in their mothers or caregivers.