Gonorrhea – Acute inflammation of the urethra in men, the urethra and the cervix in women is usually accompanied by a discharge of pus. This is what gave rise to Galen in the II century AD. suggest the term “gonorrhea”. Although this name gives a misconception about the nature of the disease (the exact translation of “semination”, from the Greek gone – the seed, rhoia – the expiration), it was preserved, completely replacing the previously used synonyms “blenorrhea”, “pierce”, “gonorrhea”. However, contagious diseases in men with the expiration of pus from the urethra were known long before Galen. For example, in the V century BC. e. about them wrote Hippocrates, who also reported on white discharge from the genital organs in women. However, the allocation of approximately the same character is accompanied by inflammatory diseases of the urogenital organs of various nature (both infectious, caused by microorganisms, and non-infectious). Only the discovery in 1879 by a German scientist Neisser in the pus of a patient with a urethritis of a special microorganism, which naturally causes inflammation of the genitourinary organs in humans, made it possible to treat gonorrhea as an independent venereal disease with scientific certainty.
Etiology of gonorrhea. The causative agent of gonorrhea is gonococcus – a gram-negative diplococcum of a bean-shaped form. Its dimensions vary from 1.25 – 1.6 μm in length and 0.7-0.9 μm in width. Gonococci are well colored with all aniline dyes. In acute processes in stained smears, a large number of gonococci are detected inside the leukocytes. In later (chronic) stages of the disease, when the discharge becomes scarce, gonococci occur less frequently, and for their detection it is sometimes necessary to resort to provocation and cultural diagnostics.
In a scanning electron microscope, gonococci have the appearance of globular or diplococcal educated with slightly bumpy surface.
In the study of ultrathin sections, it is possible to identify a cell wall, a cytoplasmic membrane, a cytoplasm with numerous ribosomes, mesosomes, a nucleoid with DNA strands in gonococci. On the surface of gonococci thin tubular filaments are detected, which are associated with their ability to transmit genetically some properties, in particular resistance to antibiotics. The capsuloid-like substance revealed in the electron microscope ensures the adaptation of the pathogen to unfavorable conditions and its persistence in the patient’s body. The cytoplasmic membrane is related to the metabolism of the cell.
Under adverse conditions, L-transformation of gonococci is possible, in which loss of the cell outer shell is observed. Gonococci grow on artificial nutrient media in the presence of human protein (ascitic agar), at a temperature of 37 ° C.
Individual strains of gonococci produce penicillinase, which contributes to their resistance to penicillin and its derivatives. In many countries recently, with unsuccessful treatment, gonococci producing penicillinase or beta-lactamase are increasingly isolated.
Epidemiology of gonorrhea. Gonococci are human parasites. Outside the human body, they quickly die. They are disastrous for various antiseptic drugs, heating over 56 ° C, drying, direct sunlight. The temperature below the optimal gonococcal is poorly tolerated and rapidly killed at 18 ° C. In the pus gonococcus retain vitality and natogenicity, until the pathological substrate has dried (ie, from 30 minutes to 4-5 hours). Infection, as a rule, occurs sexually with direct contact of a healthy person with a patient (or externally healthy carrier). Occasionally, infection is detected not through sexual intercourse, but through infected toilet items, underwear, which is more common in young girls getting infected from their mothers, with a perverted sexual intercourse, gonococcal infection of the rectum, nasopharynx, mucous membrane of the mouth, tonsils. Infection of the eyes in adults is possible with the introduction of gonococci with hands that are contaminated with secretions. In infants, eye infection occurs when passing through the birth canal of sick mothers.
The increased susceptibility of the mucous membranes of the urogenital organs, rectum, nasopharynx, mouth, tonsils, conjunctiva is explained by biochemical hormonal, immune and anatomical and physiological features of the body of men, women and children. Gonococci parasitize and preferably infect the mucous membranes covered with cylindrical epithelium.
Immunity. With gonococcal infection, both humoral and cellular responses take place, but protective immunity does not develop, the ability to prevent reinfection. Detectable in the blood serum anti-tympanic antibodies belong to different classes of immunoglobulins (IgG, IgM, IgA).
A significant part of those who have recovered from gonorrhea get it repeatedly and even repeatedly, sometimes despite the high titer of specific antibodies in the blood serum and the presence of marked sensitization of lymphocytes to gonococci. In addition to reinfection, superinfection is possible with the preservation of the gonococcus in the body. Relative immunity to a homologous gonococcus strain is known in “family gonorrhea”, in which gonococci do not cause any noticeable inflammatory response in their permanent carriers, but cause an acute disease in the infecting of third parties. Superinfection by other pathogens of such spouses is accompanied by a clinical picture of acute gonorrhea.
Currently, the country uses the International Statistical Classification X revision, based on the provisions and principles of which the following classification of gonorrhea is proposed:
A54 Gonococcal infection
А54.0 Gonococcal infection of the lower sections of the genito-urinary tract without abscessing of the periurethral and accessory glands
Gonococcal:
- cervicitis
- cystitis
- urethritis
- vulvovaginitis
A54.1 Gonococcal infection of the lower parts of the genito-urinary tract with abscessing of the periurethral and accessory glands
Gonococcal abscess of Bartholin glands
A54.2 Gonococcal pelvic peritonitis and other gonococcal infection of the urogenital organs
Gonococcal:
- epididymitis
- inflammatory disease of pelvic organs in women
- orchitis
- prostatitis
A54.3 Gonococcal infection of the eye
Gonococcal:
- conjunctivitis
- iridocyclitis
Gonococcal ophthalmia of newborns
A54.4 Gonococcal infection of the musculoskeletal system
Gonococcal:
- arthritis
- bursitis
- osteomyelitis
- synovitis
- tenosynovite
A54.5 Gonococcal pharyngitis
A54.6 Gonococcal infection of the anorectal region
A54.8 Other gonococcal infections
Gonococcal:
- brain abscess
- endocarditis
- meningitis
- myocarditis
- pericarditis
- peritonitis
- pneumonia
- sepsis
- skin lesion
Infection of men with gonorrhea, as a rule, leads to the appearance of subjective symptoms that force them to seek medical help. In women, gonococcal infection often occurs little or no symptom and is detected in preventive examinations as sexual partners or in the development of complications. Apparently, this circumstance makes it possible to explain lesser self-reversibility of medical care for women than for men.
This makes it necessary to screen for gonorrhea women who have a high risk of infection.
The gateway for gonococci in men is most often the urethra. In the first 2 h, gonococci are delayed at the site of implantation and can be destroyed with the help of personal prevention methods. On the mucous membrane of the anterior part of the urethra (before the external sphincter) gonococci rapidly multiply, spreading both on its surface, and penetrating between the cells of the epithelium into the connective tissue layer, into the urethral glands and lacunae. Gradually gonococci penetrate into the posterior urethra. In this case, there is a risk of damage to the seminal vesicles, prostate gland, epididymis. The incubation period of gonorrhea is usually 3-5 days, but sometimes it can vary from 1 to 15 days or more.
Clinical picture of gonorrhea. Traditionally, according to the clinical course, the following forms of gonorrhea in men are distinguished:
- fresh, divided into acute, subacute and sluggish (torpid);
- chronic;
- latent.
All forms of gonorrheal infection of the urogenital organs can occur with a variety of local and distant (metastatic) complications.
Gonorrheic urethritis is characterized by secretions from the urethra of inflammatory exudates and various degrees of intensity with pain sensations. In acute inflammation, there is significant hyperemia and swelling of the sponges of the external orifice of the urethra. A large amount of yellowish-green or pale yellow pus is released from the urethral opening. Sometimes subjective sensations in the form of slight burning or itching precede mucopurulent discharge. The signs of inflammation are rapidly growing, and after 1-2 days, the anterior acute gonococcal urethritis is formed. Patients feel pain and pain when urinating. With subacute anterior fresh gonococcal urethritis, mucopurulent, ungrowth, inflammation of the sponges of the outer orifice of the urethra is poorly expressed, and subjective sensations are insignificant. In the case of torpid current in the process of fresh gonococcal urethritis, there are no subjective sensations, allocation is meager or almost imperceptible. Sponges of the external opening of the urethra are not changed. Patients in this case often do not seek medical help and are the most dangerous in epidemiological terms.
Later, with gonorrhea, even without treatment, a gradual decrease in the degree of inflammatory reaction occurs, subjective disorders become weaker, and urethritis passes into a subacute and then a chronic stage.
If gonococci from the anterior urethra are transported to the posterior urethra, acute total urethritis occurs. Symptoms of anterior urethritis are joined by signs of posterior urethritis (urethrocystitis). Complaints on imperative urges on urination become frequent, in the end of which there is a sharp pain (terminal). The amount of urine is very insignificant. Sometimes at the end of the act of urination appears a droplet of blood (terminal hematuria). In some cases, with severe inflammation, there is a temperature reaction, malaise.
Diagnosis. Diagnosis of acute gonococcal urethritis, both anterior and total, is not difficult. It is based on history, clinical typical disease pattern, a two-glassed sample and is confirmed by the detection of gonococci under laboratory conditions (microscopically and culturally). If the inflammatory process is limited only by the mucous membrane of the anterior urethra, then with the successive release of urine into two cups (a two-glassed sample), the urine in the first glass, flushing out of the urethra pus, will be cloudy, and in the second glass – transparent.
With total urethritis, the urine in two glasses will be turbid, since the pus from the posterior urethra flows into the bladder due to the failure of the internal sphincter and causes total pyuria.
Chronic gonococcal urethritis develops as a result of transformation of various forms of fresh gonorrheic urethritis. It is characterized by a pronounced foci of lesions – inflammation of individual parts of the mucous membrane, lacunae and glands. In cases of lesion of only the anterior part of the urethra, subjective sensations are expressed slightly, and sometimes completely absent. The presence of an inflammatory process is detected only with the appearance of excretions or gluing of the urethral sponges in the morning after a night’s sleep. Allocations are meager, pathological phenomena are sharply increased, up to an acute urinary retention. Chronic prostatitis is characterized by a protracted course with discharge from the urethra, itching and burning. Often secret secretion of the prostate gland after the act of urination (mikrotsionnaya irostanaya) or defecation (defecatory prostatea). There are various functional disorders of the genito-urinary tract, weakening of the erection, decreased libido, premature ejaculation. The secretion of the inflamed prostate gland reveals an increased content of leukocytes, a decrease in the number of lipoid grains, and sometimes their complete absence, the phenomenon of crystallization of the secret is broken. Gonococci are rare in bacterioscopy and more often in bacteriological studies. In any form of gonorrheal process, changes in blood are observed: anemia, leukopenia or leukocytosis, eosinophilia, neutrophilia and monocytosis. ESR is often increased in acute disease.