Major M. P. Vora, M.B.B.S., D.V.D.,
Ex - Hon. Senior Venereologist, St. George’s Hospital, Bombay
The Indian Practitioner
A monthly journal of Medicine, Surgery & Public Health
Vol. XXI, No. 6 of June 1968;
Pages: 331 - 337
G onorrhoea is an infectious disease predominantly of the sexually active persons due to the gonococcus, the intra-cellular gram-negative diplococcus of Neissar. It is a paired organism having adjacent sides slightly concave with a narrow but distinct space between them. It is a strict parasite which is often transferred from host to host. By far the most common mode of infection is as the result of sexual relation. It has a special predilection for the immature and columnar epithelium of the genito-urinary tract. Accidental contamination of the conjunctiva and the urogenital passage of the female child is occasionally met with. Gonococcal infection produces effects which vary considerably from patient to patient depending on the primary site of infection, its anatomic extent and complications. The pathogenicity of the organism is not clearly understood and it is difficult to determine whether a particular strain is pathognomic or not especially in the female. Morphologically five distinct types of gonococcal colonies are described, out of which the type one is found to be the most virulent. Its virulence is maintained through successive seventy-five passages in culture. Clinical evidence suggests that in a given host, a strain of parasites may over a long period, alternates between pathogenicity and existence as a commensal. Hence the distinction between infection and invasion becomes important. There has been awareness of the possibility that many females as well as some males act as asymptomatic carriers of gonorrhoea for a period of time.
In the male
Gonorrhoea causes inflammation of the mucous membrane of the urethra and its communicating structures but occasionally it may invade the blood stream and give rise to metastatic lesions. The primary sites of infection are the urethra, paraurethral ducts ,and tyson’s ducts. The incubation period varies from 2 to 14 days. The clinical onset is usually constant. There is usually smarting, burning and discomfort in purulent character. Dysuria and frequency may be complained of. The external urinary meatus is red, oedematous and pouting. The urine contains pus cells and looks hazy. The infection remains localised to the anterior urethra for the first few days and reaches the posterior urethra in about ten days. At times, it may spread much more quickly and cause painful nocturnal erections.
Balano-posthitis: It is seen in the uncircumcised patients and is due to lack of cleanliness and excoriation of the superficial lining.
Tysonitis or its abscess : Tyson’s ducts are situated at the base of the frenum in close association with the coronal sulcus. The openings become red and pouting. An abscess gives rise to a small tender swelling on either side of the frenum. When it bursts it leaves a small ulcer.
Inflammation of the para-urethral ducts: The para-urethral ducts open on either side of the external urinary meatus just inside. A careful inspection of the lips of the urinary meatus will reveal pin-point redness and pus oozing from the opening. Gumming of the lips of the urethra is common.
Littritis: The Littre’s glands are situated in the roof, floor, and lateral sides of the anterior urethra. They are frequently involved. Their affection is often responsible for the persistence of infection. This can be confirmed by urethroscopy or by palpating the swollen glands, when a straight metal sound is passed into the urethra. Once these glands are involved mere chemotherapy may not be effective; anterior urethral dilatations and massage over the sound, as a part of treatment, becomes necessary for the eradication of the infection. However, this must not be started until the acute stage of infection has subsided.
Peri-urethral abscess: When a Littre’s gland duct becomes occluded, an abscess is formed. The common sites are near the fossa navicularis or the bulb. The presence of a palpable swelling in the corpus spongiosum and edema of the shaft are suggestive. The abscess may point on the surface or into the urethra. During the subsequent progress of the case, periodic urethral dilatations become necessary to prevent the formation of fibrous stricture.
Cowperitis: The ducts of Cowper’s glands open into the floor of the bulb. The left duct opens more anteriorly than the right and is more frequently infected. Pain in the perineum and the rectum and a palpable swelling in the perineum suggest this complication. The glands can be best palpated with the index finger in the rectum and the thumb on the surface, on either side of the median raphe of the perineum. Normally they are not palpable. When inflammed, they present tender olive-sized swellings.
Prostatitis: It may be acute, subacute or chronic. An acute attack is accompanied by fever, suprapubic pain, pain in the rectum, pain at the end of micturition. Per rectal examination shows the prostate enlarged, tender, irregular on the surface, with areas of softening. The prostatic abscess may burst into the urethra, or in the peri-prostatic tissue and gravitate towards the perineum or into the rectum, when rectal gonorrhoea is almost certain. Chronic prostatitis is the commonest cause of persistent infection. Involvement of the posterior urethra and neighbouring structures indicates the need of local therapeutic measures such as prostatic massage, urethral dilatation and irrigations, in addition to chemotherapy. These procedures are introduced when the acute stage has passed off.
Vesiculitis : Involvement of the seminal vesicles is closely associated with infection of common ejaculatory ducts, prostate an dthe posterior urethra. The attack may be acute or chronic. Terminal dysuria and haematuria, painful erections, fever, supra-pubic pain, strangury and discomfort in the rectum are common manifestations. Seminal vesicles are enlarged, distended and tender.
Funiculitis and epididymitis : Involvement of the vas deferens and epididymis arises from direct extension of infection from the posterior urethra. It occurs in the second or third week of infection. The spermatic cord is thickened, rigid and tender. It is the left one which is more frequently affected. A swelling involving the epididymis and the spermatic cord, pain and heaviness in the scrotum, fever and red, hot and tender condition of the scrotal skin are obvious on examination.
Trigonitis, cystitis and upper urinary tract infection : The infection is generally confined to the trigone of the bladder. Supra-pubic discomfort and tenderness, frequent micturition, pain at the end of urination, and haematuria at the end are some of the manifestations. The infection may spread to cause pyelitis and pyelo-nephritis.
Urethral Stricture : This may occur at the external urinary meatus, in the anterior or posterior urethra. Difficulty in passing urine, small urinary stream, and at times retention of urine are met with. The passage of a curved sound of size 15, 16 (French Scale) or 8/9 (English scale) becomes impossible. Rectal gonorrhoea is not so common in the males as it is in the females. It is often asymptomatic for months. Homosexual relation is the mode of infection.
Metastatic complications : Gonococci sometimes invade the blood stream and produce metastatic effects. Arthritis, keratodermia, blenorrhagica, septicaemia, endocarditis, meningitis, iritis and iridocyclitis have been reported. Some of these effects are supposed to be due to an associated ‘non-specific’ infection which is probably acquired at the same time as gonorrhoea. This is true in case of eye complications.
In the female
The primary sites of infection in the female are the urethra, Skene’s ducts, Bartholinian ducts or the cervix. The vaginal fornices may get involved in the later stages. The symptoms are usually less marked and often seem to be entirely absent in about 30 to 40 per cent of cases. It is rare to find a profuse vaginal discharge in a purely gonococcal infection. When it is present, it is often due to the co-existing infection with Trichomonas vaginalis or mixed bacterial infection. The patient should not pass urine at least four hours preceding the examination. In the early stages, dysuria, frequency of micturition and its urgency or retention may be complained of. A low backache, alteration in the menstrual cycle and general ill-health are common complaints. Purulent discharge from the cervix, urethra or Bartholinian ducts may be present. Redness and ectopium of the urinary meatus and the Bartholin’s duct, redness and erosion of the cervix or the swelling and tenderness of the Bartholin’s gland may be noticed. In the early and acute stage, the organism can be easily detected in smears and cultures from appropriate sites but it is hard to find it in the chronic stage or where there is a mixed infection. Under such conditions, a series of tests may have to be undertaken to demonstrate the causative organism.
Skenitis : The pair of para-urethral ducts open on the floor or on the sides of the urethra, just inside the urinary meatus. The external urethral openings red and pouting, a drop of pus can be milked out by massaging the floor of the urethra, and the openings of the gland ducts appear red and inflamed with a small quantity of pus.
Cystitis : It is more common in the females than in the males. The trigone of the bladder is mainly affected. Urgency and frequency of micturition, terminal haematuria, suprapubic pain, tenderness, fever with rigors, etc. may be complained of.
Vulvitis : It is common in female children under fourteen years of age. In the adult female, the vulvar surface is rarely involved in gonococcal infection alone. The vulva appears red, excoriated and inflamed, there is profuse purulent discharge and itching and irritation at the site. This manifestation in the adults should suggest an additional infection with T.vaginalis.
Bartholinitis : The infection is generally unilateral, the left gland being more frequently infected than the right one. An acute pain worse on walking, the labium majus is swollen and tender, the inner surface of the labium minus on the affected side reveals red inflamed ductal opening with purulent discharge, plus there may be fever. An abscess may form and burst open.
Cervicitis and endocervicitis : In the adult female the endocervix is infected primarily almost as frequently as the urethra. The vaginal portion of the cervix appears swollen, red with its lips everted. Small erosions or ulcers may be present. Purulent discharge pours from the opening. In the chronic stage, Nabothian follicles or retention cysts may be seen on the cervix.
Endometritis and metritis : As an extension of infection upwards, it gives rise to marked constitutional upset with fever. A profuse blood- stained discharge from the cervix and enlarged and tender uterus are noticed.
Salpingitis : The fallopian tubes are involved as a result of extension of the disease from the endocervix. It may be acute or insidious in its onset. The occurrence of acute abdominal symptoms, fever with rigors and vomiting, increased pulse rate, swelling and tenderness in the fornices suggest the complication.
Pelvic peritonitis : Localised peritonitis is frequent as the result of salpingitis. It may be masked by the signs and symptoms of salpingitis or pyosalpinx or oopheritis.
Proctitis : The gonococcal infection of the anus and of the rectum is rather more frequent in the females than in the men. The majority acquire as the result of direct extension. Sodomy and rupture of gonococcal abscess into the rectum amount for the minority. It is often asymptomatic for months. Metastatic complications are similar to those met with in the males.
Urethral discharge or burning and vaginal discharges are symptoms often of obscure origin and so distressing to the patient as to constitute a real clinical problem. In these cases, it is all easy to assume that by these they mean gonorrhoea, whereas they often mean something else such as prostatorrhoea, pollution impotency, Phosphaturia or infection due to other organism. Unless the gonococcus is demonstrated, they should not be classified as gonorrhoea. Hence the distinction between gonorrhoea and other causes giving rise to similar signs and symptoms becomes of paramount importance, especially when specific and effective drugs are freely available. Once the diagnosis is established, an attempt must be made to trace the contacts and treat them. The important responsibility is often forgotten with tragic results and therefore worth reiterating.
Smears : The direct examination of smears taken from appropriate sites and stained with Gram’s stain is commonly employed and is fairly reliable in the acute fresh stage of infection. However, this does not always hold good today. The Mimea of Herellae group can cause urethritis and mimic the gonococcus in ordinary gram-stained smears. They are gram-negative diplococci both intra- and extra-cellular and indistinguishable from gonococcus. They are not sensitive to penicillin but to other broad-spectrum antibiotics. Unlike gonococci, they grow well on MacConkey’s enteric culture medium and as gram-negative rods on sheep-blood agar medium. Unless one uses these procedures, it will be impossible to say whether it is gonorrhoea or Mimea urethritis. Failure to obtain good results with penicillin offers a valuable clue.
Fermentation test : Gonococci ferment glucose but not maltose or saccharose.
Oxidase test : 1% teramethyl-p-phenylendiamine solution is poured on the culture plate. Gonococcal colonies turn pale violet.
Culture : In certain cases specially medico-legal, it is necessary to employ this method where absolute accuracy is essential. Gonococcus is a difficult organism to grow; however good results are obtained from Stuart’s Transport Medium and Thayer and Martin (1966) Medium containing vancomycin, colistimethate and Nystatin.
Fluorescent test : Immunofluorescent technique for the demonstration of gonococci yields better results even than the culture. By the use of a conjugate fluorescein isothocynate and globulin fraction of gonococcal K-antigen immune serum, gonococci can be detected by ultraviolet microscopy. Gonococci can be visualized readily in the smears and cultures after 12 hours of incubation. The advent of fluorescent antibody techniques for the identification of Neisseria gonococci in direct smears and smears from fresh cultures provides more effective and very reliable laboratory aids than had been available in the past. Apparently asymptomatic carrier is a great problem which can be dealt with by this technique.
Complement Fixation Test (G.C.F.T.) : It has limited value. It becomes positive when the posterior urethra is involved or when systemic complications develop. The test may remain positive after an effective treatment for about 2 months. If the gonococcal complement fixation tests are consistently negative over a period of six months, then the cure of the infection may be safely assured.
Sensitivity test : This is valuable from the point of differentiating Mimea from gonococcus and employing right therapy.
Serologic test for syphilis : As a routine this test should be done at the beginning of treatment and the end of the surveillance period. Preferably two tests should be employed and it is very desirable that one of these should be quantitative to act as a base-line for assessing the activity of the infection. Double infection is common in about 7 per cent of cases.
Since the introduction of sulpha drugs and antibiotics in the therapeutics, gonorrhoea which was once a disease of great chronicity with frequent relapses, troublesome complications and protracted disability, has now become readily amenable to treatment with almost complete freedom from complications. A relapse or treatment-failure usually occurs in the first week without the urine being cleared of pus cells. Local complications can exist in association with an acute fresh, subacute or chronic urethritis. When gonorrhoea fails to react favourably to routine treatment, some local complication will almost invariably be present in some inaccessible area or the organism has turned out to be resistant to the chemotherapy. Failure to recognise the potentialities of the infection, is often responsible for not being able to eradicate gonococcal infection from the genito-urinary tract. If the infection persists, one has to think of an undiscovered complication or the presence of a mixed primary infection or resistant organism.
The treatment of gonorrhoea depends on the sex of the patient, the site of the primary infection, its anatomic extent and complications. Patients who are given to alcoholic drinks or sexual excitement are difficult to cure. While prescribing the chemotherapy, one must give adequate dosage over an adequate period to maintain the effective concentration of the drug in the tissues until the infection is completely eliminated. Wide variations in the blood levels and its duration following the drug administration are at the root of treatment failures, relapses and making the organism drug-resistant. The routine amount of treatment for an acute fresh uncomplicated gonorrhoea in the female is double of what is considered adequate in the male. A complicated or old-standing gonorrhoea needs three times the amount of treatment that is used normally for an acute fresh infection. Besides, it needs local therapeutic and supportive measures such as urethral dilatations, prostatic massage and urethral lavage. While treating gonorrhoeal complications, the aim should not only be to relieve the symptoms but also to treat the primary cause i.e. posterior urethritis. It is not possible here to go into details of treatment for the various complications of gonorrhoea. The treatment of an acute fresh uncomplicated gonorrhoea will be dealt with.
Sulpha drugs : Sulphadiazine, Ganstrisin or Sulphathiazole one gram four to five times a day orally for five to six days is considered adequate for a fresh acute uncomplicated gonorrhoea in the male. It has no effect on the course of concomitant syphilis. Residual urethritis which often follows the use of penicillin is uncommon. Though certain strains of gonococci occasionally exhibit resistance to sulpha drug, the writer has often used this therapy with fair amount of success in preference to antibiotics. The first loading dose of 2 grams with a tumbler of water is given. If intolerance is detected or the organism is found to be resistant, a change in the chemotherapy is indicated. The test of time and experience has proved that enthusiasm, which new remedies often arouse, is short-lived and baseless.
Penicillin-G : Apart from anaphylactic shock, penicillin therapy in gonorrhoea poses the risk that concomitant syphilis may go unrecognised. A simultaneous infection with gonorrhoea and syphilis is common in about 5 to 7 per cent of cases. Whenever it is suspected, it is wise to with-hold penicillin till the presence of syphilis is ruled out or confirmed. Unexplained fever during early stage of penicillin therapy for an acute gonorrhoea is strongly suggestive of concomitant syphilis. If there is primary mixed infection of the urethra (staphylococcus and gonococcus), those staphylococci that survive the lower concentration of penicillin, produce a penicillinase-like substance or nutritive factor, which enables gonococci to survive in otherwise inhibitory concentration of penicillin. The role of staphylococcus is significant in cases of gonococcal urethritis that does not respond to penicillin therapy. This often results in residual urethritis. During the last few years, susceptibility of Neisseria gonorrhoea to penicillin has considerably decreased i.e. from 100% in 1954 to 44% in 1966. Consequently the effective blood level of penicillin which was 0.025 per ml. in 1945 has to be raised to 2.00 per ml. in 1966. Hence the scheme of dosage recommended is 1.2 to 2.4 m.u. in one I.M. injection for the male and 2.4 to 4.8 m.u. of aqueous procain penicillin fortified in two injections at 24 hour interval for the female, for an acute fresh uncomplicated gonorrhoea. Long-acting penicillins like benethamine, benzathine, etc. which do not give quickly an effective blood level, are not advised. Mycoplasma is often associated with or follows N. gonorrhoeal urethritis and this leads to the persistence of the residual post-gonococcal urethritis.
For these reasons, it is necessary to re-examine the routine use of penicillin in the treatment of gonorrhoea.
Other antibiotics equally effective in the treatment are:
Cephaloridine : 2 gm I.M., one or two injections.
Kanamycin : 2 gm I.M., two injections at 24 hours interval. It has no effect on the course of syphilis.
Oxytetracycline : 500 mgm I.M. plus 250 mgm orally four times a day for seven days.
Spectinomycine Sulphate : 2 gm I.M. one to two injections for two days.
Streptomycine : One gm I.M. daily for two days.
Spiramycine : 250 mgm six hourly by mouth for 7 days.
Tetracycline : 250 mgm six hourly by mouth for 5 to 7 days.
Ampicillin : 250 mgm six hourly by mouth for 5 to 7 days.
Tests of cure : After the completion of the treatment and disappearance of signs and symptoms, the patient should be kept under observation for a period of 3 to 6 months. It is impossible to determine the precise point at which a permanent cure has been achieved and the possibilities of error are very great. It is, therefore, imperative to carry out searching tests of a cure. Consistently negative findings, clinical, bacteriological and serological, are necessary to establish a cure. The patient should be examined at least three times early in the morning before the urine is passed. Microscopic examination of the urine held for five hours, after the passage of a full-sized urethral sound, prostatic massage and secretions should be done for the evidence of pus cells and gonococci. Finally cultures for gonococci, the serologic test for syphilis and urethroscopy should be undertaken to confirm the cure. The gonococcal complement fixation tests should be consistently negative over a period of six months.