Etiology

Sexual contact without a condom is a primary cause for acquisition of gonorrhea in sexually active adults and adolescents. This may include any penetrative sex (usually referring to a penis) that involves a mucosa-lined orifice (oropharynx, vagina, and anus).[5][6][7][8] The transmission probability for a single unprotected heterosexual contact is estimated to be around 58% for male to female and 23% for female to male transmission.[9][10]

Gonococcal infection among infants usually results from exposure to infected cervical exudates at birth. It presents as an acute illness 2 to 5 days after birth. The most severe manifestations are ophthalmia neonatorum and sepsis, which can include arthritis and meningitis. Less severe manifestations include rhinitis, vaginitis, urethritis, and reinfection at a site of fetal monitoring. Ophthalmia neonatorum, if left untreated, can lead to severe eye complications or disseminated infection.

Concomitant gonococcal infection increases the risk of sexually transmitted HIV as suggested by increased seminal HIV viral load in urethritis, and a doubling of relative risk has been suggested.[11][12]

Neisseria gonorrhoeae does not survive long outside of a human and therefore sexual abuse must be strongly suspected in any child with gonorrhea.[13][14]

Pathophysiology

Neisseria gonorrhoeae has an affinity for human mucosal epithelium that is mediated by outer membrane proteins.[15]N gonorrhoeae can elude the immune system by changing the outer membrane antigens through genomic plasticity related to DNA mutation or recombination with related species.[16] Of special importance, chromosomal DNA changes and plasmid transfer have mediated resistance to many common antibiotics.[17] Humans are the only known host.

Experimental inoculation of the male urethra has resulted in infection from an inoculum of 250 bacterial cells.[18] The incubation period for symptomatic urethritis depends on the inoculum dose, but the median time has been reported as 3.4 days. The first symptom in men is dysuria before or concomitant with discharge.[19] Although not well studied, detection of N gonorrhoeae may be possible even after the first day of infection especially with sensitive nucleic acid amplification tests (NAATs). Asymptomatic infection occurs in <15% of male urethral infections and closer to 60% of female cervical infections.[20] Duration of infection may be as long as 6 months if untreated, but this has not been well characterized. Repeated exposure to N gonorrhoeae may result in reinfection.[21] Unlike with HIV, circumcision has no impact on the transmission of gonorrhea.[22]

Local genital structures such as the Mullerian glands and Cowper glands can rarely be infected. Ascending infection with N gonorrhoeae along anatomically contiguous routes can lead to male complications of prostatitis, epididymitis, or orchitis (unilateral disease most common). In women, ascending infection can lead to pelvic inflammatory disease (endometritis, salpingitis, tubo-ovarian abscesses) and rarely peritoneal spread including perihepatic abscesses (Fitz-Hugh-Curtis syndrome). Unilateral or bilateral gonococcal conjunctivitis is possible in those exposed to infected secretions. In approximately 0.1% to 0.3% of cases more virulent strains of N gonorrhoeae may be invasive and hematogenously spread to cause septic arthritis, meningitis, endocarditis, and osteomyelitis.[23]

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