Introduction

Firstly, my apologies to anyone who might find this article distasteful or graphic. I love writing for #healthybutsmart and there is a definite feel-good factor when talking about forest medicine, cinnamon, fasting, Himalayan sea salt etc. Not so really with the topic of gonorrhea.

I know this because I have been a practising infectious diseases physician for 20 years and I am well aware of people’s reactions to this topic. If you don’t believe me, just casually mention sexually transmitted infections to the parents of teenager and watch their reaction. However, in order to add value and remain true to the investigative journalism style of #healthybutsmart, I have to be slightly hard core (sorry, no pun intended).

Be warned, if you are looking for a more happy clappy article ( oops sorry again, then this article may well not be for you.

If you are a curious truth seeker, here goes.

What is Gonorrhea?

Gonorrhea is a sexually transmitted infection caused by a bacteria known as Neisseria gonorrheae. It was discovered in 1879. Looking through a microscope, it looks like two round cells stuck together.

How Common is Gonorrhea?

Many people who are given a diagnosis of gonorrhea think that they are one of the extremely rare people with this infection. Not so. It is just that people are super happy to tell everyone about their strep throat but not their gonorrhea.

The Center for Disease Control in the USA say that 820,000 new cases of gonorrhea are diagnosed each year. This makes gonorrhea the second most common reportable sexually transmitted infectious disease (after chlamydia). It is also estimated that the ratio of diagnosed gonorrhea to undiagnosed gonorrhea is 1:1. This means that there may be 820,000 people with undiagnosed gonorrhea out there somewhere.

The reaction from most medical students who learn these statistics is ‘That’s it, I am becoming a monk’. Let’s say that we usually find that they don’t follow through with the plan for lifelong abstinence. At least, we hope that their lectures in sexually transmitted infections encourages them to use condoms.

Why such high rates of gonorrhea, you might well ask? Does this just reflect high rates of unsafe sex? Well, it is a little more complex than that. Understanding the way that gonorrhea affects men and women helps us to understand the high rates of infection. Additionally, it gives us an insight into the smart design of a bacteria that is programmed for survival with humans being just a part of the grand design. We, humans, often assume that the world revolves around us. Not so.

Gonorrhea in Men

Men infected with gonorrhea usually have symptoms. This usually prompts them to seek medical care. From a public health perspective, this is good news. Realistically, few men with full-blown gonorrhea will be interested in sex. However, the onset of symptoms occurs after men are infectious (capable of passing on the infection to someone else). This means that a man is capable of transmitting infection between the time that he contracts infection and develops the tell-tale symptoms.

Gonorrhea in Women

The story in women is different. Women often have no symptoms (until complications occur) which makes women with gonorrhea potent reservoirs of ongoing infection.

Where can you get Gonorrhea?

The polite answer to this question is ‘at sites of exposure’. To be more blunt about it, this means:

  • Eyes
  • Mouth
  • Urethra
  • Vagina
  • Cervix
  • Rectum
  • Penis
  • (depending on… well you can fill in the blanks yourself).

Infections can spread from these sites to cause bloodstream infections (sepsis), meningitis and/or arthritis infections.

Is Ejaculation Necessary?

That would be no. Ejaculation is not a prerequisite for contracting gonorrhea. It can be passed on by any close (intimate) contact between two people. That leads to another really common question that we are asked in clinic.

Can you get it from toilet seats?

That would also be a no. The gonococcus bacteria is very fragile and does not survive for long outside the body. That is why close (intimate) contact is needed for transmission. Again to be more blunt, we are talking about mucous membrane to mucous membrane contact.

How is gonorrhea diagnosed?

Symptomatic patients usually come to clinic and give a very clear list of symptoms such as green-yellow discharge +++ (we are talking tissue paper in underwear type of scenario while waiting for the clinic to open), pain on urination or defecation, frequent urination and/or testicular pain and swelling .

Urine and swabs from the ‘sites of exposure’ are taken to check for the presence of gonorrhea.

How is it diagnosed?

Two main techniques are used in the diagnosis of gonorrhea in the laboratory.

  1. Old fashioned microscopy and culture of the bacteria
  2. More modern nucleic acid amplification tests (NAATS).

Double Trouble

It is not unusual for people to have dual infection with both chlamydia and gonorrhea.

What are the long term complications of gonorrhea?

Long term complications of gonorrhea are more commonly seen in women than men. Complications include pelvic inflammatory disease, infertility and ectopic pregnancy (where the fetus is growing outside of the uterus and does not result in a viable pregnancy) .

Now before you get terrified, keep reading. If you are secretly reading this article under the bedclothes with a flash lamp, hang in there, these complications can usually be avoided with screening and prompt treatment of infection.

What is the Fitz Hugh Curtis Syndrome?

This syndrome is uber-rare (the type of question asked of honors students in the final medical exam). It was first described in 1934 and is a rare complication of gonorrhea infection where it causes inflammation of the liver capsule (a membrane which covers the liver).

Good and Bad News

The good news is that gonorrhea infection can be eradicated.

The not so good news is the issue of resistance.

The Piece De Resistance

Bacteria are programmed to survive and thrive. Public enemy  #1 for bacteria = antibiotics. Bacteria evolve and develop mechanisms to evade antibiotic therapy. This is known as resistance. In plain English, resistance means that the usual dose of antibiotics may not cure the infection. Since 1986 there has been a sentinel surveillance system in place in the USA to monitor for resistance of important bacteria. This surveillance data is used to help policy makers decide on the treatment guidelines for any infectious disease including gonorrhea. Essentially there is a tango between the bug and the drug.

In many ways, it is similar to the laws of physics.

‘To every action, there is an equal and opposite reaction’.

We decide to use agent ‘X’ to treat gonorrhea.

Gonorrhea develops resistance and agent ‘X’ stops working.

We analyze the resistance data and decide to switch to agent ‘Y’.

Gonorrhea develops resistance and agent ‘Y’’ stops working.

And so on.

The slightly good news is that this does not happen quickly.

It is a slow tango.

How do we deal with resistant bacteria?

  1. Change the class of antibiotics.
  2. Give two antibiotics together.
  3. Change from oral to injectables.

That is exactly what we see in the way that the guidelines for the treatment of gonorrhea have evolved in tandem with the resistance patterns detected in the circulating strains of gonorrhea.

Here is a snapshot of the recent timelines of the evolution of the guidelines for the treatment of gonorrhea.

  • 2007 Oral Cephalosporins
  • 2010 Oral Cephalosporins + doxycycline/azithromycin
  • 2012  Injection of Cephalosporins + azithromycin.

Is There Any Research?

There are 17,000 publications for the search term gonorrhea. To put this into context, there are 28,000 results for the search term chlamydia.

Who Makes The Guidelines?

Key organizations involved in writing guidelines for gonorrhea are:

  • The Center for Disease Control (1)
  • The British Association For Sexual Health and  HIV (2).

What Are The Best Supported Treatments According To Research?

The current (as in current at the time of writing this article) guidelines for uncomplicated ano-genital gonorrhea recommend:

ceftriaxone 500mg by intramuscular injection plus azithromycin 1gm orally (3, 4).

Let’s deconstruct this regimen:

two different families of antibiotics (a cephalosporin and a macrolide) which means they work differently and this reduces the chance that the bacteria will be resistant

one drug is given intramuscularly to again reduce the chance of the emergence of resistance.

Another advantage of this regimen is the fact that it is administered in the clinic so that the entire treatment is observed.

Now let’s look at the quality of the treatment guideline.This guideline is considered to be a level of evidence grade IV and grade C recommendation.

This means that the evidence behind this recommendation was a series of cases.

To benchmark this:

  • Level 1      High Quality Randomized Controlled Trials
  • Level II      Lesser Quality  Randomized Controlled Trials
  • Level III     Case Control Studies
  • Level IV     Case Series
  • Level V      Expert Opinion
  • Grade A     Strong Recommendation
  • Grade B     Recommendation
  • Grade C     Optional (5).

Why such poor quality data behind such an important infection? As we have seen in our snoop work in general for #healthybutsmart, many tenets of medicine are not backed by rock solid research. Additionally, resistance means that the goalposts keep changing. Research trials can take years to design and execute. Well designed research in 2018 which is based on 2018 resistance data may be totally outdated by the time it is ready to be published.

Here is a sample of one of the studies in the field (6). Researchers from Johns Hopkins analyzed data from STD clinics between 2004 and 2011. They compared ceftriaxone plus azithormycin with cefrtriaxone plus doxycycline in patients who needed retreatment of their infection. They found a trend towards superiority of the azithromycin arm of the study. Interesting but hardly Nobel Prize worthy.

Special Considerations

Special consideration needs to be given to people who fall into any of the following categories:

  • Pregnancy
  • New born babies (who acquire gonorrhea during delivery)
  • Allergy to penicillin and/or
  • Disseminated infection.

Why Do Partners Have To Be Treated?

Oh, this is an issue that causes lots of angst in the clinic. Recent sex partners (within 60 days of the onset of symptoms or diagnosis) are referred for evaluation and treatment. Coordination is essential to avoid reinfection of either partner/partners. Practically speaking this mans that sex partners are told to avoid unprotected sexual intercourse (UPSI) for 7 days after they and their partner/partners complete therapy. Failure to do so means that people are advised to start the treatment and avoidance cycle all over again.

Question: How could people fail to comply with this very simple advice?
Answer: Human nature.

Advice that seems very doable on a Thursday morning in a clinic can seem oh so difficult on a Saturday night.

What Does Mouthwash Have To Do With This?

A much talked about study is the Listerine study that was published last year (7). The pharynx can act as a reservoir for gonorrhea. Australian investigators compared Listerine mouthwashes at dilutions of up to 1:4 for 1 min to a saline buffer and found that Listerine resulted in significant reductions in total Neisseria gonorrhoeae levels in the pharynx.

This does not prove that Listerine mouthwash will reduce your risk of gonorrhea but it is pretty interesting. FYI- Listerine Cool Mint and Total Care flavours were used in the study.

Social Media Links

If the area of sexually transmitted infections interests you, then you can follow the CDC on Facebook (8) or Twitter (9). Thankfully there is no Instagram equivalent! I don’t know many people who do follow sexually transmitted infections on social media and even fewer who share posts from these sites with their BFF.

I am not a great fan of cat memes but given a choice between sexually transmitted infections or cat memes in my social media feed, I guess I would have to go for the silly looking cat.

Conclusions

While the bacteria that causes gonorrhea may only have been identified last century, the history of both sex and sexually transmitted infections dates back to the beginning of time.

It always interests me to compare the body language of people in antenatal and sexually transmitted infections waiting rooms. Moms-to-be in the antenatal clinic room may look tired but they usually also look happy and people shower them with congratulations. People in the sexually transmitted infection clinic often look uncomfortable and can’t wait to get out the door. I am pretty sure that the words ‘Oh congratulations, you have gonorrhea’ have never been uttered in a clinic.

Yet, both patient groups need healthcare support because of the very same thing. Yes, sex. Many people continue to have very judgmental attitudes to sex. When all is said and done, sexually transmitted infections are just infections and sex is just sex.

The data behind the gonorrhea guidelines may not be robust in terms of randomized clinical trials, but they are responsive (meaning that they respond to changes in resistance patterns). This is hugely important. A responsive real-time guideline is much more informative than an outdated but well designed clinical trial.