Gonorrhea in women is a specific infection caused by the gram–negative microorganism Neisseria gonorrhoeae and affecting the mucous membrane of the genitourinary tract, rectum, oral cavity, pharynx. The genitourinary form is manifested by purulent discharge from the vagina with an unpleasant odor, dysuria, pulling abdominal pain, itching and soreness in the area of the external genitals, but may also have an asymptomatic course. Methods for the diagnosis of gonorrhea in women include examination on a chair and laboratory tests (smear microscopy, back-seeding of secretions, PCR, PIF). Etiotropic atibiotic therapy is performed with cephalosporins, penicillins, fluoroquinolones.
Gonorrhea in women is a venereal disease that can occur in urogenital (gonorrheal urethritis, cervicitis, bartholinitis) and extragenital forms (gonorrheal proctitis, stomatitis, pharyngitis, blennorrhea). In the structure of STIs, it ranks second in prevalence after chlamydia and is often detected simultaneously with it. Most cases of gonorrhea are diagnosed in women aged 15-29. With a single unprotected sexual contact with a partner with gonorrhea, the risk of infection is 60-90%. A high degree of contagion, the appearance of strains of gonococcus resistant to known antibiotics, an adverse effect on reproductive function – these and other factors make the prevention of gonorrhea a priority task of venereology and gynecology.
Causes of gonorrhea in women
The pathogen causing gonorrhea, Neisseria gonorrhoeae, is a gram-negative aerobic diplococcus having a bean-shaped form. Inside the human body, the pathogen is highly resistant, it quickly dies in the external environment. Gonococcus pathogenicity factors are: a capsule with antiphagocytic activity; villi with which the bacterium attaches to the epithelium; endotoxin secreted by the cell wall; membrane proteins with pronounced antigenic properties.
With the help of surface proteins, gonococci attach to the cells of the cylindrical epithelium, causing their death and peeling. Phagocytes are produced by polynuclear neutrophils, within which they retain viability and the ability to reproduce. Usually gonococci initiate a specific local inflammation, but when they get into the blood they can cause a disseminated gonococcal infection. Quite often, gonorrhea in women occurs in the form of a mixed infection: gonorrhea-chlamydia, gonorrhea-trichomonas, gonorrhea-mycoplasma, gonorrhea-candidiasis.
The predominant way of infection is sexual, infection is possible both with unprotected vaginal and oral-genital or anal-genital contact. Often there is a multi-focal, multi-organ lesion. The non-sexual path of infection can be realized during childbirth when the child passes through the birth canal. Household infection is extremely rare – mainly when a child is in close contact with a mother with gonorrhea (for example, in the case of using a shared bed, towels, hygiene items, etc.).
Factors contributing to the high prevalence of gonorrhea among women are the low level of general culture, early onset of sexual activity, numerous sexual relationships, neglect of barrier methods of contraception and spermicidal agents during casual sexual intercourse, prostitution. The ascent of infection is facilitated by childbirth, intrauterine interventions (probing of the uterine cavity, abortion, RVV), menstruation, non-compliance with intimate hygiene.
Depending on the prescription of the disease, there are fresh (lasting up to 2 months) and chronic (lasting over 2 months) gonorrhea in women. Taking into account the severity of the symptoms, the fresh form may have an acute, subacute or torpid course. Chronic infection, as a rule, is asymptomatic, with periodic exacerbations. In the absence of specific local manifestations, but the release of the pathogen in the scrapings from the mucous membranes, they talk about latent infection, or gonococcus.
There are genital and extragenital forms of gonorrhea in women. According to the localization principle, gonorrhea of the lower parts of the genitourinary tract (urethritis, paraurethritis, vestibulitis, bartholinitis, cervicitis) and gonorrhea of the pelvic organs (endometritis, salpingitis, adnexitis, pelvioperitonitis) are differentiated. The course of gonorrhea in women can be uncomplicated and complicated.
Symptoms of gonorrhea in women
Gonorrhea of the lower genitourinary tract
The incubation period for lesions of the lower genitourinary tract is on average 5-10 days (with ascending, disseminated gonorrhea and estrogenital forms may increase). In almost half of infected women, gonorrhea has an asymptomatic or low-symptomatic course. Local manifestations depend on the predominant lesion of a particular organ, but gonorrhea in women often occurs in a mixed form. The classic signs of the disease are the appearance of abundant vaginal discharge of white or yellowish color with an unpleasant odor. This sign is often regarded by a woman as a manifestation of nonspecific vaginitis or thrush, and therefore attempts are being made to treat the infection independently, erasing the true clinical picture.
- Gonorrheal cervicitis (endocervicitis). The specific inflammatory process in gonorrhea in women most often involves the cervix. In addition to whites, in this case, the woman notes itching and burning in the vagina, in the area of the external genitals and perineum, due to their irritation by purulent secretions. Due to maceration on the posterior lip of the cervix, true erosion often occurs. Intermenstrual spotting may occur. During sexual intercourse, the patient experiences discomfort and painful sensations. At rest, there is heaviness in the lower abdomen and pulling pains in the sacrum area. In the outcome of chronic gonorrheal cervicitis, nabotovian cysts are formed, hypertrophy of the cervix is formed.
- Gonorrheal urethritis. The defeat of the urinary tract is indicated by frequent urination, accompanied by a burning sensation and pain, imperative urges, a feeling of incomplete emptying of the bladder. The external opening of the urethra during examination is edematous and hyperemic, painful on palpation; when pressed, a purulent discharge appears from it. Complications of gonorrheal urethritis with the upward spread of infection can be cystitis and pyelonephritis.
- Gonorrhea bartholinitis. The bartholinium glands in gonorrhea in women are affected a second time due to the leakage of pus from the urethra or cervix. When the excretory duct is blocked, the glands become inflamed, increase in size, become sharply painful – an abscess of the bartholinium gland is formed. In advanced cases, the abscess can spontaneously open with the formation of non-healing fistulas, from which there is a constant outflow of pus.
Gonorrheal endometritis. This clinical form of gonorrhea in women occurs with liquid purulent-serous or succulent discharge from the genital tract, dull pain in the lower abdomen and back, subfebrility. As a result of violations of the proliferative and secretory transformation of the endometrium, menstrual disorders such as hyperpolymenorrhea may occur; sometimes acyclic uterine bleeding occurs. With the delay of purulent contents in the uterine cavity, the pyometra clinic develops.
- Gonorrheal salpingitis and salpingoophoritis. It develops when the fallopian tubes and ovaries are affected, it is often bilateral. The acute phase of gonorrhea in women manifests with fever and chills, aching (sometimes cramping) pains in the lower abdomen. When sealing both ends of the fallopian tube (uterine and ampullary), it is possible to form a hydrosalpinx, and then a pyosalpinx, and in the case of the transition of inflammation to the ovary, a piovar, tuboovarian abscess. Against the background of an extensive inflammatory process in the pelvis, a pronounced adhesive process is formed.
- Gonorrheic pelvioperitonitis. This form of gonorrhea in women is caused by the spread of infection from the fallopian tubes to the peritoneum of the pelvis. Pelvioperitonitis of gonococcal etiology manifests violently: there are sharp pains in the lower abdomen with irradiation into the epigastrium and mesogastrium, symptoms of muscle protection. The temperature is quickly understood to febrile values, vomiting, gas retention and stool are noted. Peritonitis rarely develops, since the rapid formation of adhesions separates the inflammatory process from the abdominal cavity.
Complications of gonorrhea in women
The danger of gonorrhea lies not only in the high degree of contagiousness and the variety of clinical forms, but also in the frequent development of complications, both in the woman herself and in the offspring. Thus, gonorrheal endometritis often causes uterine infertility in women, and gonorrheal salpingitis and salpingoophoritis – tubal infertility and ectopic pregnancy.
Gonorrhea of pregnant women can provoke spontaneous abortion and premature birth; cause intrauterine development delay and antenatal fetal death, intrauterine infection of the fetus with the development of gonoblennorrhea, otitis, gonococcal sepsis of the newborn; postpartum purulent-septic complications in the woman in labor.
With disseminated gonococcal infection, skin lesions, gonorrheal tenosynovitis, arthritis, hepatitis, myopericarditis, endocarditis, meningitis, pneumonia, osteomyelitis, sepsis may occur. The asymptomatic course of gonorrhea in women does not guarantee the absence of complications.
Genital forms of gonorrhea in women are usually diagnosed by a gynecologist or venereologist, extragenital ones can be detected by a dentist, otolaryngologist, ophthalmologist or proctologist. In the anamnesis, as a rule, there are indications of casual sexual intercourse or multiple sexual contacts. In typical cases, when examined on a chair, an outflow of ribbon-like mucopurulent discharge from the external pharynx of the cervix, signs of vulvovaginitis are revealed. During a vaginal examination, a slightly enlarged, painful uterus, a conglomerate of fused fallopian tubes and ovaries can be palpated.
In order to confirm the diagnosis, material is taken from the vagina, cervical canal, urethra, rectum, oral cavity, conjunctiva (depending on the localization of the primary focus). Laboratory diagnostic tests include microscopy of smears with Gram staining, seeding of the separated for gonococcus, examination of scraping by PCR and PIF. Serological studies (RIF, ELISA, RSC) do not allow differentiating previously transferred and current gonorrhea in women, therefore, they usually do not play a decisive role in diagnosis.
If latent or chronic gonorrhea is suspected in women, when the pathogen is not detected in scrapings, various methods of provocation are used: chemical (lubrication of the urethra and cervical canal with protargol), mechanical (massage of the urethra), biological (intramuscular administration of pyrogenal or gonovaccine), thermal (conducting physiotherapy – ozokeritotherapy, paraffin therapy, UHF etc.), alimentary (consumption of spicy, salty food, alcohol), physiological (menstruation). After the provocation, the biological material is taken three times: after 24, 48, 72 hours.
Treatment and prevention
When prescribing therapy, the form, localization, severity of gonorrhea manifestations in women, the presence of concomitant infections and complications are taken into account. The basis of therapy is a course of antibiotic therapy with penicillin, cephalosporin, fluoroquinolone drugs. When gonorrhea is combined with chlamydia or trichomoniasis, metronidazole or doxycycline is connected to therapy.
With fresh gonorrhea in women, occurring with a lesion of the lower parts of the genitourinary tract, a single dose or administration of an antibiotic (ceftriaxone, azithromycin, ciprofloxacin, cefixime) is sufficient. The course of treatment for ascending gonorrhea or mixed infection is extended to 7-10 days. Immune stimulants, autohemotherapy, and the introduction of a gonococcal vaccine are connected to the treatment of chronic gonorrhea in women. Local treatment includes washing the urethra with 0.5% silver nitrate solution, washing the vagina with antiseptics (solutions of potassium permanganate, chlorhexidine, miramistin). A mandatory measure is the treatment of a sexual partner. After the inflammatory process subsides, physiotherapy procedures (UFO, electrophoresis, UHF) are prescribed.
With complicated forms of gonorrhea in women (tubovarial abscess, pyosalpinx, etc.), surgical treatment is indicated – removal of appendages. In case of pelvioperitonitis, laparotomy is necessary to sanitize the abdominal cavity. With an acute suppurative process in the area of the bartholinium gland, the abscess is opened, the wound is washed and drained.
When identifying a woman with gonorrhea, it is necessary to examine family members or sexual partners. For personal prevention purposes, it is recommended to use condoms during casual sexual contacts. After unprotected sexual intercourse, you should contact a medical institution as soon as possible for emergency prevention of STIs. Gonorrhea screening is a mandatory part of the pregnancy management program and the annual gynecological examination of women. Sanitary and educational work plays an important role in the prevention of gonorrhea.