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==Overview==
==Overview==
Gonorrhea ('''gonorrhoea''' in British English) is amongst the most common [[sexually transmitted disease]]s in the world and is caused by [[Gram-negative]] [[Bacteria|bacterium]] ''[[Neisseria gonorrheae]]''. The term comes from Ancient Greek γονόρροια (''gonórrhoia''), literally "flow of seed"; in ancient times it was incorrectly believed that the [[pus]] discharge associated with the disease contained semen.<ref>[http://www.yourdictionary.com/ahd/g/g0191000.html Definition of the term gonorrhea]</ref>
Gonorrhea ('''gonorrhoea''' in British English) is among the most common [[sexually transmitted diseases]] in the world. In the United States, gonorrhea is the second most common STD (after [[chlamydia]]).<ref name=Common-infection> CDC. Sexually transmitted disease surveillance 2013. Atlanta: US Department of Health and Human Services; 2014. </ref>
''[[Neisseria gonorrhoeae]]'' is a species of [[Gram-negative]], coffee bean-shaped [[diplococci]] [[bacteria]] responsible for the [[sexually transmitted infection]] [[gonorrhea]].<ref name=Sherris>{{cite book |editor1-last=Ryan |editor1-first=KJ |editor2-last=Ray |editor2-first=CG |title=Sherris Medical Microbiology | edition = 4th | publisher = McGraw Hill | year = 2004 | isbn = 0-8385-8529-9 }}</ref>


The first place this bacterium infects is usually the [[columnar epithelium]] of the [[urethra]] and [[endocervix]]. Non-genital sites in which it thrives are in the [[rectum]], the [[oropharynx]] and the [[conjunctiva]]e of the eyes. The [[vulva]] and [[vagina]] in women are usually spared because they are lined by [[stratified]] [[epithelial cell]]s—in women the [[cervix]] is the usual first site of infection.
Gonorrhea can infect mucus-secreting [[epithelial cells]] in both men and women.
The first place this bacterium infects is usually the [[columnar epithelium]] of the [[urethra]] and [[endocervix]]. Non-genital sites in which this bacterium thrives include the [[rectum]], the [[oropharynx]], and the [[conjunctiva|conjunctivae]] of the eyes.  
Established routes of transmission of ''[[Neisseria gonorrhoeae]]'' include vaginal and rectal intercourse, fellatio, cunnilingus, and [[perinatal]].
The main pathogenicity of the ''[[Neisseria gonorrhea]]'' stems from the ability of the [[pili|surface pili]] to attach to the surface of the [[urethra]], [[fallopian tubes]], and [[endocervix]].<ref name="pmid4958881">{{cite journal| author=Sparling PF| title=Genetic transformation of Neisseria gonorrhoeae to streptomycin resistance. | journal=J Bacteriol | year= 1966 | volume= 92 | issue= 5 | pages= 1364-71 | pmid=4958881 | doi= | pmc=276432 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4958881  }} </ref>
In '''pregnancy''', gonococcus can be transmitted to the fetus at the time of delivery.
Additionally, development of '''disseminated gonococcal infection''' is the result of ''Neisserial'' organisms' dissemination to the blood.<ref name=DGI>WATRING, WATSON G., and DANIEL L. VAUGHN. "Gonococcemia in pregnancy." Obstetrics & Gynecology 48.4 (1976): 428-430.</ref><ref name=DGI-2> Angulo, Juan M., and Luis R. Espinoza. "Gonococcal arthritis." Comprehensive therapy 25.3 (1999): 155-162.</ref>


Gonorrhea spreads during [[sexual intercourse]]. Infected women also can pass gonorrhea to their newborn infants during delivery, causing eye infections ([[conjunctivitis]]) in their babies (which if left untreated, can cause blindness). Doctors have often attempted to treat this immediately by applying small amounts of [[silver nitrate]] to the eyes of all newborn babies. Gonorrhea among females can also be transmitted from one individual to another via contact to surfaces that may still be damp from prior contact.
Common risk factors in the development of gonorrhea include sexual activity, multiple sex partners, previous history of [[sexually transmitted diseases]], having a sexual partner with a past history of any [[sexually transmitted disease]], and failure to use condoms during sex.<ref name="pmid9607868">{{cite journal| author=Klausner JD, Barrett DC, Dithmer D, Boyer CB, Brooks GF, Bolan G| title=Risk factors for repeated gonococcal infections: San Francisco, 1990-1992. | journal=J Infect Dis | year= 1998 | volume= 177 | issue= 6 | pages= 1766-9 | pmid=9607868 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9607868  }} </ref>
In 50 to 70% of women, the initial infection with ''[[Neisseria gonorrhea]]'' may be asymptomatic. The most common complication of untreated gonorrhea is [[pelvic inflammatory disease|pelvic inflammatory disease (PID)]], which may lead to increased risks of [[ectopic pregnancy]]. If left untreated, [[ectopic pregnancy]] can be life-threatening to the mother.<ref name="pmid2512520">{{cite journal| author=McNeeley SG| title=Gonococcal infections in women. | journal=Obstet Gynecol Clin North Am | year= 1989 | volume= 16 | issue= 3 | pages= 467-78 | pmid=2512520 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2512520  }} </ref>
In men, gonorrhea usually results in [[urethritis]], which may result in [[dysuria]]. If left untreated, gonorrhea may result in inflammation of the epididymis ([[epididymitis]]), prostate gland ([[prostatitis]]), and urethral structure. Disseminated gonococcal infection (DGI) occurs in about 0.5 to 3% of patients, commonly following asymptomatic mucosal infection in both sexes.  


===Historical Perspective===
Empiric treatment for gonorrhea is usually initiated prior to receipt of laboratory results. Nucleic acid amplification tests ([[NAAT|NAATs]]) are the test of choice in all individuals who present with urogenital symptoms.<ref name=CDC-Guid>"Sexually transmitted diseases treatment guidelines (2015)." Reproductive Endocrinology 24 (2015): 51-56.http://www.cdc.gov/std/tg2015/gonorrhea.htm Accessed on September 2015</ref>
Gonorrhea is an ancient disease with Biblical Testament references. However, the exact time of onset of gonorrhea cannot be accurately determined from the historical record.<ref name=History-Gonorreha> Genco, Caroline Attardo. Neisseria: molecular mechanisms of pathogenesis. Horizon Scientific Press, 2010.</ref>  
The mainstay of therapy for gonococcal infections is [[antimicrobial]] therapy. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials; accordingly, a combination therapy with [[azithromycin]] and a [[cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of [[antibiotic resistance]].<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
In 1879, gonorrhea was referred to as “the clap” by German bacteriologist Albert Neisser.<ref name=Gonorrhea> Unemo M, Shafer WM. Antimicrobial resistance in Neisseria gonorrhoeae in the 21st century: past, evolution, and future. Clin Microbiol Rev 2014;27:587–613. </ref>
Effective measures for the primary prevention of gonorrhea infection include practicing abstinence, avoiding high-risk sexual behaviors (e.g., having unprotected sex or multiple sexual partners), and using latex condoms. Measure for the secondary prevention of gonorrhea infection include early detection, treatment of sexual partners, and treatment of other [[sexually transmitted infections]] (e.g., [[chlamydia]]).<ref name=clinical-prevention>Centers for Disease Control and Pevention. clinical prevention guidance (2015). http://www.cdc.gov/std/tg2015/clinical.htm Accessed on September 25, 2016</ref><ref name=primary-prev>LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med 2014;161:894–901.</ref><ref name=gono-condom>Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36–51.</ref>


===Classification===
==Historical Perspective==
Based on anatomic location gonorrhea may be classified into three subtypes: urogenital, extragenital, and disseminated gonococcal infection.
Gonorrhea is an ancient disease with biblical references. However, the exact time of onset of gonorrhea in history cannot be accurately determined from the extant historical record.<ref name=History-Gonorreha> Genco, Caroline Attardo. Neisseria: molecular mechanisms of pathogenesis. Horizon Scientific Press, 2010.</ref> In 1879, gonorrhea was referred to as “the clap” by German bacteriologist Albert Neisser.<ref name=Gonorrhea> Unemo M, Shafer WM. Antimicrobial resistance in Neisseria gonorrhoeae in the 21st century: past, evolution, and future. Clin Microbiol Rev 2014;27:587–613. </ref>
Additionally, gonococcal infections may be classified according to the affected organ system into many subtypes.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid3101626">{{cite journal| author=Rompalo AM, Hook EW, Roberts PL, Ramsey PG, Handsfield HH, Holmes KK| title=The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis. | journal=Arch Intern Med | year= 1987 | volume= 147 | issue= 2 | pages= 281-3 | pmid=3101626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3101626  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
===Pathophysiology===
Gonorrhea is a sexually transmitted disease (STD) that is caused by ''[[Neisseria gonorrhea]]''.
It can infect mucus-secreting epithelial cells both in men and women.
The recognized routes of transmission of the ''[[Neisseria gonorrhoeae]]'' include vaginal intercourse, rectal intercourse, fellatio, cunnilingus, and [[perinatal]].
The main pathogenicity of the ''[[Neisseria gonorrhea]]'' obtains from the attachment ability of the [[pili|surface pili]] to the surface of the [[urethra]], [[fallopian tubes]] and [[endocervix]].<ref name="pmid4958881">{{cite journal| author=Sparling PF| title=Genetic transformation of Neisseria gonorrhoeae to streptomycin resistance. | journal=J Bacteriol | year= 1966 | volume= 92 | issue= 5 | pages= 1364-71 | pmid=4958881 | doi= | pmc=276432 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4958881  }} </ref><ref name="pmid4631989">{{cite journal| author=Swanson J| title=Studies on gonococcus infection. IV. Pili: their role in attachment of gonococci to tissue culture cells. | journal=J Exp Med | year= 1973 | volume= 137 | issue= 3 | pages= 571-89 | pmid=4631989 | doi= | pmc=2139381 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4631989  }} </ref><ref name="pmid9701824">{{cite journal| author=Wolfgang M, Lauer P, Park HS, Brossay L, Hébert J, Koomey M| title=PilT mutations lead to simultaneous defects in competence for natural transformation and twitching motility in piliated Neisseria gonorrhoeae. | journal=Mol Microbiol | year= 1998 | volume= 29 | issue= 1 | pages= 321-30 | pmid=9701824 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9701824  }} </ref>
Anotehr virulence factors of gonorrhea is [[porin]]. two main porin serotypes include PorB.1A strains (resulting in a disseminated gonococcal infection) and PorB.1B strains (resulting in local genital infections).<ref name="pmid6407021">{{cite journal| author=Young JD, Blake M, Mauro A, Cohn ZA| title=Properties of the major outer membrane protein from Neisseria gonorrhoeae incorporated into model lipid membranes. | journal=Proc Natl Acad Sci U S A | year= 1983 | volume= 80 | issue= 12 | pages= 3831-5 | pmid=6407021 | doi= | pmc=394146 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6407021  }} </ref><ref name="pmid11157049">{{cite journal| author=Ram S, Cullinane M, Blom AM, Gulati S, McQuillen DP, Monks BG et al.| title=Binding of C4b-binding protein to porin: a molecular mechanism of serum resistance of Neisseria gonorrhoeae. | journal=J Exp Med | year= 2001 | volume= 193 | issue= 3 | pages= 281-95 | pmid=11157049 | doi= | pmc=2195916 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11157049  }} </ref><ref name="pmid9705949">{{cite journal| author=Ram S, McQuillen DP, Gulati S, Elkins C, Pangburn MK, Rice PA| title=Binding of complement factor H to loop 5 of porin protein 1A: a molecular mechanism of serum resistance of nonsialylated Neisseria gonorrhoeae. | journal=J Exp Med | year= 1998 | volume= 188 | issue= 4 | pages= 671-80 | pmid=9705949 | doi= | pmc=2213355 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9705949  }} </ref>


In '''pregnancy''', gonococcus can be transmitted to the fetus at the time of delivery. This results in infection of the [[Neonatal Conjunctivitis|conjuctiva]]. This appears 1 to 4 days after birth as severe discharge with marked swelling and redness of the eyelids and conjunctiva.
==Classification==
Additionally, development of '''disseminated gonococcal infection''' is the result of ''Neisserial'' organisms dissemination to the blood due to a variety of predisposing factors, such as change in PH, pregnancy, menstruation, PorB.1A strains, and complement deficiencies.<ref name=DGI>WATRING, WATSON G., and DANIEL L. VAUGHN. "Gonococcemia in pregnancy." Obstetrics & Gynecology 48.4 (1976): 428-430.</ref><ref name=DGI-2> Angulo, Juan M., and Luis R. Espinoza. "Gonococcal arthritis." Comprehensive therapy 25.3 (1999): 155-162.</ref><ref name="pmid3088132">{{cite journal| author=Bohnhoff M, Morello JA, Lerner SA| title=Auxotypes, penicillin susceptibility, and serogroups of Neisseria gonorrhoeae from disseminated and uncomplicated infections. | journal=J Infect Dis | year= 1986 | volume= 154 | issue= 2 | pages= 225-30 | pmid=3088132 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3088132  }} </ref><ref name="pmid6415361">{{cite journal| author=O'Brien JP, Goldenberg DL, Rice PA| title=Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. | journal=Medicine (Baltimore) | year= 1983 | volume= 62 | issue= 6 | pages= 395-406 | pmid=6415361 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6415361  }} </ref>
Based on anatomic location, gonorrhea may be classified into three subtypes: [[urogenital]], extragenital, and disseminated gonococcal infection.
===Causes===
Additionally, gonococcal infections may be classified into many subtypes according to the affected organ system.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid3101626">{{cite journal| author=Rompalo AM, Hook EW, Roberts PL, Ramsey PG, Handsfield HH, Holmes KK| title=The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis. | journal=Arch Intern Med | year= 1987 | volume= 147 | issue= 2 | pages= 281-3 | pmid=3101626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3101626  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
'''''Neisseria gonorrhoeae''''', also known as '''''gonococci''''' (plural), '''''gonococcus''''' (singular), or '''gonorrhoea''' (in British English), is a species of [[Gram-negative]] coffee bean-shaped [[diplococci]] [[bacteria]] responsible for the [[sexually transmitted infection]] [[gonorrhea]].<ref name=Sherris>{{cite book |editor1-last=Ryan |editor1-first=KJ |editor2-last=Ray |editor2-first=CG |title=Sherris Medical Microbiology | edition = 4th | publisher = McGraw Hill | year = 2004 | isbn = 0-8385-8529-9 }}</ref>
 
Gonorrhea ('''gonorrhoea''' in British English) is amongst the most common [[sexually transmitted disease]]s in the world and is caused by [[Gram-negative]] [[Bacteria|bacterium]] ''[[Neisseria gonorrheae]]''. The term comes from Ancient Greek γονόρροια (''gonórrhoia''), literally "flow of seed"; in ancient times it was incorrectly believed that the [[pus]] discharge associated with the disease contained semen.<ref>[http://www.yourdictionary.com/ahd/g/g0191000.html Definition of the term gonorrhea]</ref>
==Pathophysiology==
===Differential diagnosis===
Gonorrhea is a sexually transmitted disease (STD) that is caused by the bacterium ''[[Neisseria gonorrhea]]''.
It can infect mucus-secreting epithelial cells in both men and women.
Established routes of transmission of the ''[[Neisseria gonorrhoeae]]'' include vaginal intercourse, rectal intercourse, fellatio, cunnilingus, and [[perinatal]].
The main pathogenicity of the ''[[Neisseria gonorrhea]]'' stems from the ability of the [[pili|surface pili]] to attach to the surface of the [[urethra]], [[fallopian tubes]], and [[endocervix]].<ref name="pmid4958881">{{cite journal| author=Sparling PF| title=Genetic transformation of Neisseria gonorrhoeae to streptomycin resistance. | journal=J Bacteriol | year= 1966 | volume= 92 | issue= 5 | pages= 1364-71 | pmid=4958881 | doi= | pmc=276432 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4958881  }} </ref><ref name="pmid4631989">{{cite journal| author=Swanson J| title=Studies on gonococcus infection. IV. Pili: their role in attachment of gonococci to tissue culture cells. | journal=J Exp Med | year= 1973 | volume= 137 | issue= 3 | pages= 571-89 | pmid=4631989 | doi= | pmc=2139381 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4631989  }} </ref><ref name="pmid9701824">{{cite journal| author=Wolfgang M, Lauer P, Park HS, Brossay L, Hébert J, Koomey M| title=PilT mutations lead to simultaneous defects in competence for natural transformation and twitching motility in piliated Neisseria gonorrhoeae. | journal=Mol Microbiol | year= 1998 | volume= 29 | issue= 1 | pages= 321-30 | pmid=9701824 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9701824  }} </ref>
Another virulence factor of gonorrhea is [[porin]]. There are two main porin serotypes: PorB.1A strains (resulting in a disseminated gonococcal infection) and PorB.1B strains (resulting in local genital infections).<ref name="pmid6407021">{{cite journal| author=Young JD, Blake M, Mauro A, Cohn ZA| title=Properties of the major outer membrane protein from Neisseria gonorrhoeae incorporated into model lipid membranes. | journal=Proc Natl Acad Sci U S A | year= 1983 | volume= 80 | issue= 12 | pages= 3831-5 | pmid=6407021 | doi= | pmc=394146 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6407021  }} </ref><ref name="pmid11157049">{{cite journal| author=Ram S, Cullinane M, Blom AM, Gulati S, McQuillen DP, Monks BG et al.| title=Binding of C4b-binding protein to porin: a molecular mechanism of serum resistance of Neisseria gonorrhoeae. | journal=J Exp Med | year= 2001 | volume= 193 | issue= 3 | pages= 281-95 | pmid=11157049 | doi= | pmc=2195916 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11157049  }} </ref><ref name="pmid9705949">{{cite journal| author=Ram S, McQuillen DP, Gulati S, Elkins C, Pangburn MK, Rice PA| title=Binding of complement factor H to loop 5 of porin protein 1A: a molecular mechanism of serum resistance of nonsialylated Neisseria gonorrhoeae. | journal=J Exp Med | year= 1998 | volume= 188 | issue= 4 | pages= 671-80 | pmid=9705949 | doi= | pmc=2213355 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9705949  }} </ref>
 
In '''pregnancy''', gonococcus can be transmitted to the fetus at the time of delivery. This results in infection of the [[Neonatal Conjunctivitis|conjuctiva]]. This appears 1 to 4 days after birth as severe discharge with marked swelling and redness of the eyelids and [[conjunctiva]].
Additionally, development of '''disseminated gonococcal infection''' is the result of ''Neisserial'' organisms' dissemination to the blood due to a variety of predisposing factors, such as change in PH, [[pregnancy]], [[menstruation]], PorB.1A strains, and complement deficiencies.<ref name=DGI>WATRING, WATSON G., and DANIEL L. VAUGHN. "Gonococcemia in pregnancy." Obstetrics & Gynecology 48.4 (1976): 428-430.</ref><ref name=DGI-2> Angulo, Juan M., and Luis R. Espinoza. "Gonococcal arthritis." Comprehensive therapy 25.3 (1999): 155-162.</ref><ref name="pmid3088132">{{cite journal| author=Bohnhoff M, Morello JA, Lerner SA| title=Auxotypes, penicillin susceptibility, and serogroups of Neisseria gonorrhoeae from disseminated and uncomplicated infections. | journal=J Infect Dis | year= 1986 | volume= 154 | issue= 2 | pages= 225-30 | pmid=3088132 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3088132  }} </ref><ref name="pmid6415361">{{cite journal| author=O'Brien JP, Goldenberg DL, Rice PA| title=Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. | journal=Medicine (Baltimore) | year= 1983 | volume= 62 | issue= 6 | pages= 395-406 | pmid=6415361 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6415361  }} </ref>
 
==Causes==
'''''Neisseria gonorrhoeae''''', also known as '''''gonococci''''' (plural), '''''gonococcus''''' (singular), or '''gonorrhoea''' (in British English), is a species of [[Gram-negative]], coffee bean-shaped [[diplococci]] [[bacteria]] that is responsible for the [[sexually transmitted infection]] [[gonorrhea]].<ref name=Sherris>{{cite book |editor1-last=Ryan |editor1-first=KJ |editor2-last=Ray |editor2-first=CG |title=Sherris Medical Microbiology | edition = 4th | publisher = McGraw Hill | year = 2004 | isbn = 0-8385-8529-9 }}</ref>
Gonorrhea ('''gonorrhoea''' in British English) is among the most common [[sexually transmitted diseases]] in the world. The term comes from the Ancient Greek word γονόρροια (''gonórrhoia''), literally "flow of seed"; in ancient times, it was incorrectly believed that the [[pus]] discharge associated with the disease contained semen.<ref>[http://www.yourdictionary.com/ahd/g/g0191000.html Definition of the term gonorrhea]</ref>
 
==Differential diagnosis==
Gonorrhea must be differentiated from other sexually transmitted pathogens, nongonococcal [[urethritis]], [[vaginitis]], [[cervicitis]], [[urinary tract infections]], [[prostatitis]], and [[orchitis]].
Gonorrhea must be differentiated from other sexually transmitted pathogens, nongonococcal [[urethritis]], [[vaginitis]], [[cervicitis]], [[urinary tract infections]], [[prostatitis]], and [[orchitis]].
Additionally, disseminated gonococcal infection must be differentiated from [[herpes simplex virus|herpes simplex virus (HSV)]], nongonococcal [[septic arthritis]], [[syphilis]], HIV infection,  [[rheumatic fever]], [[reactive arthritis]] , and [[Lyme disease]].<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid3101626">{{cite journal| author=Rompalo AM, Hook EW, Roberts PL, Ramsey PG, Handsfield HH, Holmes KK| title=The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis. | journal=Arch Intern Med | year= 1987 | volume= 147 | issue= 2 | pages= 281-3 | pmid=3101626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3101626  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
Additionally, disseminated gonococcal infection must be differentiated from [[herpes simplex virus|herpes simplex virus (HSV)]], nongonococcal [[septic arthritis]], [[syphilis]], [[HIV]] infection,  [[rheumatic fever]], [[reactive arthritis]] , and [[Lyme disease]].<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid3101626">{{cite journal| author=Rompalo AM, Hook EW, Roberts PL, Ramsey PG, Handsfield HH, Holmes KK| title=The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis. | journal=Arch Intern Med | year= 1987 | volume= 147 | issue= 2 | pages= 281-3 | pmid=3101626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3101626  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
===Epidemiology===
 
==Epidemiology==
Gonorrhea is a very common infectious disease.  
Gonorrhea is a very common infectious disease.  
In the United State, gonorrhea is the second most common STD after [[chlamydia]].<ref name=Common-infection> CDC. Sexually transmitted disease surveillance 2013. Atlanta: US Department of Health and Human Services; 2014. </ref>
In the United State, gonorrhea is the second most common STD (after [[chlamydia]]).<ref name=Common-infection> CDC. Sexually transmitted disease surveillance 2013. Atlanta: US Department of Health and Human Services; 2014. </ref>
In 2012, the incidence of gonorrhea was reported 106 million cases worldwide.<ref name=Gonorrhea-fact> World Health Organization. Emergence of multi-drug resistant Neisseria gonorrhoeae http://apps.who.int/iris/bitstream/10665/70603/1/WHO_RHR_11.14_eng.pdf Accessed on September 8, 2016</ref>
In 2012, the incidence of gonorrhea was reported as 106 million cases worldwide.<ref name=Gonorrhea-fact> World Health Organization. Emergence of multi-drug resistant Neisseria gonorrhoeae http://apps.who.int/iris/bitstream/10665/70603/1/WHO_RHR_11.14_eng.pdf Accessed on September 8, 2016</ref>
In 2014, a total 350,062 cases gonorrhea were reported in United States.<ref name=CDC-factsheet> Centers for Disease Control and Prevention. Reported STDs in the United States 2014 National Data for Chlamydia, Gonorrhea, and Syphilis http://www.cdc.gov/std/stats14/std-trends-508.pdf </ref>
In 2014, a total 350,062 cases of gonorrhea were reported in United States.<ref name=CDC-factsheet> Centers for Disease Control and Prevention. Reported STDs in the United States 2014 National Data for Chlamydia, Gonorrhea, and Syphilis http://www.cdc.gov/std/stats14/std-trends-508.pdf </ref>
===Risk factors===
 
Common risk factors in the development of gonorrhea include sexual activity, multiple sex partners, previous history of [[sexually transmitted disease]]s, partner with a past history of any [[sexually transmitted disease]], and failure to use a condom during sex.<ref name="pmid9607868">{{cite journal| author=Klausner JD, Barrett DC, Dithmer D, Boyer CB, Brooks GF, Bolan G| title=Risk factors for repeated gonococcal infections: San Francisco, 1990-1992. | journal=J Infect Dis | year= 1998 | volume= 177 | issue= 6 | pages= 1766-9 | pmid=9607868 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9607868  }} </ref><ref name=CDC-risk-gonorrhea>Centers for Disease Control and Prevention http://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm Accessed September 20, 2016</ref><ref name="pmid9314811">{{cite journal| author=Mertz KJ, Levine WC, Mosure DJ, Berman SM, Dorian KJ, Hadgu A| title=Screening women for gonorrhea: demographic screening criteria for general clinical use. | journal=Am J Public Health | year= 1997 | volume= 87 | issue= 9 | pages= 1535-8 | pmid=9314811 | doi= | pmc=1380985 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9314811  }} </ref>
==Risk factors==
===Screening===
Common risk factors for the development of gonorrhea include sexual activity, having multiple sex partners, previous history of [[sexually transmitted disease]]s, having a partner with a past history of any [[sexually transmitted disease]], and failure to use a condom during sex.<ref name="pmid9607868">{{cite journal| author=Klausner JD, Barrett DC, Dithmer D, Boyer CB, Brooks GF, Bolan G| title=Risk factors for repeated gonococcal infections: San Francisco, 1990-1992. | journal=J Infect Dis | year= 1998 | volume= 177 | issue= 6 | pages= 1766-9 | pmid=9607868 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9607868  }} </ref><ref name=CDC-risk-gonorrhea>Centers for Disease Control and Prevention http://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm Accessed September 20, 2016</ref><ref name="pmid9314811">{{cite journal| author=Mertz KJ, Levine WC, Mosure DJ, Berman SM, Dorian KJ, Hadgu A| title=Screening women for gonorrhea: demographic screening criteria for general clinical use. | journal=Am J Public Health | year= 1997 | volume= 87 | issue= 9 | pages= 1535-8 | pmid=9314811 | doi= | pmc=1380985 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9314811  }} </ref>
The U.S. Preventive Services and Task Force (USSTF) recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. The current evidence is insufficient to assess the balance of benefits and harms of screening for gonorrhea in [[heterosexual]] men. However, USSTF recommends at least annual screening for gonorrhea among men who have sex with men (MSM).<ref name=STD-guildline>{{cite web | title = 2015 Sexually Transmitted Diseases Treatment Guidelines (CDC) | url = http://www.cdc.gov/std/tg2015/screening-recommendations.htm }}</ref><ref name=Gonorrhea-recomm>Workowski KA, Bolan GA. Sexually transmitted diseases treat- ment guidelines, 2015. MMWR Recomm Rep 2015;64:60–68.</ref><ref name=USPSTF>US preventive services task forces. Gonorrhea and chlamydia screening (2014) https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/chlamydia-and-gonorrhea-screening Accessed on September 28, 2016</ref>
===Natural history, complications, and prognosis===
In 50 to 70% of women, the Initial infection with ''[[Neisseria gonorrhea]]'' may be asymptomatic.
Initial infection is usually seen in the cervical region, but due to the presence of the surface pili, the infection may ascend through the uterus into the fallopian tubes and finally out into the [[peritoneal cavity]]. 
The exact incubation period of gonorrhea is unknown. It may result in [[cervicitis]] and [[urethritis]] which may present with [[dysuria]], vaginal [[pruritus]] and vaginal [[mucopurulent discharge]]. 
If gonococcal infection left untreated, it can progress to [[fibrosis]]. The fibrosis can result in fallopian tube stricture, tubo-ovarian [[cyst]] or [[abscess]], [[pelvic inflammatory disease|pelvic inflammatory disease (PID)]], [[Fitz-Hugh-Curtis syndrome|Perihepatitis (Fitz-Hugh-Curtis syndrome)]],and bartholinitis.The most common complication of untreated gonorrhea is [[pelvic inflammatory disease|pelvic inflammatory disease (PID)]] which may lead to increased risks of [[ectopic pregnancy]]. If left untreated, [[ectopic pregnancy|Ectopic pregnancies]] can be life-threatening to the mother.<ref name="pmid2512520">{{cite journal| author=McNeeley SG| title=Gonococcal infections in women. | journal=Obstet Gynecol Clin North Am | year= 1989 | volume= 16 | issue= 3 | pages= 467-78 | pmid=2512520 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2512520  }} </ref><ref name="pmid7427703">{{cite journal| author=Stansfield VA| title=Diagnosis and management of anorectal gonorrhoea in women. | journal=Br J Vener Dis | year= 1980 | volume= 56 | issue= 5 | pages= 319-21 | pmid=7427703 | doi= | pmc=1045815 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7427703  }} </ref>
In men, untreated gonorrhea may result in inflammation of the epididymis ([[epididymitis]]), prostate gland ([[prostatitis]]) and urethral structure (urethritis).
disseminated gonococcal infection (DGI) occurs in about 0.5 to 3% of patients, commonly following asymptomatic mucosal infection in both sexes. However, women are more likely to developed disseminated gonococcal infection than men.
Disseminated gonococcal infection can lead to multiple distant sites of infection such as [[brain]], [[heart]] and [[joint]]s. Most common sign and symptoms include [[arthritis]] or [[arthralgias]], [[tenosynovitis]], and multiple skin lesions.


Common [[complications]] of gonococcal infection in women may include [[salpingitis]], [[pelvic inflammatory disease]], [[Infertility]], [[dyspareunia]], and [[ectopic pregnancy]]
==Screening==
Common [[complications]] of gonococcal infection in men may include post-inflammatory urethral strictures, [[abscess|urethral abscess]], [[lymphangitis|Penile lymphangitis]], *penile edema, [[urinary tract infection]], and [[kidney failure]].
The U.S. Preventive Services and Task Force (USSTF) recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. Current evidence is insufficient to assess the balance of benefits and harms of screening for gonorrhea in [[heterosexual]] men. However, USSTF recommends at least annual screening for gonorrhea among men who have sex with men (MSM).<ref name=STD-guildline>{{cite web | title = 2015 Sexually Transmitted Diseases Treatment Guidelines (CDC) | url = http://www.cdc.gov/std/tg2015/screening-recommendations.htm }}</ref><ref name=Gonorrhea-recomm>Workowski KA, Bolan GA. Sexually transmitted diseases treat- ment guidelines, 2015. MMWR Recomm Rep 2015;64:60–68.</ref><ref name=USPSTF>US preventive services task forces. Gonorrhea and chlamydia screening (2014) https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/chlamydia-and-gonorrhea-screening Accessed on September 28, 2016</ref>
 
==Natural history, complications, and prognosis==
In 50 to 70% of women, the initial infection with ''[[Neisseria gonorrhea]]'' may be asymptomatic.
Initial infection is usually observed in the cervical region, but due to the presence of the surface pili, the infection may ascend through the [[uterus]] into the [[fallopian tubes]] and finally out into the [[peritoneal cavity]]. 
The exact [[incubation period]] of gonorrhea is unknown. It may result in [[cervicitis]] and [[urethritis]], which may present with [[dysuria]], vaginal [[pruritus]], and vaginal [[mucopurulent discharge]]. 
If gonococcal infection is left untreated, it can progress to [[fibrosis]]. Fibrosis can result in fallopian tube stricture, tubo-ovarian [[cyst]] or [[abscess]], [[pelvic inflammatory disease|pelvic inflammatory disease (PID)]], [[Fitz-Hugh-Curtis syndrome|Perihepatitis (Fitz-Hugh-Curtis syndrome)]], and/or bartholinitis. The most common complication of untreated gonorrhea is [[pelvic inflammatory disease|pelvic inflammatory disease (PID)]], which may lead to an increased risk of [[ectopic pregnancy]]. If left untreated, [[ectopic pregnancy]] can be life-threatening for the mother.<ref name="pmid2512520">{{cite journal| author=McNeeley SG| title=Gonococcal infections in women. | journal=Obstet Gynecol Clin North Am | year= 1989 | volume= 16 | issue= 3 | pages= 467-78 | pmid=2512520 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2512520  }} </ref><ref name="pmid7427703">{{cite journal| author=Stansfield VA| title=Diagnosis and management of anorectal gonorrhoea in women. | journal=Br J Vener Dis | year= 1980 | volume= 56 | issue= 5 | pages= 319-21 | pmid=7427703 | doi= | pmc=1045815 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7427703  }} </ref>
In men, gonorrhea usually results in [[urethritis]], which may result in [[dysuria]]. If left untreated, gonorrhea may result in inflammation of the epididymis ([[epididymitis]]), prostate gland ([[prostatitis]]), and urethral structure (urethritis).
Disseminated gonococcal infection (DGI) occurs in about 0.5 to 3% of patients, commonly following asymptomatic mucosal infection in both sexes.
Disseminated gonococcal infection can lead to the infection of multiple distant sites such as the [[brain]], [[heart]], and [[joints]]. The most common signs and symptoms include [[arthritis]] or [[arthralgias]], [[tenosynovitis]], and multiple [[skin lesions]].
 
Common [[complications]] of gonococcal infection in women may include [[salpingitis]], [[pelvic inflammatory disease]], [[Infertility]], [[dyspareunia]], and [[ectopic pregnancy]].
Common [[complications]] of gonococcal infection in men may include post-inflammatory urethral strictures, [[abscess|urethral abscess]], [[lymphangitis|penile lymphangitis]], penile edema, [[urinary tract infection]], and [[kidney failure]].
The prognosis of urogenital and disseminated gonococcal infection are generally good with adequate treatment.
The prognosis of urogenital and disseminated gonococcal infection are generally good with adequate treatment.


==Diagnosis==
==Diagnosis==
===History and Symptoms===
===History and Symptoms===
It is critical to obtain a detailed and thorough sexual history from the patient. Specific areas of focus when obtaining a history from the patient include number and type of sexual partners, contraception use, and previous history of sexually transmitted diseases.The majority of women with gonorrhea are asymptomatic while others have [[vaginal discharge]], lower abdominal pain, or pain with intercourse. Common symptom of gonococcal infection among men includes [[urethritis]], which associated with burning with urination and discharge from the penis. Either sex may also acquire gonorrhea of the throat from performing oral sex on an infected partner, usually a male partner. Such infection is asymptomatic in 90% of cases, and produces a [[sore throat]] in the remaining 10%. The incubation period is 2 to 14 days with most of these symptoms occurring between 4–6 days after being infected.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid9038638">{{cite journal| author=Sherrard J, Barlow D| title=Gonorrhoea in men: clinical and diagnostic aspects. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 6 | pages= 422-6 | pmid=9038638 | doi= | pmc=1195730 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9038638  }} </ref><ref name="pmid76760">{{cite journal| author=Barlow D, Phillips I| title=Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects. | journal=Lancet | year= 1978 | volume= 1 | issue= 8067 | pages= 761-4 | pmid=76760 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=76760  }} </ref><ref name="pmid119330">{{cite journal| author=Osborne NG, Grubin L| title=Colonization of the pharynx with Neisseria gonorrhoeae: experience in a clinic for sexually transmitted diseases. | journal=Sex Transm Dis | year= 1979 | volume= 6 | issue= 4 | pages= 253-6 | pmid=119330 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=119330  }} </ref> Rarely, gonorrhea may cause skin legions and joint infection (pain and swelling in the joints) after traveling through the blood stream. Very rarely it may settle in the heart causing [[endocarditis]] or in the spinal column causing [[meningitis]].<ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
It is critical to obtain a detailed and thorough sexual history from the patient. Specific areas of focus when obtaining a history from the patient include number and type of sexual partners, contraception use, and previous history of sexually transmitted diseases. The majority of women with gonorrhea are asymptomatic, while some have [[vaginal discharge]], lower abdominal pain, or pain during intercourse. Common symptoms of gonococcal infection among men include [[urethritis]], which is associated with burning with urination and discharge from the penis. Either sex may also acquire gonorrhea of the throat from performing oral sex on an infected partner, usually a male partner. Such infection is asymptomatic in 90% of cases, and produces a [[sore throat]] in the remaining 10%. The [[incubation period]] is 2 to 14 days, with most of these symptoms occurring between 4 and 6 days after infection.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid9038638">{{cite journal| author=Sherrard J, Barlow D| title=Gonorrhoea in men: clinical and diagnostic aspects. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 6 | pages= 422-6 | pmid=9038638 | doi= | pmc=1195730 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9038638  }} </ref><ref name="pmid76760">{{cite journal| author=Barlow D, Phillips I| title=Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects. | journal=Lancet | year= 1978 | volume= 1 | issue= 8067 | pages= 761-4 | pmid=76760 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=76760  }} </ref><ref name="pmid119330">{{cite journal| author=Osborne NG, Grubin L| title=Colonization of the pharynx with Neisseria gonorrhoeae: experience in a clinic for sexually transmitted diseases. | journal=Sex Transm Dis | year= 1979 | volume= 6 | issue= 4 | pages= 253-6 | pmid=119330 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=119330  }} </ref> Rarely, gonorrhea may cause [[skin lesions]] and [[joint]] infection (pain and swelling in the joints) after traveling through the blood stream. Very rarely, it may settle in the heart, causing [[endocarditis]], or in the spinal column, causing [[meningitis]].<ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
 
===Physical examination===
===Physical examination===
Women with gonococcal infection usually appear to be well until complications such as [[Pelvic inflammatory disease|PID]] develop.  Physical examination of women with gonococcal infection is usually remarkable for [[mucopurulent discharge|mucopurulent]] [[urethral]], [[cervical]] or [[vaginal]] discharge, friable appearance of the cervix, and cervical motion tenderness. Common physical examination finding of gonococcal infection among men includes [[Mucopurulent discharge|mucopurulent]] urethral discharge. Less commonly penile edema, and epididymal tenderness and edema ([[epididymitis]]) may also be seen as a part of complicated gonococcal infection.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid9038638">{{cite journal| author=Sherrard J, Barlow D| title=Gonorrhoea in men: clinical and diagnostic aspects. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 6 | pages= 422-6 | pmid=9038638 | doi= | pmc=1195730 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9038638  }} </ref><ref name="pmid76760">{{cite journal| author=Barlow D, Phillips I| title=Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects. | journal=Lancet | year= 1978 | volume= 1 | issue= 8067 | pages= 761-4 | pmid=76760 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=76760  }} </ref>
Women with gonococcal infection usually appear to be well until the development of such complications as [[Pelvic inflammatory disease|PID]].  Physical examinations of women with gonococcal infection are usually remarkable for [[mucopurulent discharge|mucopurulent]] [[urethral]], [[cervical]], or [[vaginal]] discharge; friable appearance of the [[cervix]]; and cervical motion tenderness. Common physical examination finding of gonococcal infection in men include [[Mucopurulent discharge|mucopurulent]] urethral discharge. Less commonly, penile [[edema]] and epididymal tenderness and edema ([[epididymitis]]) may also be seen as part of a complicated gonococcal infection.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid9038638">{{cite journal| author=Sherrard J, Barlow D| title=Gonorrhoea in men: clinical and diagnostic aspects. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 6 | pages= 422-6 | pmid=9038638 | doi= | pmc=1195730 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9038638  }} </ref><ref name="pmid76760">{{cite journal| author=Barlow D, Phillips I| title=Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects. | journal=Lancet | year= 1978 | volume= 1 | issue= 8067 | pages= 761-4 | pmid=76760 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=76760  }} </ref>


Physical examination of patients with pharyngeal gonococcal infection is usually remarkable for mild pharyngeal exudates and rectal gonococcal infection is usually remarkable for [[Mucopurulent discharge|mucopurulent]] anal discharge.
Physical examination of patients with pharyngeal gonococcal infection is usually remarkable for mild pharyngeal exudates and rectal gonococcal infection is usually remarkable for [[Mucopurulent discharge|mucopurulent]] anal discharge.
Physical examination of patients with disseminated gonococcal infection (DGI) is usually remarkable for fever, pustular or vesicular rash, and musculoskeletal findings.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
Physical examination of patients with disseminated gonococcal infection (DGI) is usually remarkable for [[fever]], pustular or vesicular rash, and musculoskeletal findings.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
 
===Images===
===Images===
The following are images associated with gonorrhea physical examination.<ref>STD Gonorrhea Infection Gallery http://www.std-gov.org/std_picture/gonorrhea_w.htm Accessed on September 22, 2016</ref><ref name=CDCGonorrheapic>Centers for Disease Control and Prevention. Public Health Image Library (PHIL)  http://phil.cdc.gov/phil/home.asp Accessed on September 22, 2016</ref>
The following images are associated with gonorrhea physical examination.<ref>STD Gonorrhea Infection Gallery http://www.std-gov.org/std_picture/gonorrhea_w.htm Accessed on September 22, 2016</ref><ref name=CDCGonorrheapic>Centers for Disease Control and Prevention. Public Health Image Library (PHIL)  http://phil.cdc.gov/phil/home.asp Accessed on September 22, 2016</ref>
<div align="center">
<div align="center">
<gallery heights="150" widths="150">
<gallery heights="150" widths="150">
Image: Gonorrhea07.jpeg|Purulent discharge emanating from the cervical os, and pooling in the vagina
Image:Gonorrhea penile discharge.jpg|Penile discharge in a patient with gonorrhea - Source: https://www.std.gov/
Image:Gonorrhea penile discharge.jpg|Penile discharge in a patient with gonorrhea
Image:220px-Gonococcal_ophthalmia_neonatorum.jpg|[[Ophthalmia neonatorum]] - Source: https://www.cdc.gov/
Image:Gonorrhea20.jpg|Gonococcal pharyngitis
Image:220px-Gonococcal_ophthalmia_neonatorum.jpg|[[Ophthalmia neonatorum]]
Image:Gonorrhea28.jpg[[Colposcopic]] view of this patient’s [[cervix]] reveled an eroded ostium due to Neisseria gonorrhea infection
Image:Gonorrhea28.jpg[[Colposcopic]] view of this patient’s [[cervix]] reveled an eroded ostium due to Neisseria gonorrhea infection
Image:Gonorrhea29.jpg|The lesion on the left hand due to the systemic dissemination of the Neisseria gonorrhea.
Image:Gonorrhea35.jpg|Lesions of skin and arthritic knee joints due to Neisseria gonorrhea - Source: https://www.cdc.gov/
Image:Gonorrhea35.jpg|Lesions of skin and arthritic knee joints due to Neisseria gonorrhea
</gallery>
</gallery>
</div>
</div>
===Laboratory tests===
===Laboratory tests===
Empiric treatment for gonorrhea usually is initiated prior to the laboratory result. A microbiologic diagnosis is important for further management in order to determining the need for test of cure, partner management, and public health reasons.
Empiric treatment for gonorrhea is usually initiated prior to the receipt of laboratory result. A microbiologic diagnosis is important for further management in order to determine the need for further testing, partner management, and public health considerations.
Any sexually active man or women presenting with signs and symptoms of [[urethritis]], [[cervicitis]], [[pelvic inflammatory disease]], and [[epididymitis]] should undergo diagnostic testing for ''[[Neisseria  gonorrhea]]''. Additionally, disseminated gonococcal infection (DGI) should be consider in all young sexually active individuals who present with [[arthralgias]] or suspected  [[septic arthritis]].
Any sexually active man or women presenting with signs and symptoms of [[urethritis]], [[cervicitis]], [[pelvic inflammatory disease]], and [[epididymitis]] should undergo diagnostic testing for ''[[Neisseria  gonorrhea]]''. Additionally, the possibility of disseminated gonococcal infection (DGI) should be considered in all young sexually active individuals who present with [[arthralgias]] or suspected  [[septic arthritis]].
Common laboratory tests for gonococcal infection may include [[Gram Stain]], [[culture]], nucleic acid amplification tests (NAATs), and Non-amplified tests. Nucleic acid amplification tests (NAATs) is a test of choice in all individuals who present with urogenital symptoms.<ref name=CDC-Guid>"Sexually transmitted diseases treatment guidelines (2015)." Reproductive Endocrinology 24 (2015): 51-56.http://www.cdc.gov/std/tg2015/gonorrhea.htm Accessed on September 2015</ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
Common laboratory tests for gonococcal infection may include [[gram stain]], [[culture]], nucleic acid amplification tests ([[NAAT]]), and non-amplified tests. Nucleic acid amplification tests are the test of choice in all individuals who present with urogenital symptoms.<ref name=CDC-Guid>"Sexually transmitted diseases treatment guidelines (2015)." Reproductive Endocrinology 24 (2015): 51-56.http://www.cdc.gov/std/tg2015/gonorrhea.htm Accessed on September 2015</ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
Additionally, synovial fluid analysis is usually sent for cell count, differential, [[gram stain]], [[culture|bacterial culture]] and [[NAAT]] in patients with suspected DGI.<ref name="pmid8185698">{{cite journal| author=Muralidhar B, Rumore PM, Steinman CR| title=Use of the polymerase chain reaction to study arthritis due to Neisseria gonorrhoeae. | journal=Arthritis Rheum | year= 1994 | volume= 37 | issue= 5 | pages= 710-7 | pmid=8185698 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8185698  }} </ref>
 
===Other diagnostic studies===
===Other diagnostic studies===
Other diagnostic studies are used when NAAT or culture are not available. Other diagnostic studies for gonorrhea infection include rapid NAAT assay (modular-cartridge based platform), [[leukocyte esterase|leukocyte esterase urine test]], Immunochromatographic tests, Nucleic acid hybridization tests and [[enzyme immunoassay|enzyme immunoassay (EIA)]].<ref name="pmid23467600">{{cite journal| author=Gaydos CA, Van Der Pol B, Jett-Goheen M, Barnes M, Quinn N, Clark C et al.| title=Performance of the Cepheid CT/NG Xpert Rapid PCR Test for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae. | journal=J Clin Microbiol | year= 2013 | volume= 51 | issue= 6 | pages= 1666-72 | pmid=23467600 | doi=10.1128/JCM.03461-12 | pmc=3716060 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23467600  }} </ref><ref name="pmid23093736">{{cite journal| author=Watchirs Smith LA, Hillman R, Ward J, Whiley DM, Causer L, Skov S et al.| title=Point-of-care tests for the diagnosis of Neisseria gonorrhoeae infection: a systematic review of operational and performance characteristics. | journal=Sex Transm Infect | year= 2013 | volume= 89 | issue= 4 | pages= 320-6 | pmid=23093736 | doi=10.1136/sextrans-2012-050656 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23093736  }} </ref><ref name="pmid8417014">{{cite journal| author=Vlaspolder F, Mutsaers JA, Blog F, Notowicz A| title=Value of a DNA probe assay (Gen-Probe) compared with that of culture for diagnosis of gonococcal infection. | journal=J Clin Microbiol | year= 1993 | volume= 31 | issue= 1 | pages= 107-10 | pmid=8417014 | doi= | pmc=262630 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8417014  }} </ref>
Other diagnostic studies are used when [[NAAT]] or culture are not available. Other diagnostic studies for gonorrhea infection include rapid NAAT assay (modular-cartridge based platform), [[leukocyte esterase|leukocyte esterase urine test]], immunochromatographic tests, nucleic acid hybridization tests, and [[enzyme immunoassay|enzyme immunoassay (EIA)]].<ref name="pmid23467600">{{cite journal| author=Gaydos CA, Van Der Pol B, Jett-Goheen M, Barnes M, Quinn N, Clark C et al.| title=Performance of the Cepheid CT/NG Xpert Rapid PCR Test for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae. | journal=J Clin Microbiol | year= 2013 | volume= 51 | issue= 6 | pages= 1666-72 | pmid=23467600 | doi=10.1128/JCM.03461-12 | pmc=3716060 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23467600  }} </ref><ref name="pmid23093736">{{cite journal| author=Watchirs Smith LA, Hillman R, Ward J, Whiley DM, Causer L, Skov S et al.| title=Point-of-care tests for the diagnosis of Neisseria gonorrhoeae infection: a systematic review of operational and performance characteristics. | journal=Sex Transm Infect | year= 2013 | volume= 89 | issue= 4 | pages= 320-6 | pmid=23093736 | doi=10.1136/sextrans-2012-050656 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23093736  }} </ref><ref name="pmid8417014">{{cite journal| author=Vlaspolder F, Mutsaers JA, Blog F, Notowicz A| title=Value of a DNA probe assay (Gen-Probe) compared with that of culture for diagnosis of gonococcal infection. | journal=J Clin Microbiol | year= 1993 | volume= 31 | issue= 1 | pages= 107-10 | pmid=8417014 | doi= | pmc=262630 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8417014  }} </ref>


==Treatment==
==Treatment==
===Medical therapy===
===Medical therapy===
The mainstay of therapy for gonococcal infections is antimicrobial therapy.  Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials, therefore a combination therapy with [[Azithromycin]] and a [[Cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of resistance.<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
The mainstay of therapy for gonococcal infections is [[antimicrobial]] therapy.  Gonorrhea treatment is complicated by the ability of ''N. gonorrhoeae'' to develop resistance to antimicrobials; accordingly, a combination therapy with [[azithromycin]] and a [[cephalosporin]] is used to improve treatment efficacy and potentially slow the emergence and spread of [[antibiotic resistance]].<ref>{{Cite journal| issn = 1545-8601| volume = 64| issue = RR-03| pages = 1–137| last1 = Workowski| first1 = Kimberly A.| last2 = Bolan| first2 = Gail A.| title = Sexually transmitted diseases treatment guidelines, 2015| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2015-06-05| pmid = 26042815}}</ref>
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*[[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
*[[Ceftriaxone]] 1-2 g IV  q 12-24 h  for 10-14 days {{and}} [[Azithromycin]] 1 g PO in a single dose
|}
|}
===Antibiotic resistant===
===Antibiotic resistant===
Gonorrhea treatment is complicated by the ability of ''[[Neisseria gonorrhoeae]]'' to develop resistance to antimicrobials. High-level resistance to expanded-spectrum [[cephalosporins]] and [[Azithromycin]] is now reported, and it seems developing another effective treatment has become unaffordable. Although new combination antibiotic treatments are being evaluated. There are no affordable alternative therapeutic options currently available for the treatment of gonococcal disease. and it seems even newly developed antibiotics will be short solution and may be developed resistance as well.<ref name=Gono-resis>Centers for Disease Control and Prevention. Combating the Threat of Antibiotic-Resistant Gonorrhea. (2016) http://www.cdc.gov/std/gonorrhea/arg/carb.htm Accessed on September 25, 2016</ref>
Gonorrhea treatment is complicated by the ability of ''[[Neisseria gonorrhoeae]]'' to develop resistance to antimicrobials. High-level resistance to expanded-spectrum [[cephalosporins]] and [[azithromycin]] is now reported, and it seems that developing another effective treatment has become unaffordable for pharmaceutical companies, though new combination [[antibiotic]] treatments are being evaluated. There are no affordable alternative therapeutic options currently available for the treatment of gonococcal disease, and it seems even newly developed antibiotics will be short-term solutions, as the bacterium may well develop resistance to them, too.<ref name=Gono-resis>Centers for Disease Control and Prevention. Combating the Threat of Antibiotic-Resistant Gonorrhea. (2016) http://www.cdc.gov/std/gonorrhea/arg/carb.htm Accessed on September 25, 2016</ref>


'''In 2006, CDC had five recommended treatment options for gonorrhea—now the U.S. has only one option remaining'''
'''In 2006, CDC had five recommended treatment options for gonorrhea. Currently, the U.S. has only one remaining option.'''
[[Image:Drug_in_Gonorrhea.jpg|500px|thumb|center]]
[[Image:Drug_in_Gonorrhea.jpg|500px|center|thumb|Source: https://www.cdc.gov/]]


===Primary prevention===
===Primary prevention===
Effective measures for the primary prevention of gonococcal infection include accurate risk assessment and counseling, practicing abstinence, avoiding high-risk sexual behaviors such as unprotected sex or multiple sexual partners, using latex condoms and being in a long-term monogamous relationship with uninfected partner.<ref name=clinical-prevention>Centers for Disease Control and Pevention. clinical prevention guidance (2015). http://www.cdc.gov/std/tg2015/clinical.htm Accessed on September 25, 2016</ref><ref name=primary-prev>LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med 2014;161:894–901.</ref><ref name=gono-condom>Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36–51.</ref>
Effective measures for the primary prevention of gonococcal infection include accurate risk assessment and counseling, practicing abstinence, avoiding high-risk sexual behaviors (e.g., unprotected sex or multiple sexual partners), using latex condoms, and being in a long-term and monogamous relationship with an uninfected partner.<ref name=clinical-prevention>Centers for Disease Control and Pevention. clinical prevention guidance (2015). http://www.cdc.gov/std/tg2015/clinical.htm Accessed on September 25, 2016</ref><ref name=primary-prev>LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med 2014;161:894–901.</ref><ref name=gono-condom>Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36–51.</ref>
 
===Secondary prevention===
===Secondary prevention===
Strategies for the secondary prevention of gonococcal infection include early detection, treatment of sexual partners, and treatment of other sexually transmitted infections (such as [[chlamydia]]).<ref name=clinical-prevention>Centers for Disease Control and Pevention. clinical prevention guidance (2015). http://www.cdc.gov/std/tg2015/clinical.htm Accessed on September 25, 2016</ref><ref name=primary-prev>LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med 2014;161:894–901.</ref><ref name=gono-condom>Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36–51.</ref>
Strategies for the secondary prevention of gonococcal infection include early detection, treatment of sexual partners, and treatment of other sexually transmitted infections (e.g., [[chlamydia]]).<ref name=clinical-prevention>Centers for Disease Control and Pevention. clinical prevention guidance (2015). http://www.cdc.gov/std/tg2015/clinical.htm Accessed on September 25, 2016</ref><ref name=primary-prev>LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med 2014;161:894–901.</ref><ref name=gono-condom>Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36–51.</ref>
 
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 21:55, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Gonorrhea (gonorrhoea in British English) is among the most common sexually transmitted diseases in the world. In the United States, gonorrhea is the second most common STD (after chlamydia).[1] Neisseria gonorrhoeae is a species of Gram-negative, coffee bean-shaped diplococci bacteria responsible for the sexually transmitted infection gonorrhea.[2]

Gonorrhea can infect mucus-secreting epithelial cells in both men and women. The first place this bacterium infects is usually the columnar epithelium of the urethra and endocervix. Non-genital sites in which this bacterium thrives include the rectum, the oropharynx, and the conjunctivae of the eyes. Established routes of transmission of Neisseria gonorrhoeae include vaginal and rectal intercourse, fellatio, cunnilingus, and perinatal. The main pathogenicity of the Neisseria gonorrhea stems from the ability of the surface pili to attach to the surface of the urethra, fallopian tubes, and endocervix.[3] In pregnancy, gonococcus can be transmitted to the fetus at the time of delivery. Additionally, development of disseminated gonococcal infection is the result of Neisserial organisms' dissemination to the blood.[4][5]

Common risk factors in the development of gonorrhea include sexual activity, multiple sex partners, previous history of sexually transmitted diseases, having a sexual partner with a past history of any sexually transmitted disease, and failure to use condoms during sex.[6] In 50 to 70% of women, the initial infection with Neisseria gonorrhea may be asymptomatic. The most common complication of untreated gonorrhea is pelvic inflammatory disease (PID), which may lead to increased risks of ectopic pregnancy. If left untreated, ectopic pregnancy can be life-threatening to the mother.[7] In men, gonorrhea usually results in urethritis, which may result in dysuria. If left untreated, gonorrhea may result in inflammation of the epididymis (epididymitis), prostate gland (prostatitis), and urethral structure. Disseminated gonococcal infection (DGI) occurs in about 0.5 to 3% of patients, commonly following asymptomatic mucosal infection in both sexes.

Empiric treatment for gonorrhea is usually initiated prior to receipt of laboratory results. Nucleic acid amplification tests (NAATs) are the test of choice in all individuals who present with urogenital symptoms.[8] The mainstay of therapy for gonococcal infections is antimicrobial therapy. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials; accordingly, a combination therapy with azithromycin and a cephalosporin is used to improve treatment efficacy and potentially slow the emergence and spread of antibiotic resistance.[9] Effective measures for the primary prevention of gonorrhea infection include practicing abstinence, avoiding high-risk sexual behaviors (e.g., having unprotected sex or multiple sexual partners), and using latex condoms. Measure for the secondary prevention of gonorrhea infection include early detection, treatment of sexual partners, and treatment of other sexually transmitted infections (e.g., chlamydia).[10][11][12]

Historical Perspective

Gonorrhea is an ancient disease with biblical references. However, the exact time of onset of gonorrhea in history cannot be accurately determined from the extant historical record.[13] In 1879, gonorrhea was referred to as “the clap” by German bacteriologist Albert Neisser.[14]

Classification

Based on anatomic location, gonorrhea may be classified into three subtypes: urogenital, extragenital, and disseminated gonococcal infection. Additionally, gonococcal infections may be classified into many subtypes according to the affected organ system.[15][16][17]

Pathophysiology

Gonorrhea is a sexually transmitted disease (STD) that is caused by the bacterium Neisseria gonorrhea. It can infect mucus-secreting epithelial cells in both men and women. Established routes of transmission of the Neisseria gonorrhoeae include vaginal intercourse, rectal intercourse, fellatio, cunnilingus, and perinatal. The main pathogenicity of the Neisseria gonorrhea stems from the ability of the surface pili to attach to the surface of the urethra, fallopian tubes, and endocervix.[3][18][19] Another virulence factor of gonorrhea is porin. There are two main porin serotypes: PorB.1A strains (resulting in a disseminated gonococcal infection) and PorB.1B strains (resulting in local genital infections).[20][21][22]

In pregnancy, gonococcus can be transmitted to the fetus at the time of delivery. This results in infection of the conjuctiva. This appears 1 to 4 days after birth as severe discharge with marked swelling and redness of the eyelids and conjunctiva. Additionally, development of disseminated gonococcal infection is the result of Neisserial organisms' dissemination to the blood due to a variety of predisposing factors, such as change in PH, pregnancy, menstruation, PorB.1A strains, and complement deficiencies.[4][5][23][24]

Causes

Neisseria gonorrhoeae, also known as gonococci (plural), gonococcus (singular), or gonorrhoea (in British English), is a species of Gram-negative, coffee bean-shaped diplococci bacteria that is responsible for the sexually transmitted infection gonorrhea.[2] Gonorrhea (gonorrhoea in British English) is among the most common sexually transmitted diseases in the world. The term comes from the Ancient Greek word γονόρροια (gonórrhoia), literally "flow of seed"; in ancient times, it was incorrectly believed that the pus discharge associated with the disease contained semen.[25]

Differential diagnosis

Gonorrhea must be differentiated from other sexually transmitted pathogens, nongonococcal urethritis, vaginitis, cervicitis, urinary tract infections, prostatitis, and orchitis. Additionally, disseminated gonococcal infection must be differentiated from herpes simplex virus (HSV), nongonococcal septic arthritis, syphilis, HIV infection, rheumatic fever, reactive arthritis , and Lyme disease.[15][16][17]

Epidemiology

Gonorrhea is a very common infectious disease. In the United State, gonorrhea is the second most common STD (after chlamydia).[1] In 2012, the incidence of gonorrhea was reported as 106 million cases worldwide.[26] In 2014, a total 350,062 cases of gonorrhea were reported in United States.[27]

Risk factors

Common risk factors for the development of gonorrhea include sexual activity, having multiple sex partners, previous history of sexually transmitted diseases, having a partner with a past history of any sexually transmitted disease, and failure to use a condom during sex.[6][28][29]

Screening

The U.S. Preventive Services and Task Force (USSTF) recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. Current evidence is insufficient to assess the balance of benefits and harms of screening for gonorrhea in heterosexual men. However, USSTF recommends at least annual screening for gonorrhea among men who have sex with men (MSM).[30][31][32]

Natural history, complications, and prognosis

In 50 to 70% of women, the initial infection with Neisseria gonorrhea may be asymptomatic. Initial infection is usually observed in the cervical region, but due to the presence of the surface pili, the infection may ascend through the uterus into the fallopian tubes and finally out into the peritoneal cavity. The exact incubation period of gonorrhea is unknown. It may result in cervicitis and urethritis, which may present with dysuria, vaginal pruritus, and vaginal mucopurulent discharge. If gonococcal infection is left untreated, it can progress to fibrosis. Fibrosis can result in fallopian tube stricture, tubo-ovarian cyst or abscess, pelvic inflammatory disease (PID), Perihepatitis (Fitz-Hugh-Curtis syndrome), and/or bartholinitis. The most common complication of untreated gonorrhea is pelvic inflammatory disease (PID), which may lead to an increased risk of ectopic pregnancy. If left untreated, ectopic pregnancy can be life-threatening for the mother.[7][33] In men, gonorrhea usually results in urethritis, which may result in dysuria. If left untreated, gonorrhea may result in inflammation of the epididymis (epididymitis), prostate gland (prostatitis), and urethral structure (urethritis). Disseminated gonococcal infection (DGI) occurs in about 0.5 to 3% of patients, commonly following asymptomatic mucosal infection in both sexes. Disseminated gonococcal infection can lead to the infection of multiple distant sites such as the brain, heart, and joints. The most common signs and symptoms include arthritis or arthralgias, tenosynovitis, and multiple skin lesions.

Common complications of gonococcal infection in women may include salpingitis, pelvic inflammatory disease, Infertility, dyspareunia, and ectopic pregnancy. Common complications of gonococcal infection in men may include post-inflammatory urethral strictures, urethral abscess, penile lymphangitis, penile edema, urinary tract infection, and kidney failure. The prognosis of urogenital and disseminated gonococcal infection are generally good with adequate treatment.

Diagnosis

History and Symptoms

It is critical to obtain a detailed and thorough sexual history from the patient. Specific areas of focus when obtaining a history from the patient include number and type of sexual partners, contraception use, and previous history of sexually transmitted diseases. The majority of women with gonorrhea are asymptomatic, while some have vaginal discharge, lower abdominal pain, or pain during intercourse. Common symptoms of gonococcal infection among men include urethritis, which is associated with burning with urination and discharge from the penis. Either sex may also acquire gonorrhea of the throat from performing oral sex on an infected partner, usually a male partner. Such infection is asymptomatic in 90% of cases, and produces a sore throat in the remaining 10%. The incubation period is 2 to 14 days, with most of these symptoms occurring between 4 and 6 days after infection.[15][34][35][36] Rarely, gonorrhea may cause skin lesions and joint infection (pain and swelling in the joints) after traveling through the blood stream. Very rarely, it may settle in the heart, causing endocarditis, or in the spinal column, causing meningitis.[17]

Physical examination

Women with gonococcal infection usually appear to be well until the development of such complications as PID. Physical examinations of women with gonococcal infection are usually remarkable for mucopurulent urethral, cervical, or vaginal discharge; friable appearance of the cervix; and cervical motion tenderness. Common physical examination finding of gonococcal infection in men include mucopurulent urethral discharge. Less commonly, penile edema and epididymal tenderness and edema (epididymitis) may also be seen as part of a complicated gonococcal infection.[15][34][35]

Physical examination of patients with pharyngeal gonococcal infection is usually remarkable for mild pharyngeal exudates and rectal gonococcal infection is usually remarkable for mucopurulent anal discharge. Physical examination of patients with disseminated gonococcal infection (DGI) is usually remarkable for fever, pustular or vesicular rash, and musculoskeletal findings.[15][17]

Images

The following images are associated with gonorrhea physical examination.[37][38]

Laboratory tests

Empiric treatment for gonorrhea is usually initiated prior to the receipt of laboratory result. A microbiologic diagnosis is important for further management in order to determine the need for further testing, partner management, and public health considerations. Any sexually active man or women presenting with signs and symptoms of urethritis, cervicitis, pelvic inflammatory disease, and epididymitis should undergo diagnostic testing for Neisseria gonorrhea. Additionally, the possibility of disseminated gonococcal infection (DGI) should be considered in all young sexually active individuals who present with arthralgias or suspected septic arthritis. Common laboratory tests for gonococcal infection may include gram stain, culture, nucleic acid amplification tests (NAAT), and non-amplified tests. Nucleic acid amplification tests are the test of choice in all individuals who present with urogenital symptoms.[8][17] Additionally, synovial fluid analysis is usually sent for cell count, differential, gram stain, bacterial culture and NAAT in patients with suspected DGI.[39]

Other diagnostic studies

Other diagnostic studies are used when NAAT or culture are not available. Other diagnostic studies for gonorrhea infection include rapid NAAT assay (modular-cartridge based platform), leukocyte esterase urine test, immunochromatographic tests, nucleic acid hybridization tests, and enzyme immunoassay (EIA).[40][41][42]

Treatment

Medical therapy

The mainstay of therapy for gonococcal infections is antimicrobial therapy. Gonorrhea treatment is complicated by the ability of N. gonorrhoeae to develop resistance to antimicrobials; accordingly, a combination therapy with azithromycin and a cephalosporin is used to improve treatment efficacy and potentially slow the emergence and spread of antibiotic resistance.[43]

Type of gonococcal infection Regimen
Uncomplicated Recommended regimen
Uncomplicated Alternative regimen
  • Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose
  • Test of cure should be performed after 1 week
Alternative regimens for severe Cephalosporin allergy
Arthritis and arthritis-dermatitis syndrome
Gonococcal meningitis and endocarditis

Antibiotic resistant

Gonorrhea treatment is complicated by the ability of Neisseria gonorrhoeae to develop resistance to antimicrobials. High-level resistance to expanded-spectrum cephalosporins and azithromycin is now reported, and it seems that developing another effective treatment has become unaffordable for pharmaceutical companies, though new combination antibiotic treatments are being evaluated. There are no affordable alternative therapeutic options currently available for the treatment of gonococcal disease, and it seems even newly developed antibiotics will be short-term solutions, as the bacterium may well develop resistance to them, too.[44]

In 2006, CDC had five recommended treatment options for gonorrhea. Currently, the U.S. has only one remaining option.

Source: https://www.cdc.gov/

Primary prevention

Effective measures for the primary prevention of gonococcal infection include accurate risk assessment and counseling, practicing abstinence, avoiding high-risk sexual behaviors (e.g., unprotected sex or multiple sexual partners), using latex condoms, and being in a long-term and monogamous relationship with an uninfected partner.[10][11][12]

Secondary prevention

Strategies for the secondary prevention of gonococcal infection include early detection, treatment of sexual partners, and treatment of other sexually transmitted infections (e.g., chlamydia).[10][11][12]

References

  1. ↑ 1.0 1.1 CDC. Sexually transmitted disease surveillance 2013. Atlanta: US Department of Health and Human Services; 2014.
  2. ↑ 2.0 2.1 Ryan, KJ; Ray, CG, eds. (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN 0-8385-8529-9.
  3. ↑ 3.0 3.1 Sparling PF (1966). "Genetic transformation of Neisseria gonorrhoeae to streptomycin resistance". J Bacteriol. 92 (5): 1364–71. PMC 276432. PMID 4958881.
  4. ↑ 4.0 4.1 WATRING, WATSON G., and DANIEL L. VAUGHN. "Gonococcemia in pregnancy." Obstetrics & Gynecology 48.4 (1976): 428-430.
  5. ↑ 5.0 5.1 Angulo, Juan M., and Luis R. Espinoza. "Gonococcal arthritis." Comprehensive therapy 25.3 (1999): 155-162.
  6. ↑ 6.0 6.1 Klausner JD, Barrett DC, Dithmer D, Boyer CB, Brooks GF, Bolan G (1998). "Risk factors for repeated gonococcal infections: San Francisco, 1990-1992". J Infect Dis. 177 (6): 1766–9. PMID 9607868.
  7. ↑ 7.0 7.1 McNeeley SG (1989). "Gonococcal infections in women". Obstet Gynecol Clin North Am. 16 (3): 467–78. PMID 2512520.
  8. ↑ 8.0 8.1 "Sexually transmitted diseases treatment guidelines (2015)." Reproductive Endocrinology 24 (2015): 51-56.http://www.cdc.gov/std/tg2015/gonorrhea.htm Accessed on September 2015
  9. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  10. ↑ 10.0 10.1 10.2 Centers for Disease Control and Pevention. clinical prevention guidance (2015). http://www.cdc.gov/std/tg2015/clinical.htm Accessed on September 25, 2016
  11. ↑ 11.0 11.1 11.2 LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med 2014;161:894–901.
  12. ↑ 12.0 12.1 12.2 Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36–51.
  13. ↑ Genco, Caroline Attardo. Neisseria: molecular mechanisms of pathogenesis. Horizon Scientific Press, 2010.
  14. ↑ Unemo M, Shafer WM. Antimicrobial resistance in Neisseria gonorrhoeae in the 21st century: past, evolution, and future. Clin Microbiol Rev 2014;27:587–613.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Workowski KA, Bolan GA, Centers for Disease Control and Prevention (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815.
  16. ↑ 16.0 16.1 Rompalo AM, Hook EW, Roberts PL, Ramsey PG, Handsfield HH, Holmes KK (1987). "The acute arthritis-dermatitis syndrome. The changing importance of Neisseria gonorrhoeae and Neisseria meningitidis". Arch Intern Med. 147 (2): 281–3. PMID 3101626.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Rice PA (2005). "Gonococcal arthritis (disseminated gonococcal infection)". Infect Dis Clin North Am. 19 (4): 853–61. doi:10.1016/j.idc.2005.07.003. PMID 16297736.
  18. ↑ Swanson J (1973). "Studies on gonococcus infection. IV. Pili: their role in attachment of gonococci to tissue culture cells". J Exp Med. 137 (3): 571–89. PMC 2139381. PMID 4631989.
  19. ↑ Wolfgang M, Lauer P, Park HS, Brossay L, Hébert J, Koomey M (1998). "PilT mutations lead to simultaneous defects in competence for natural transformation and twitching motility in piliated Neisseria gonorrhoeae". Mol Microbiol. 29 (1): 321–30. PMID 9701824.
  20. ↑ Young JD, Blake M, Mauro A, Cohn ZA (1983). "Properties of the major outer membrane protein from Neisseria gonorrhoeae incorporated into model lipid membranes". Proc Natl Acad Sci U S A. 80 (12): 3831–5. PMC 394146. PMID 6407021.
  21. ↑ Ram S, Cullinane M, Blom AM, Gulati S, McQuillen DP, Monks BG; et al. (2001). "Binding of C4b-binding protein to porin: a molecular mechanism of serum resistance of Neisseria gonorrhoeae". J Exp Med. 193 (3): 281–95. PMC 2195916. PMID 11157049.
  22. ↑ Ram S, McQuillen DP, Gulati S, Elkins C, Pangburn MK, Rice PA (1998). "Binding of complement factor H to loop 5 of porin protein 1A: a molecular mechanism of serum resistance of nonsialylated Neisseria gonorrhoeae". J Exp Med. 188 (4): 671–80. PMC 2213355. PMID 9705949.
  23. ↑ Bohnhoff M, Morello JA, Lerner SA (1986). "Auxotypes, penicillin susceptibility, and serogroups of Neisseria gonorrhoeae from disseminated and uncomplicated infections". J Infect Dis. 154 (2): 225–30. PMID 3088132.
  24. ↑ O'Brien JP, Goldenberg DL, Rice PA (1983). "Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms". Medicine (Baltimore). 62 (6): 395–406. PMID 6415361.
  25. ↑ Definition of the term gonorrhea
  26. ↑ World Health Organization. Emergence of multi-drug resistant Neisseria gonorrhoeae http://apps.who.int/iris/bitstream/10665/70603/1/WHO_RHR_11.14_eng.pdf Accessed on September 8, 2016
  27. ↑ Centers for Disease Control and Prevention. Reported STDs in the United States 2014 National Data for Chlamydia, Gonorrhea, and Syphilis http://www.cdc.gov/std/stats14/std-trends-508.pdf
  28. ↑ Centers for Disease Control and Prevention http://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm Accessed September 20, 2016
  29. ↑ Mertz KJ, Levine WC, Mosure DJ, Berman SM, Dorian KJ, Hadgu A (1997). "Screening women for gonorrhea: demographic screening criteria for general clinical use". Am J Public Health. 87 (9): 1535–8. PMC 1380985. PMID 9314811.
  30. ↑ "2015 Sexually Transmitted Diseases Treatment Guidelines (CDC)".
  31. ↑ Workowski KA, Bolan GA. Sexually transmitted diseases treat- ment guidelines, 2015. MMWR Recomm Rep 2015;64:60–68.
  32. ↑ US preventive services task forces. Gonorrhea and chlamydia screening (2014) https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/chlamydia-and-gonorrhea-screening Accessed on September 28, 2016
  33. ↑ Stansfield VA (1980). "Diagnosis and management of anorectal gonorrhoea in women". Br J Vener Dis. 56 (5): 319–21. PMC 1045815. PMID 7427703.
  34. ↑ 34.0 34.1 Sherrard J, Barlow D (1996). "Gonorrhoea in men: clinical and diagnostic aspects". Genitourin Med. 72 (6): 422–6. PMC 1195730. PMID 9038638.
  35. ↑ 35.0 35.1 Barlow D, Phillips I (1978). "Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects". Lancet. 1 (8067): 761–4. PMID 76760.
  36. ↑ Osborne NG, Grubin L (1979). "Colonization of the pharynx with Neisseria gonorrhoeae: experience in a clinic for sexually transmitted diseases". Sex Transm Dis. 6 (4): 253–6. PMID 119330.
  37. ↑ STD Gonorrhea Infection Gallery http://www.std-gov.org/std_picture/gonorrhea_w.htm Accessed on September 22, 2016
  38. ↑ Centers for Disease Control and Prevention. Public Health Image Library (PHIL) http://phil.cdc.gov/phil/home.asp Accessed on September 22, 2016
  39. ↑ Muralidhar B, Rumore PM, Steinman CR (1994). "Use of the polymerase chain reaction to study arthritis due to Neisseria gonorrhoeae". Arthritis Rheum. 37 (5): 710–7. PMID 8185698.
  40. ↑ Gaydos CA, Van Der Pol B, Jett-Goheen M, Barnes M, Quinn N, Clark C; et al. (2013). "Performance of the Cepheid CT/NG Xpert Rapid PCR Test for Detection of Chlamydia trachomatis and Neisseria gonorrhoeae". J Clin Microbiol. 51 (6): 1666–72. doi:10.1128/JCM.03461-12. PMC 3716060. PMID 23467600.
  41. ↑ Watchirs Smith LA, Hillman R, Ward J, Whiley DM, Causer L, Skov S; et al. (2013). "Point-of-care tests for the diagnosis of Neisseria gonorrhoeae infection: a systematic review of operational and performance characteristics". Sex Transm Infect. 89 (4): 320–6. doi:10.1136/sextrans-2012-050656. PMID 23093736.
  42. ↑ Vlaspolder F, Mutsaers JA, Blog F, Notowicz A (1993). "Value of a DNA probe assay (Gen-Probe) compared with that of culture for diagnosis of gonococcal infection". J Clin Microbiol. 31 (1): 107–10. PMC 262630. PMID 8417014.
  43. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  44. ↑ Centers for Disease Control and Prevention. Combating the Threat of Antibiotic-Resistant Gonorrhea. (2016) http://www.cdc.gov/std/gonorrhea/arg/carb.htm Accessed on September 25, 2016


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