Gonococcal infection

　　The pathogen of gonorrhea is Neisseria gonorrhoeae, which belongs to the genus Neisseria of the family Neisseriaceae. The Neisseria gonorrhoeae is kidney-shaped, with two concave surfaces facing each other, of consistent size, about 0.7 micrometers in length, and 0.5 micrometers in width. It is an aerobic, CO2-loving bacterium, Gram-negative, and most suitable for growth in a moist environment with a temperature of 35℃ and containing 5% CO2. It often exists within polymorphonuclear leukocytes, in an elliptical or spherical shape, often arranged in pairs, without flagella, capsules, or spores, and has poor resistance to external physical and chemical conditions. It is most afraid of dryness and can die within 1 to 2 hours in a dry environment. It is also easily fatal under high or low temperatures. It also has weak resistance to various chemical disinfectants.

　　Complications of male gonorrhea

　　1. Symptoms of gonorrhea complicated with prostatitis:One day or half a day before the onset of acute prostatitis, the urethral discharge often suddenly stops or decreases. The patient has high fever, frequent urination, and pain. Rectal examination shows enlargement of the prostate with tenderness. The urine is turbid. If not treated in time, the prostate may form an abscess. Patients with chronic prostatitis generally have no obvious symptoms, and on the first urination after getting up, there is a sealing phenomenon at the urethral opening, and a small amount of white secretion is discharged when the penis is squeezed. Secretion examination may find epithelial cells, a few pus cells, and gonococci.

　　2. Symptoms of gonorrhea complicated with seminal vesitis:Acute symptoms include fever, frequent urination, dysuria, cloudy terminal urine with blood, and rectal examination can palpate the enlarged seminal vesicle with severe tenderness. Chronic symptoms are asymptomatic, and rectal examination shows the seminal vesicle is hard with fibrosis.

　　3. Symptoms of gonorrhea complicated with epididymitis:Generally occurs after acute urethritis, with unilateral cases being more common. There may be low fever, swelling and tenderness of the epididymis, and reflexive pain in the ipsilateral inguinal and lower abdominal regions. Palpation shows swelling of the epididymis with severe tenderness. The urine is often turbid.

　　4. Male gonorrhea can be complicated with urethral stricture:Recurrent gonorrhea can cause urethral stricture, and a few cases may develop into seminal vesicle stricture or obstruction, leading to secondary seminal vesicle cyst and infertility.

　　Complications of female gonorrhea

　　Complications of female gonorrhea include gonococcal pelvic inflammatory disease, including acute salpingitis, endometritis, secondary salpingo-ovarian abscess and pelvic abscess caused by rupture, and peritonitis, etc. Due to mismanagement or misdiagnosis, female patients with gonorrhea are very prone to further development from urinary生殖器 infection to pelvic and adnexal infection, leading to serious consequences such as infertility, abdominal pain, and even life-threatening conditions.

　　The clinical manifestations caused by Neisseria gonorrhoeae infection depend on the degree of infection, the sensitivity of the body, the virulence of the bacteria, the site of infection, and the duration of infection, as well as the general health of the body, whether sexual activity is excessive, and alcoholism, etc.

　　1. Primary infection

　　(1) Male gonorrhea:

　　① Acute gonorrhea: The incubation period is 1 to 14 days, usually 2 to 5 days, and is characterized by acute urethritis symptoms, with the urethral opening red and swollen, itchy, and slightly painful, followed by thin mucous discharge, causing discomfort during urination. About 2 days later, the secretion becomes thick, the urethral opening leaks pus, the pus is deep yellow or greenish yellow, the redness and swelling extend to the entire glans penis and part of the urethra, and symptoms such as frequent urination, urgency, dysuria, difficulty in urination, and inconvenience in movement appear. At night, the penis often has painful erections. There may be enlargement and redness, swelling, and pain in the inguinal lymph nodes, which may also become suppurative. 50% to 70% of patients may have post-infection complications of gonococcal invasion of the posterior urethra, manifested as urgent need to urinate, frequent urination, acute urinary retention, and general symptoms are usually mild, with a few patients having fever up to about 38℃, general discomfort, lack of appetite, and so on.

　　② Chronic gonorrhea: Symptoms last for more than 2 months. Due to incomplete treatment, gonococci can hide in the urethra, paraurethral glands, and urethral crypts, causing the course to become chronic. If the patient is physically weak, has anemia, tuberculosis, etc., the condition may present as chronic from the beginning. It is often a combined infection of the anterior and posterior urethra, favoring the bulb, membranous, and prostate parts of the urethra. It is manifested as a frequent sensation of urethral itching, a burning sensation or mild tingling during urination, thin urine flow, weak urination, and dribbling. Most patients have a small amount of serous scab at the urethral orifice in the morning. If the vulva or penile root is compressed, thin mucous fluid may be seen. The urine is basically clear, and gonococcal threads can be seen.

　　(2) Female gonorrhea:The main site of primary gonococcal infection in women is the cervix, and some patients have no自觉 symptoms, manifested as increased leukorrhea, which is purulent or non-characteristic. There are often vulvar itching and burning sensation, accompanied by cervical congestion and tenderness. Occasional lower abdominal pain and lumbar pain, urethral congestion, tenderness, and purulent secretion, with mild frequency, urgency, and dysuria, burning sensation during urination; gonococcal vaginitis is less common, symptoms are mild, some patients have abdominal distension, back pain, and more leukorrhea, some patients have lower abdominal pain and menorrhagia, etc.

　　2. Secondary infection

　　(1) Complications of male gonorrhea:

　　① Prostatitis: Acute prostatitis has symptoms such as fever, chills, perineal pain, and associated urinary tract infection symptoms such as difficulty in urination. During examination, the prostate is swollen and tender, and淋球菌 can be found in the prostatic massage fluid smear or culture. Chronic prostatitis symptoms are mild, and most cases have secretion at the urethral orifice in the morning.

　　② Epididymitis and seminal vesiculitis: Most cases are unilateral, with epididymal swelling and pain, testicular tenderness, enlargement, seminal vesiculitis may have fever, frequent urination, urgency, dysuria, cloudy and bloody terminal urine. Rectal examination can palpate the enlarged seminal vesicle, with severe tenderness at the same time. Chronic seminal vesiculitis usually has no自觉 symptoms, and rectoscopy may show hard seminal vesicles with fibrosis.

　　③ Urethral bulbitis: It occurs in the perineum or its left and right sides, presenting as nodules of finger size, pain, difficulty in urination due to urethral compression, acute cases may abscess and ulcerate, and may have systemic symptoms such as fever.

　　④ Urethral stricture: Recurrent attacks can cause urethral stricture, and a small number of cases may occur seminal vesicle stricture or obstruction, resulting in difficulty in urination. In severe cases, urinary retention may occur, which may lead to seminal vesicle stricture, seminal vesicle cysts, and infertility.

　　(2) Complications of female gonorrhea:The main complications of female gonorrhea include gonococcal pelvic inflammatory disease, such as acute salpingitis, endometritis, secondary salpingo-ovarian abscess and pelvic abscess caused by rupture, peritonitis, etc., which usually occur suddenly after menstruation, with high fever, chills, headache, nausea, vomiting, lower abdominal pain, increased purulent leukorrhea, bilateral adnexal thickening, and tenderness.

　　3. Other parts of gonorrhea

　　(1) Gonococcal conjunctivitis: Newborns often develop symptoms 2 to 3 days after birth, mostly bilateral, manifested as red and swollen eyelids with purulent secretions. In adults, it is usually self-infected and often unilateral, with symptoms similar to newborns. Due to the overflow of pus, it is俗称 “pus eye”, If treatment is delayed, corneal perforation may occur, leading to blindness.

　　(2)淋球菌性咽炎：表现为急性咽炎或急性扁桃体炎，偶伴发热和颈淋巴结肿大，有咽干不适、咽痛、吞咽痛等症状。

　　(3)淋球菌性肛门直肠炎：表现为里急后重，有脓血便，肛管黏膜充血，脓性分泌物，淋球菌培养阳性。

　　4.播散性淋球菌感染
　　播散性淋球菌感染是由于淋球菌通过血行播散到全身，出现较严重的全身感染，如淋球菌性败血症、关节炎、心内膜炎、脑膜炎等。

　　预防淋病，应做到以下几点：
　　1.进行健康教育，避免非婚性行为。
　　2.提倡安全性行为，推广使用安全套。
　　3.注意隔离消毒，防止交叉感染。
　　4.认真做好病人性伴的随访工作，及时进行检查和治疗。
　　5.执行对孕妇的性病检查和新生儿预防性滴眼制度，防止新生儿淋菌性眼炎。
　　6.对高危人群定期检查，以发现感染者和病人，消除隐匿的传染源。

　　检查包括涂片检查、培养检查、药敏试验及产青霉素酶淋球菌(PPNG)测定、抗原检测、基因诊断等。

　　1.涂片检查：取患者尿道分泌物或宫颈分泌物，作革兰染色，在多形核白细胞内找到革兰阴性双球菌，女性宫颈分泌物中杂菌多，敏感性和特异性较差，阳性率仅为50％～60％，且有假阳性，因此世界卫生组织推荐用培养法检查女性患者，慢性淋病由于分泌物中淋球菌较少，阳性率低，因此要取前列腺按摩液，以提高检出率，咽部涂片发现革兰阴性双球菌不能诊断淋病，因为其他奈瑟球菌属在咽部是正常的菌群，另外对症状不典型的涂片阳性应作进一步检查。

　　2.培养检查：淋球菌培养是诊断的重要佐证，培养法对症状很轻或无症状的男性，女性患者都是较敏感的方法，只要培养阳性就可确诊，在基因诊断问世以前，培养是世界卫生组织推荐的筛选淋病的惟一方法，目前国外推荐选择培养基有改良的Thayer-Martin(TM)培养基和New York City(NYC)培养基，中国采用巧克力琼脂或血琼脂培养基，均含有抗生素，可选择地抑制许多其他细菌生长，在36℃，70％湿度，含5％～10％二氧化碳(烛缸)环境中培养，24～48h观察结果，培养后还需进行菌落形态，革兰染色，氧化酶试验和糖发酵试验等鉴定，培养阳性率男性80％～95％，女性80％～90％。

　　3. Antigen detection

　　(1) Solid-phase enzyme immunoassay (EIA): Can be used to detect Neisseria antigens in clinical specimens.

　　(2) Direct immunofluorescence test: Directly detect Neisseria outer membrane protein-1 through fluorescently labeled monoclonal antibodies.

　　4. Gene diagnosis

　　(1) Gene probe diagnosis: The gene probe diagnosis of Neisseria, the probes used include: plasmid DNA probe, chromosome gene probe, and rRNA gene probe. The sensitivity of gene probe diagnosis is poor.

　　(2) Gene amplification detection: The emergence of PCR technology has further improved the sensitivity of Neisseria detection. It has the advantages of rapidity, sensitivity, specificity, and simplicity. It can directly detect extremely small amounts of pathogens in clinical specimens. It is necessary to prevent contamination during operation to avoid false positives.

　　5. Drug sensitivity test:After the culture is positive, further drug sensitivity tests should be performed. Use the paper disc diffusion method for sensitivity tests, or use the agar plate dilution method to determine the minimum inhibitory concentration (MIC), which is used to guide the selection of antibiotics.

　　6. PPNG detection:Beta-lactamase, using the paper disc acidity quantification method, using Whatman No. 1 filter paper PPNG strain can change its color from blue to yellow, positive as P-PPNG, negative as N-PPNG.

　　7. Other:Patients with mild myocarditis may show conduction block on the electrocardiogram.

　　Dietary principles for Neisseria gonorrhoeae infection:

　　1. Light diet. During the acute attack, it is advisable to eat sticky rice porridge, noodles, silver ear soup, mung bean soup, and fruits and vegetables with heat-clearing and detoxifying properties.

　　2. Foods rich in protein and vitamins. After the condition is stable, it is advisable to eat cakes, wontons, dumplings, milk, soy milk, eggs, lean pork, shrimps, fresh vegetables, and fruits, etc. Sweet and salty can be mixed, and it can be eaten in small amounts and multiple times. It is also advisable to drink more water to promote the excretion of toxins.

　　Dietary taboos for Neisseria gonorrhoeae infection:

　　Avoid spicy and irritating foods. Such as chili, pepper, ginger, scallion, wasabi, alcohol, strong tea, etc.; eat less drying and hot foods, such as leeks, pickled vegetables, preserved vegetables, cilantro, lamb, etc.

　　1. Treatment principles
　　(1) Early diagnosis and timely treatment First, after being infected, the diagnosis should be established as soon as possible, and there should be no arbitrary treatment before diagnosis. Secondly, treatment should be initiated immediately after diagnosis.
　　(2) Clarify clinical type and judge whether there are complications. It is extremely important to correctly guide treatment by clarifying the clinical classification.
　　(3) Clarify drug resistance. Determine whether there is resistance to penicillin, tetracycline, and other drugs, which is helpful for correctly guiding treatment.
　　(4) Clarify whether to merge Chlamydia or Mycoplasma infection. If Chlamydia or Mycoplasma infection is to be merged, a joint drug treatment plan should be formulated.
　　(5) Correct, adequate, regular, comprehensive treatment The most sensitive drugs for gonococci should be selected for treatment. The dosage should be sufficient, the course of treatment should be regular, and the method of administration should be correct.
　　(6) Strict evaluation of efficacy and follow-up observation The standard for cure should be strictly controlled, and the efficacy evaluation should be adhered to. Only after reaching the standard for cure can it be judged as cured to prevent recurrence. Cured patients should persist in regular follow-up examinations.
　　(7) Concurrent examination and treatment The partners of patients should be examined and treated at the same time. Both husband and wife or both sexual partners should be examined and treated concurrently.
　　2. General Precautions
　　Abstain from sexual activity until cured. Pay attention to rest, maintain the balance of water, electrolytes, and carbohydrates for those with complications. Pay attention to local hygiene of the vulva.
　　3. General Therapy
　　For uncomplicated gonorrhea, such as gonococcal urethritis, cervicitis, and proctitis, ceftriaxone is administered intramuscularly, once a dose; or gentamicin is administered intramuscularly, once a dose; or cefotaxime is administered intramuscularly, once a dose. The second choice is other third-generation cephalosporins, which can be selected as alternative drugs if their efficacy has been proven to be good. If chlamydial infection cannot be ruled out, combined with drugs for chlamydial infection.
　　According to the data of China's gonococcal resistance monitoring in recent years, the chromosomal resistance of Chinese gonococcal isolates to penicillin and tetracycline is relatively common, and penicillin and tetracycline are no longer recommended as treatment for gonorrhea. In addition, fluoroquinolone-resistant gonococci have become relatively common in China, and the resistance rate of resistant strains has increased year by year. In some areas, the resistance rate of gonococcal isolates to this class of drugs reaches 75% to 99%, and clinical cases of treatment failure with fluoroquinolone drugs for gonorrhea are also common. Therefore, it is not recommended to use fluoroquinolone drugs for the treatment of gonorrhea.
　　Pediatric Gonorrhea: Patients weighing more than 45kg are treated according to the adult regimen, and children weighing less than 45kg are treated as follows. Patients under 8 years of age are prohibited from using tetracycline drugs. Ceftriaxone is recommended for single-dose intramuscular administration; or gentamicin is recommended for single-dose intramuscular administration, the dosage of which is decided by the doctor.
　　For complications of gonorrhea, such as epididymitis, seminal vesiculitis, and prostatitis, ceftriaxone is used intramuscularly, once a day, for a total of 10 days; or gentamicin is used intramuscularly, once a day, for a total of 10 days; or cefotaxime is used intramuscularly, once a day, for a total of 10 days.