GONORRHEA
The symptoms of acute gonorrhea of the vulva may appear from 1 day to several days after contact, are often mild or transitory, and may be overlooked. The patient may experience burning on urination, urinary frequency, leukorrhea, and itching in the vestibule. Occasionally, however, the first suggestive manifestation of disease is not apparent until the following menses or shortly thereafter, when the ascending infection has resulted in an acute salpingitis. Examination of the external genitalia may reveal a congested vestibule bathed in pus and an inflammation of the urethra and Skene and Bartholin ducts. The acute infection ascends via the mucosa and epithelium of the urogenital tract and may give rise to an endometritis, peritonitis (pelvic inflammatory disease), and tuboovarian abscess. By lymphatic absorption and hematogenous spread, it may result in septicemia, endocarditis, arthritis and tenosynovitis. Although if untreated, gonorrheal infection may, at times, be uncomplicated and self-limited, the tendency for establishment of deep-seated chronic foci is strong. These occur particularly within compound tubular glands and structures lined by columnar epithelium, such as the periurethral and Bartholin glands and the endocervix.
In acute urethritis, the mucosa of the external urethral meatus is
reddened and edematous. On gentle stripping of the urethra, a few drops of
thick yellow pus escape. The inflammatory reaction results in urinary frequency,
urgency, and dysuria.
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| Plate 6-12 |
Acute skenitis is evident in the swollen, slightly raised, injected ostia
of Skene ducts, which expel pus when milked. The ducts may harbor gonorrheal
organisms over long periods of time. Thickened ducts and conspicuous orifices
from which beads of pus can be expressed suggest a chronic infection.
In acute bartholinitis, the openings of the Bartholin ducts, normally
inconspicuous, become more apparent because of the surrounding inflammation. On
palpation, the Bartholin gland may be enlarged and tender. The infection can
progress rapidly, resulting in an extremely painful swelling of the lower half
of the labia. Eventually, a tender, red fluctuant abscess may develop, with
taut, congested overlying skin, edema of the labia, and regional
lymphadenopathy. This abscess may persist or may lead to a chronic infection,
evidenced by enlargement of the gland, recurrent abscesses, and cyst formation.
Chronic urethritis may be manifested by a palpable induration of the
posterior urethral wall mainly due to a persistence of infection within the
shallow posterior urethral glands, seen endoscopically as small granular areas
on the urethral floor. The only symptom may be a burning sensation on urination.
In vulvovaginitis of childhood gonorrhea, the vagina and the vestibule of
the vulva are inflamed and edematous and are covered by a creamy, yellow-green discharge. The profuse leukorrhea results in secondary irritation of the
labia and perineum. The adult vaginal mucosa, by virtue of its thickness and
acidic environment, is more resistant to the gonococcus, but in child-hood and
after menopause the vagina is far more susceptible to infection because of its
thin epithelial layer and its alkaline environment.
Culture on Thayer-Martin agar plates kept in a CO2- rich
environment may be used to document the infection. Cervical cultures provide
80% to 95% diagnostic sensitivity. Cultures should also be obtained from the urethra and anus, although these additional cultures do not significantly
increase the sensitivity of testing. A Gram stain of any cervical discharge for
the presence of gram-negative intracellular diplococcus supports the
presumptive diagnosis but does not establish it (sensitivity 50% to 70%,
specificity 97%). A solid-phase enzyme immunoassay may also be used. Even when
the diagnosis is established by other methods, all cases of gonorrhea should
have cultures obtained to assess antibiotic susceptibility, although therapy
should not be delayed pending the results.
