Gonorrhea mcb. Gonorrhea (ICD diagnosis code: A54.9)

The clinical symptoms of gonorrhea in men are characterized by discharge from the urethra, as well as itching and burning during urination. An objective examination of the lips of the urethra is sharply hyperemic, edematous, the urethra itself is infiltrated, pain is noted on palpation. Copious flow freely from the urethra purulent discharge yellowish-green in color, which often macerate the inner leaf of the foreskin. With late treatment, hyperemia and swelling of the skin of the glans penis and foreskin can be observed. Superficial erosions may form on the glans penis. With rectal infection, there is discharge from the anus or pain in the perineum. In men under 40 years of age. and also in persons with reduced resistance, epididymitis occurs due to the penetration of gonococci into the appendage from the prostatic urethra through the vas deferens. The disease begins suddenly with pain in the epididymis and in the groin. Patients have an increase in body temperature up to 39-40 ° C, chills, headache, weakness. On palpation, the appendage is enlarged, dense and painful. The skin of the scrotum is tense, hyperemic, there is no folding of the skin. Gonococcal lesion of the appendages leads to the formation of scars in the ducts of the epididymis. As a result, azoospermia and infertility occur. An asymptomatic course can be observed in 10% of cases with damage to the urethra, 85% - with damage to the rectum, 90% - with damage to the pharynx. Disseminated gonococcal infection (DGI) is most often manifested by fever. damage to the joints (one or more) and skin. The manifestation of gonococcal dermatitis is accompanied by the formation of necrotic pustules on an erythematous base, and erythematous and hemorrhagic spots, papulo-pustules, blisters can also be observed. Most frequent localization rashes are distal parts of the limbs or near the affected joints. The sheaths of the tendons, especially the hands and feet, are also affected (tenosipovitis). DGI is more common in women than in men. The risk of developing DGI increases during pregnancy and during the premenstrual period. The manifestation of gonococcal infection in the form of meningitis or endocarditis is very rare.

The clinical symptoms of gonorrhea in women are almost asymptomatic, which leads to late detection of the disease and the development of complications. The primary localization of the lesion is the cervical canal, and inflammatory changes develop both in the integumentary epithelium and in the stroma of the uterine mucosa. Damage to the urethra (urethritis) is observed in 70-90% of patients, and damage to the vulva and vagina usually develops secondarily. On examination, the discharge is mucopurulent in nature, contact bleeding may be noted. Lesions of the basal layer of the endometrium occur as a result of the penetration of gonococci into the uterine cavity during menstruation or after childbirth and abortion. The penetration of gonococci from the endometrium into the muscular layer of the uterus (endometritis) is more often observed after abortion and childbirth. Characteristic of ascending gonorrhea is the rapid spread of infection from the uterus to the fallopian tubes, ovaries, and peritoneum. When spread purulent process pelvioperitopit occurs in the cavity of the gas peritoneum, a fibrin-rich transudate causes the formation of adhesions and adhesions of the fallopian tube and ovary with neighboring organs. It's accompanied acute pain in the lower abdomen and pain on palpation, fever up to 39 ° C.

In 50% of cases with damage to the cervix, 85% of cases - the rectum and 90% - the pharynx, an asymptomatic infection is observed.

The infection often proceeds as a mixed one (gonorrheal-Trichomonas, gonorrheal-chlamydial, etc.). As a rule, several organs are infected (multifocal lesion).

Gonococcal conjunctivitis in newborns

The defeat of the conjunctiva of the eyes in newborns occurs during the passage through the birth canal of a mother with gonorrhea and is accompanied by redness, swelling, and gluing of the eyelids. From under their edges or the inner corner of the eye, pus flows out, the conjunctiva of the eye becomes hyperemic, swells. If appropriate treatment is not started in a timely manner, corneal ulceration up to its perforation is possible, which can subsequently lead to complete blindness. Gonococcal eye disease in adults may be the result of gonococcal sepsis or, most often, direct transmission of the infection by the hands, "dirty discharge from the genitourinary organs. With inflammation of the conjunctiva, a purulent discharge appears, its partial or even complete destruction.

Indications for testing

symptoms or signs of discharge from the urethra;
mucopurulent cervicitis;
the presence of a sexually transmitted infection (STI) or PID in a sexual partner;
screening for STIs at the request of the patient or with the recent arrival of a new sexual partner;
vaginal discharge in the presence of risk factors for STIs (age younger than 25 years, a recent sexual partner);
acute orchiepididymitis in men younger than 40 years;
acute PID;
casual sexual intercourse without means of protection;
purulent conjunctivitis in newborns.

Laboratory diagnostics

Verification of the diagnosis of gonorrhea is based on the detection of Neisseria gonorrhea in materials from the genitals, rectum. pharynx, eye using one of the methods.

A rapid diagnostic test (microscopy of methylene blue Gram-stained smears from the urethra, cervix, or rectum) quickly identifies typical Gram-negative diplococci.

All samples should be analyzed by culture and antigen amplification methods (nucleic acid amplification).

Additional Research

setting a complex of serological reactions to syphilis;
determination of antibodies to HIV, hepatitis B and C;
clinical analysis of blood, urine;
Ultrasound of the pelvic organs;
ureteroscopy, colposcopy;
cytological examination of the mucous membrane of the cervix;
2-glass Thompson test;
study of prostate secretion.

The expediency of the provocation is decided individually by the attending physician. Indications, volume and frequency of additional studies are determined by the nature and severity of clinical manifestations of gonococcal infection.

Gonorrhea is an infectious disease caused by a specific pathogen - gonococcus, transmitted mainly through sexual contact and characterized mainly by lesions of the mucous membranes of the genitourinary organs. Gonococcal lesions of the oral mucosa and rectum are also observed, which is detected after orogenital or homosexual contacts.

The source of infection are mainly patients with chronic gonorrhea, mostly women, because their chronic process is almost imperceptible, longer, more difficult to diagnose. Patients with acute and subacute gonorrhea in the presence of an acute inflammatory process usually avoid sexual intercourse. Gonorrhea is transmitted almost exclusively through sexual contact. In some cases, non-sexual infection is possible through linen, sponges, towels, on which non-dried gonorrheal pus has been preserved. Infection of a newborn can occur during childbirth when the fetus passes through the birth canal of a sick mother.

Etiology. The causative agent of gonorrhea is Neisseria gonorrhoeae, a gram-negative diplococcus that has the shape of coffee beans facing each other with their concave surface. Gonococci have a well-defined three-layer outer wall and cytoplasmic membrane, cytoplasm with ribosomes and a nuclear vacuole. Gonococci are usually located intracellularly in the protoplasm of leukocytes, usually in groups, but extracellular gonococci can sometimes be seen. Studies of gonococci in recent years indicate changes in their biological properties (the presence of capsules, phagosomes, β-lactamase, reduced sensitivity to antibiotics, the appearance of L-forms). Gonococci infect mucous membranes, in particular the urethra, vagina, rectum, mouth, nose, and larynx. The process can spread to the prostate gland, seminal vesicles, epididymis, testis, vas deferens, and in women - to the uterus, ovaries, fallopian tubes. Spreading through the bloodstream, gonococci can sometimes cause gonococcal sepsis and metastases to various organs. Gonococcal bacteremia affects the joints, eyes, pleura, endocardium, muscles, bones, and nerves. In newborns, the eyes are affected, conjunctivitis and keratitis develop.

Gonorrhea classification

The classification of gonococcal infection presented in the International Statistical Classification of Diseases of the 10th revision differs from that adopted in Russia and the CIS countries.

International Statistical Classification of Diseases and Related Health Problems Tenth Revision (ICD-10)

Sexually transmitted infections (A50-A64)

A54 Gonococcal infection

A54.0 Gonococcal infection of the lower genitourinary tract without abscessing of the periurethral and adnexal glands

Gonococcal: cervicitis NOS, cystitis NOS, urethritis NOS, vulvovaginitis NOS.

Excludes: with: - abscess of the urogenital glands (A 54.1), periurethral abscess (A 54.1)

A54.1 Gonococcal infection of the lower genitourinary tract with abscess formation of the periurethral and adnexal glands

Gonococcal abscess of Bartholin's glands

A54.2 Gonococcal pelvioperitonitis and other gonococcal infections of the urinary tract

Gonococcal (oe): epididymitis (No. 51.1), pelvic inflammatory disease in women (No. 74.3), orchitis (No. 51.0), prostatitis (No. 51.0).

Excludes: gonococcal peritonitis (A 54.8).

A54.3 Gonococcal eye infection

Gonococcal conjunctivitis (H 13.1), iridocyclitis (H 22.0).

Gonococcal ophthalmia of the newborn.

A54.4 Gonococcal infection of the musculoskeletal system

Gonococcal: arthritis (M 01.3), bursitis (M 73.0), osteomyelitis (M 90.2), synovitis (M 68.0), tenosynovitis (M 68.0).

A54.5 Gonococcal pharyngitis

A54.6 Gonococcal infection of the anorectal region

A54.8 Other gonococcal infections

Gonococcal (th) (th): brain abscess (G 07), endocarditis (I 39.8), meningitis (G 01), myocarditis (I 41.0), pericarditis (I 32.0), peritonitis (K 67.1), pneumonia (J 17.0) , sepsis, skin lesions.

Excludes: gonococcal pelvioperitonitis (A 54.2)

A54.9 Gonococcal infection, unspecified

Gonorrhea - infection caused by gonococcus (Neisseria gonorrhoeae), with a primary lesion of the genitourinary organs.

ICD-10 CODE A54 Gonococcal infection.

EPIDEMIOLOGY OF GONORRHEA

According to WHO, 200 million people are diagnosed with the disease every year. In Russia, after a slight decrease in the 1990s, the increase in the incidence of gonorrhea since 2001 has increased to 102.2 per 100,000 population.

PREVENTION OF GONORRHEA

The basis of prevention timely diagnosis and adequate treatment of patients with gonorrhea. For this, they carry out preventive examinations, especially among employees of children's institutions, canteens. Pregnant women who are registered in the antenatal clinic or applied for termination of pregnancy are subject to mandatory examination. Personal prevention includes personal hygiene, the exclusion of casual sexual intercourse, the use of a condom or the instillation of chemical protective equipment into the vagina: miramistin ©, chlorhexidine, etc. Prevention of gonorrhea in newborns is carried out immediately after birth: children are instilled into the conjunctival sac 1-2 drops of 30% sulfacetamide solution.

SCREENING

Sexual partners are involved in the examination if sexual contact occurred 30 days before the onset of symptoms of the disease, as well as persons who were in close household contact with the patient. In asymptomatic gonorrhea, sexual partners who have been in contact for 60 days before diagnosis are examined. Children of mothers with gonorrhea are subject to examination, as well as girls in case of detection of gonorrhea in persons caring for them. Sick staff are not allowed to work.

CLASSIFICATION OF GONORRHEA

The classification of gonorrhea is currently accepted, as set out in the International Statistical Classification of Diseases, X revision of 1999.

A54.0 Gonococcal infection of the lower genitourinary tract without periurethral or accessory gland abscess.

A54.1 Gonococcal infection of the lower genitourinary tract with abscess formation of the periurethral and adnexal glands.
A54.2+ Gonococcal pelvioperitonitis and other gonococcal infection of the urogenital organs.
A54.3 Gonococcal eye infection.
A54.4+ Gonococcal infection of the musculoskeletal system.
A54.5 Gonococcal pharyngitis.
A54.6 Gonococcal infection of the anorectal region.
A54.8 Other gonococcal infections.
A54.9 Gonococcal infection, unspecified.

This classification is close to that set out in the methodological materials "Diagnostics, treatment and prevention of STDs" (1997).

Gonorrhea of the lower urinary tract without complications.
Gonorrhea of the lower urinary tract with complications.
Gonorrhea of the upper urinary tract and pelvic organs.
Gonorrhea of other organs.

Gonorrhea of the lower urogenital tract includes damage to the urethra, paraurethral glands, glands of the vestibule of the vagina, mucous membrane of the cervical canal, vagina; to gonorrhea of the upper genitourinary tract (ascending) - damage to the uterus, appendages and peritoneum.

They also offer a classification (1993), which is based on the duration and severity of the clinical manifestations of the disease. Distinguish:

fresh (with a disease duration of up to 2 months), which is divided into acute, subacute and torpid (low-symptomatic or asymptomatic with scanty exudate, in which gonococci are found);
chronic (lasting more than 2 months or with an unknown duration of the disease). Chronic gonorrhea can occur with exacerbations.

Gonococcal carriage is possible (the pathogen does not cause the appearance of exudate and there are no subjective disorders).

ETIOLOGY OF GONORRHEA

Gonococcus is a paired coccus (diplococcus) bean-shaped, gram-negative, located intracellularly (in the cytoplasm of leukocytes). Gonococci are highly sensitive to the effects of adverse environmental factors: they die at temperatures above 55 ° C, drying, treatment with antiseptic solutions, under the influence of direct sunlight. Gonococcus remains viable in fresh pus until dry. The main route of infection is sexual (from an infected partner). The contagiousness of the infection for women is 50-70%, for men - 25-50%. Much less often, gonorrhea is transmitted by household means (through dirty linen, towels, washcloths), mainly in girls. The possibility of intrauterine infection has not been proven. Gonococci are immobile, do not form spores; have thin tubular filaments (drank), with the help of which they are fixed on the surface epithelial cells, spermatozoa, erythrocytes.

Outside, gonococci are covered with a capsule-like substance that makes them difficult to digest. Persistence of infection is possible inside leukocytes, Trichomonas, epithelial cells (incomplete phagocytosis), which complicates the treatment.

With inadequate treatment, L-forms of gonococci may form, differing in their morphological and biological characteristics from typical forms. L forms are spherical, have different sizes and colors. They are insensitive to the drugs that caused their formation, antibodies and complement due to the loss of some of their antigenic properties. The persistence of L forms complicates the diagnosis and treatment of the disease and contributes to the survival of the infection in the body as a result of reversion to vegetative forms. With the widespread use of antibiotics, a large number of strains of gonococcus that produce the enzyme β-lactamase and, accordingly, are resistant to antibiotics containing β-lactam ring.

PATHOGENESIS OF GONORRHEA

Gonococci mainly affect the urinary tract, lined with columnar epithelium - the mucous membrane of the cervical canal, fallopian tubes, urethra, paraurethral and large vestibular glands. With genital-oral contacts, gonorrheal pharyngitis, tonsillitis and stomatitis can develop, with genital-anal contacts - gonorrheal proctitis. When the pathogen enters the mucous membrane of the eyes, including when the fetus passes through the infected birth canal, there are signs of gonorrheal conjunctivitis.

The vaginal wall, covered with stratified squamous epithelium, is resistant to gonococcal infection. However, in some cases (during pregnancy, in girls and in postmenopausal women), when the epithelium becomes thinner or loose, gonorrheal vaginitis may develop.

Gonococci, entering the body, are quickly fixed on the surface of epithelial cells with the help of pili, and then penetrate deep into the cells, intercellular gaps and subepithelial space, causing destruction of the epithelium and the development of an inflammatory reaction.

Gonorrheal infection in the body most often spreads along the length (canalicular) from the lower urinary tract to the upper. Gonococcus adhesion to the surface of spermatozoa and enterobiasis inside Trichomonas often contribute to faster advancement.

Sometimes gonococci enter the bloodstream (usually they die under the action of the bactericidal activity of the serum), leading to generalization of the infection and the appearance of extragenital lesions, among which joint lesions are most common. Gonorrheal endocarditis and meningitis develop less frequently.

In response to the introduction of the causative agent of gonorrhea, antibodies are produced in the body, but the immune system is ineffective. A person can become infected and get sick with gonorrhea many times. This can be explained by the antigenic variability of gonococcus.

CLINICAL PICTURE OF GONORRHEA IN WOMEN

The incubation period of gonorrhea ranges from 3 to 15 days, rarely up to 1 month. Gonorrhea of the lower urinary tract is often asymptomatic. With pronounced manifestations of the disease, dysuric phenomena, itching and burning in the vagina, pus-like creamy discharge from the cervical canal are noted. On examination, hyperemia and swelling of the mouth of the urethra and cervical canal are found.

Gonorrhea of the upper section (ascending) is usually manifested by a violation general condition, complaints of pain in the lower abdomen, fever up to 39 ° C, nausea, sometimes vomiting, chills, liquid stool, frequent and painful urination, impaired menstrual cycle. The spread of infection beyond the internal os is facilitated by artificial interventions - abortion, curettage of the uterine mucosa, probing of the uterine cavity, taking endometrial aspirate, cervical biopsy, and the introduction of an IUD. Often, an acute ascending inflammatory process is preceded by menstruation, childbirth. An objective examination reveals purulent or sanious-purulent discharge from the cervical canal, an enlarged, painful, soft uterus (with endomyometritis), edematous, painful appendages (with salpingo-oophoritis), pain on palpation of the abdomen, symptoms of peritoneal irritation (with peritonitis). Often, an acute infectious process in the uterine appendages is complicated by the development of tubo-ovarian inflammatory formations, up to the appearance of abscesses (especially when a disease occurs against the background of the use of an IUD).

Previously, the following symptoms were described in the literature, characteristic of ascending gonorrhea:

Availability blood secretions from the genital tract;
bilateral damage to the uterine appendages;
the relationship of the disease with menstruation, childbirth, abortion, intrauterine interventions;
a quick effect of the therapy: a decrease in the number of leukocytes in the blood and a decrease in body temperature with elevated ESR.

Currently, the gonorrheal process does not have typical clinical signs, since almost all cases show mixed infection. Mixed infection lengthens incubation period, contributes to more frequent recurrence, complicates diagnosis and treatment.

Chronization inflammatory process leads to disruption of the menstrual cycle, the development of adhesions in the pelvis, which can subsequently cause infertility, ectopic pregnancy, miscarriage, chronic pelvic pain syndrome.

Gonorrheal proctitis is most often asymptomatic, but sometimes accompanied by itching, burning in the anus, painful bowel movements, tenesmus.

To clinical manifestations gonorrhea in pregnant women include cervicitis or vaginitis, premature opening of the membranes, fever during or after childbirth, septic abortion. Rarely, gonococcal infection during pregnancy occurs in the form of salpingitis (only in the first trimester).

DIAGNOSIS OF GONORRHEA IN WOMEN

Diagnosis is based on anamnesis data, physical examination. Basic Methods laboratory diagnostics gonorrhea - bacterioscopic and bacteriological, aimed at detecting the pathogen. Identification of gonococcus is carried out according to three signs: diplococcus, intracellular location, gram-negative microorganism. Due to the high ability to variability under the influence of adverse effects environment gonococcus can not always be detected by bacterioscopy, the sensitivity and specificity of which are 45–80% and 38%, respectively. For diagnosing erased and asymptomatic forms of gonorrhea, as well as in children and pregnant women, the bacteriological method is more suitable. Sowing of the material is carried out on specially created artificial nutrient media. When the material is contaminated with extraneous accompanying flora, the isolation of gonococcus becomes difficult, therefore, selective media with the addition of antibiotics are used to detect it. If it is impossible to inoculate immediately, the material for research is placed in a transport medium. Cultures grown on a nutrient medium are subjected to microscopy, their properties and sensitivity to antibiotics are determined. The sensitivity of the bacteriological method is 90–100%, the specificity is 98%. Material for microscopy and inoculation is taken with a Volkmann spoon or a bacteriological loop from the cervical canal, vagina, urethra, if necessary, from the rectum or any other place where gonococcus can presumably be located. Scrapings or washings with isotonic sodium chloride solution are taken from the rectum.

Other methods of laboratory diagnosis of gonorrhea (immunofluorescence, enzyme immunoassay, DNA diagnostics) are rarely used, they are not mandatory.

Procedure for diagnosing gonorrhea:

1. Bacterioscopy (analysis of a freshly stained smear taken from 3 points: U, V, C), in acute gonorrhea, the pathogen is located mainly inside leukocytes, and in chronic gonorrhea - extracellularly.
2. Bacteriological examination, with the determination of sensitivity to antibacterial drugs. Indications: repeated receipt of a negative result of bacterioscopy;
the presence in smears from pathological material of microorganisms suspicious of gonococcus;
with clinical or epidemiological suspicion of gonorrhea.

3. Immunofluorescence reaction (RIF).
4. Immunofluorescence analysis (ELISA).
5. Molecular methods: polymerase chain reaction and ligase chain reaction (PCR, LCR).
6. In the absence of gonococci in smears and cultures, provocative tests are carried out using immunological, chemical, thermal methods, possible complications and the consequences of their implementation:

1) chemical - lubrication of the urethra to a depth of 1-2 cm with 1-2% solution of silver nitrate, rectum to a depth of 4 cm with 1% Lugol's solution in glycerin, cervical canal to a depth of 1-1.5 cm with 2-5% solution of silver nitrate ;
2) biological - administration of gonovaccine intramuscularly at a dose of 500 million microbial bodies or simultaneous administration of gonovaccine with pyrogenal at a dose of 200 MPD;
3) thermal - daily diathermy for 3 days (on the 1st day for 30 minutes, on the 2nd day - 40 minutes, on the 3rd - 50 minutes) or inductothermy for 3 days, 15 -20 minutes. Detachable for laboratory analysis is taken daily 1 hour after physiotherapy;
4) physiological - taking smears on the days of menstruation;
5) combined - conducting biological, chemical and thermal provocative tests on the same day. Detachable is taken after 24, 48 and 72 hours, and crops are carried out 72 hours after the combined test.

DIFFERENTIAL DIAGNOSIS OF GONORRHEA

Differential diagnosis is carried out with other urogenital STIs, and with ascending gonorrhea - with diseases accompanied by a clinical picture of an acute abdomen.

INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS

In the acute course of gonorrhea with damage to the internal genital organs, to verify the diagnosis, it may be necessary to involve related specialists (surgeon, urologist) for consultation and to perform a laparoscopic examination. With extragenital foci of infection, consultations of an ENT doctor, an oculist, an orthopedist are indicated.

TREATMENT OF GONORRHEA IN WOMEN

Sexual partners are subject to treatment if at least one of them has gonococci by a bacterioscopic or bacteriological method.

GOALS OF TREATMENT

elimination of the pathogen.

NON-MEDUCATIONAL TREATMENT OF GONORRHEA

Physiotherapy in the form of magnetotherapy, inductothermy, electrophoresis and phonophoresis of medicinal substances, laser therapy, ultraviolet radiation therapy and ultrahigh frequencies are used in the absence of acute inflammatory processes.

MEDICAL TREATMENT OF GONORRHEA

In the treatment of gonorrhea, the main place belongs to antibiotic therapy to influence the pathogen. However, the growth of strains of gonococcus resistant to currently used antibiotics should be taken into account. The reasons for ineffective treatment may be the wide possibilities of gonococcus to form L-forms, produce β-lactamase, and remain inside the cells. Treatment is prescribed taking into account the form of the disease, the localization of the inflammatory process, the presence of complications, concomitant infection, restrictions on the use of drugs due to the presence of side effects sensitivity of the pathogen to antibiotics.

Treatment regimens for gonorrhea:

Etiotropic treatment of fresh gonorrhea of the lower genitourinary system without complications consists in prescribing one of the antibiotics:

ceftriaxone - 250 mg intramuscularly once or
azithromycin 2 g orally once or
ciprofloxacin 500 mg orally as a single dose or
cefixime 400 mg orally as a single dose or
spectinomycin - 2 g intramuscularly once.

Alternative treatment regimens:

ofloxacin 400 mg orally as a single dose or
cefodisim - 500 mg intramuscularly once or
kanamycin - 2.0 g intramuscularly once or
trimethoprim + sulfamethoxazole (80 mg + 400 mg) - 10 tablets orally 1 time per day for 3 consecutive days.

Fluoroquinolones are contraindicated in children and adolescents under 14 years of age, women during pregnancy and lactation. When using alternative schemes, constant monitoring of the sensitivity of gonococcus is necessary. The frequent combination of gonorrhea with chlamydial infection dictates the need for careful diagnosis and treatment of the latter.

For the etiotropic treatment of gonorrhea of the lower genitourinary system with complications and gonorrhea of the upper sections and pelvic organs, the following are used:

ceftriaxone 1 g IM or IV every 24 hours for 7 days or
spectinomycin - 2.0 g intramuscularly every 12 hours for 7 days.

Alternative treatment regimens:

cefotaxime 1 g IV every 8 hours or
kanamycin - 1 million units intramuscularly every 12 hours or
ciprofloxacin 500 mg IV every 12 hours

Therapy with these drugs can be carried out in a shorter time, but not less than 48 hours after the disappearance of clinical symptoms. After the disappearance acute symptoms inflammatory process, treatment can be continued with the following drugs oral administration:

ciprofloxacin - 500 mg orally every 12 hours;
ofloxacin - 400 mg orally every 12 hours.

At the time of treatment exclude the intake of alcoholic beverages, you should refrain from sexual intercourse. During the period dispensary observation strongly recommend the use of a condom.

In the absence of the effect of antibiotic therapy, it is necessary to prescribe another antibiotic, taking into account the sensitivity of the pathogen. With a mixed infection, you should choose the drug, dose and duration of administration, taking into account the selected flora. After the end of treatment antibacterial drugs it is advisable to prescribe eubiotics intravaginally (lactobacilli, bifidumbacterium bifidum, lactobacilli acidophilus).

In order to prevent concomitant chlamydial infection, one of the antibiotics that affect chlamydia should be added to the treatment regimens:

azithromycin 1.0 g orally once or
doxycycline 100 mg twice a day by mouth for 7 days or
josamycin 200 mg orally for 7 to 10 days.

In the presence of an association of gonorrhea with trichomoniasis, the appointment of antiprotozoal drugs (metronidazole, tinidazole, ornidazole) is mandatory. Treatment of uncomplicated gonorrhea in pregnant women is carried out at any time, antibiotics are prescribed that do not affect the fetus:

ceftriaxone 250 mg intramuscularly once or
spectinomycin 2 g intramuscularly once.

Tetracyclines, fluoroquinolones, aminoglycosides are contraindicated.

In the presence of chorionamnionitis, pregnant women are hospitalized and intravenously prescribed benzylpenicillin 20 million units per day until the symptoms disappear or ampicillin 0.5 g 4 times a day for 7 days. With fresh acute gonorrhea of the lower urinary tract, etiotropic treatment is sufficient. In cases of a torpid or chronic course of the disease, in the absence of symptoms, antibiotic treatment is recommended to be supplemented with immunotherapy, physiotherapy, and local therapy.

Local therapy includes instillations of drugs (1-2% silver proteinate solution, 0.5% silver nitrate solution) into the urethra, vagina, microclysters with chamomile infusion (1 tablespoon per glass of water). Immunotherapy of gonorrhea is divided into specific (gonococcal vaccine) and non-specific (pyrogenal ©, prodigiosan ©, autohemotherapy). Immunotherapy is carried out either after subsiding of acute events against the background of ongoing antibiotic therapy, or before the start of antibiotic treatment for subacute, torpid or chronic course. Immunotherapy is not indicated for children under 3 years of age. In general, the use of immunomodulating agents in gonorrhea is currently limited and should be strictly justified.

In the treatment of acute forms of ascending gonorrhea, a complex of therapeutic measures is indicated, including hospitalization, bed rest, hypothermia of the hypogastric region (ice bladder), infusion therapy, desensitization ( antihistamines). With a detoxification purpose and in order to improve the rheological properties of blood, low-molecular dextrans are prescribed (rheopolyglukin ©, reogluman © or their analogues), reamberin ©, isotonic solutions of glucose or sodium chloride, glucose procaine mixture, solutions (trisol ©), etc.

Medications for the treatment of gonorrhea*

Penicillin group (the main antibiotics for the treatment of gonorrhea):
♦ benzyl-penicillin - a course dose of 4 to 8 million units (depending on the severity of the disease). Bicillin 1,3,5 is also used;
♦ ampicillin - 2-3 g per day for oral administration, in 4-6 doses. The duration of treatment depends on the severity of the disease and the effectiveness of therapy (from 5-10 days to 2-3 weeks);
♦ oxacillin - for oral use, 3 g per day in 4-6 doses. On the course - 10-14 years;
♦ ampioks - with parenteral administration, a single dose is 0.5-1 g, 4-6 times / day, for 5-7 days;
♦ carbenicillin disodium salt - when administered intramuscularly, the daily dose is from 4 to 8 g in 4-6 doses.
♦ unazine (sulacillin) - injected intramuscularly or intravenously from 1.5 to 12 g per day in 3-4 doses;
♦ amoxicillin with clavulanic acid (Augmentin) - high activity of the drug is associated with inhibition of β-lactamase; also has bactericidal activity against anaerobes. 1.2 g 3 times / day, intravenously, 3 days, then 625 mg 3 times / day. orally, 5 days.

Tetracycline group:
♦ tetracycline - inside 250 mg 4 times / day, for 14-21 days;
♦ doxycycline (unidox, vibramycin) - 1 capsule (0.1 g) 2 times a day for 10 days.

Azalides and macrolides:
♦ azithromycin (sumamed) - on the 1st day 2 tablets. 0.5 g, once; on the 2nd-5th day - 0.5 g (1 tab.), 1 time / day;
♦ midecamycin (macropen) - 400 mg 3 times / day, 6 days;
♦ spiramycin (rovamycin) - 3 million units, 3 times / day, 10 days;
♦ Josamycin (Vilprafen) - 500 mg 2 times / day, for 10-14 days;
♦ Rondomycin - 0.2 g on the 1st day once, then 0.1 g daily for 14 days;
♦ clarithromycin (clacid, fromilid) - orally 250-500 mg 2 times / day, for 10-14 days;
♦ roxithromycin (rulid, roxide, roxibid) - orally 300 mg 2 times / day, 10-14 days;
♦ erythromycin - 500 mg 4 times / day before meals inside, for 10-14 days;
♦ erythromycin ethyl succinate - 800 mg 2 times / day, 7 days;
♦ clindamycin (dalacin C) is an antibiotic of the lincosamide group. Assign 300 mg 4 times / day. after meals, 7-10 days or IM 300 mg 3 times / day, 7 days.

Aminoglycosides:
♦ kanamycin - for intramuscular injection, 1 g 2 times / day. Course dose - 6g. Do not prescribe simultaneously with other antibiotics that have oto and nephrotoxic effects.

Cephalosporins:
♦ cefazolin - 0.5 g 4 times / day. in / m or / in for 5-7 days;
♦ ceftriaxone - 1.0-2.0 g / m 2 times / day. Previously, the bottle is diluted in 2 ml of lidocaine (to reduce pain), for a course of treatment of 5-6 g;
♦ cefatoxime (claforan) - intramuscularly 1.0 g 2 times / day, per course - 8-10g;
♦ cefaclor - capsules 0.25 g 3 times / day, 7 days;
♦ cephalexin - 0.5 g 4 times / day, 7-14 days.

Fluoroquinolone preparations
♦ ofloxacin (zanocin, tarivid, ofloxin) - 200 mg 2 times / day. after meals for 7 days;
♦ ciprofloxacin (tsifran, tsiprinol, tsiprobay, tsipro-bid) - orally 500 mg 2 times / day, for 7 days;
♦ pefloxacin (abaktal) - 600 mg once a day after meals for 7 days;
♦ levofloxacin - 400 mg 2 times / day, 7-10 days;
♦ lomefloxacin (maxaquin) - 400 mg 1 time / day, 7-10 days;
♦ gatifloxacin (tebris) - 400 mg 1 time / day, 7-10 days.

SURGICAL TREATMENT OF GONORRHEA

In the presence of acute salpingitis and pelvioperitonitis, conservative treatment. In the absence of the effect of the ongoing complex anti-inflammatory therapy for 24-48 hours, with an increase in the clinical symptoms of an acute inflammatory process, laparoscopy is indicated, in which opening, sanitation and drainage of the purulent focus are possible. At clinical picture diffuse or diffuse peritonitis requires emergency operative laparotomy. The volume of the operation depends on the age of the patient, reproductive history, the severity of destructive changes in the pelvic organs.

FURTHER MANAGEMENT

To determine the effectiveness of the treatment of gonorrhea, there are certain criteria. According to the recommendations of TsNIKVI (2001), the criteria for the cure of gonorrhea (7–10 days after the end of therapy) are the disappearance of the symptoms of the disease and the elimination of gonococci from the urethra, cervical canal and rectum according to bacterioscopy. It is possible to carry out a combined provocation with three swabs taken after 24, 48 and 72 hours and seeding of the secretions. Methods of provocation are divided into physiological (menstruation), chemical (lubrication of the urethra with 1–2% silver nitrate solution, cervical canal with 2–5% silver nitrate solution), biological ( intramuscular injection gonovaccines at a dose of 500 million microbial bodies), physical (inductothermia), alimentary (spicy, salty foods, alcohol). Combined provocation is a combination of several types of provocations.

The second control study is carried out on the days of the next menstruation. It consists in bacterioscopy of discharge from the urethra, cervical canal and rectum, taken three times with an interval of 24 hours. At the third control examination (after the end of menstruation), a combined provocation is performed, after which bacterioscopic (after 24, 48 and 72 hours) and bacteriological (after 2 or 3 days) research. In the absence of gonococci, the patient is removed from the register.

In addition to this, it is advisable to serological reactions for syphilis, HIV, hepatitis B and C (before and 3 months after treatment) with an unknown source of infection.

Many experts currently dispute the feasibility of using provocations and multiple follow-up examinations and propose to reduce the period of observation of women after a full treatment of gonococcal infection, since with high efficiency modern drugs the clinical and economic sense of the measures being taken is lost.

According to European guidelines (2001), at least one follow-up examination after treatment is recommended to determine the adequacy of therapy, the presence of symptoms of gonorrhea. Laboratory control is carried out only in cases of ongoing disease, the possibility of re-infection or possible resistance of the pathogen.

INFORMATION FOR THE PATIENT

In case of casual sexual intercourse, a condom and other personal protective equipment must be used to prevent the disease. In cases of the appearance of pathological discharge from the genital tract, you should consult a doctor for examination.

FORECAST

The prognosis for timely and adequate treatment is favorable.

Gonorrhea is an infectious disease caused by gram-negative diplococcus (gonococcus lat. Neisseria gonorrhoeae), sexually transmitted and characterized by lesions of the mucous membranes of the genitourinary organs. Refers to venereal diseases.

Epidemiology

Diseases caused by gonococcus: urethritis, cervicitis, salpingitis, proctitis, bacteremia, arthritis, conjunctivitis (blennorrhea), pharyngitis. Rarely, inflammation of the pharynx and rectum occurs.

Source of infection- sick person. The pathogen is transmitted sexually, less often through household items (linen, towel, washcloth). With blenorrhea, the infection of the newborn occurs through the infected birth canal of the mother.

The genus Neisseria includes more than 20 species: N. canis, N. cinerea, N. denitrificans, N. elongata, N. flavescens, N. gonorrhoeae, N. lactamica, N. macacae, N . meningitidis, N. mucosa, N. polysaccharea, N. sicca, N. subflava, etc. Gonococci are gram-negative diplococci (from Greek diplo - double) bean-shaped, arranged in pairs, adjacent to each other with a concave side (size 1.25- 1.0 x 0.7-0.8 µm). Have a tender capsule and drank. The purulent discharge is characterized by the location of gonococci inside and outside of phagocytic cells - leukocytes (incomplete phagocytosis).

Clinical picture of gonorrhea

The disease manifests itself 3-7 days after infection and proceeds acutely or chronically.

Acute gonorrhea characterized by the release of mucus, pus, a sensation of tickling, burning and pain in the terminal part of the urethral canal, frequent urge to urinate, very painful. Approximately half of infected people do not show any symptoms, especially at the beginning of the disease. Women are most prone to asymptomatic or asymptomatic course of the disease.

From the urethra, the microorganism penetrates to the epididymis and causes inflammation (epididymitis, orchiepididymitis - inflammation of the entire structure - testicle + epididymis), which is expressed by an increase, extreme pain, general fever. This inflammation after 3-4 weeks can pass safely, or become chronic, or end with necrosis of the appendage. The spermatic cord sometimes becomes inflamed.

The disease sometimes passes to the bladder, spreads further to the ureters and causes disease of the kidneys themselves. Inflammation of the mucous membrane can spread into the depths of the tissues. The lymph nodes are also affected in gonorrhea and swell. The outer layers become inflamed and swollen. Sometimes even the necrosis of the foreskin occurs.

Acute gonorrhea in women has the same course as in men. The symptoms and course of the disease are the same. Skin lesions (eczema) develop from irritation of the outer integument with pus. Bartholin's glands suppurate. Diseases Bladder, the inner lining and integument of the uterus (para- and perimetritis) appear to be severe complications of gonorrhea. Very often gonorrhea is the cause of infertility.

Diagnostics

Microbiological diagnostics
Bacterioscopic method- coloring of two smears:

according to Gram;
1% aqueous solution of methylene blue and 1% alcohol solution of eosin.

Bacteriological method:

sowing on nutrient media containing native proteins of blood, serum or ascitic fluid; ascite-free media are used (for example, KDS-1 medium with casein hydrolyzate, yeast autolysate and native whey); optimum growth in an atmosphere of 10-20% carbon dioxide, at pH 7.2-7.4 and a temperature of 37 °C.

Serological diagnosis

RSK (Borde-Gangu reaction) or RIGA with the patient's blood serum.
Molecular biological method - test with a DNA probe (nucleic acid amplification method - NAAT).

Treatment

Gonorrhea is treated with a course of antibiotics. The drug of choice for acute uncomplicated gonorrhea is cefixime (in the Russian Federation - Ceforal Solutab) dispersible tablet, taken orally, once, at a dose of 400 mg. In complicated gonorrhea, as in gonococcal pharyngitis, the use of ceftriaxone 250 mg (eg Rocephin) is indicated.

Due to the high frequency of combination of gonorrhea with chlamydia and mycoplasma infection (Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum), the simultaneous use of doxycycline 100 mg 2 times a day for 7 days is recommended (the safest form is doxycycline monohydrate - Unidox Solutab) or azithromycin ( Sumamed) 1 gr. once.

With chlamydial urethritis in men, doxycycline has the greatest effectiveness, including when compared with azithromycin.

Prevention

For the prevention of gonorrhea, as well as other STIs, it is recommended to use latex, and if they are intolerant, polyurethane, but not natural membrane condoms.

In the case of unprotected sexual contact, it is not recommended to carry out antibacterial prophylaxis, except in cases of contact with a partner who has a high probability of infection. It is possible, although not described in any guidelines, to use antibacterial drugs before or shortly after sexual intercourse to prevent goorrhoea. The main condition, to some extent justifying the use of antibacterial prophylaxis, is contact with a supposedly infected partner and the impossibility, for a number of reasons, of waiting for the development / absence of infection. The main tablet drug, the use of which is possible with gonorrhea or the risk of its development, is cefixime, preferably a 400 mg dispersible tablet once.

The systematic use of antibiotics after each unprotected contact is fraught with the development of resistance of microorganisms, which will subsequently lead to therapy failures and serious complications. Previously effective, azithromycin is not currently used in the treatment of gonorrhea and, of course, for its prevention. Despite the low level of resistance compared, for example, with fluoroquinolones (ciprofloxacin, ofloxacin and others), the latter exceeds the WHO recommended for social dangerous infections 5% threshold. The prophylactic use of azithromycin may be justified in the prevention of genital chlamydial infection, however, a small number of studies cannot be evidence of this potentially. useful property macrolides.

Self-treatment of gonorrhea is unacceptable, it is dangerous by the transition of the disease to chronic form, and the development of irreversible damage to the body. All sexual partners of patients with symptoms of gonorrhea who have had sexual contact with them in the last 14 days, or the last sexual partner if contact occurred earlier than this period, are subject to examination and treatment. In the absence of clinical symptoms in a patient with gonorrhea, all sexual partners are examined and treated for the last 2 months. For the period of treatment of gonorrhea, alcohol, sexual relations are excluded; during the period of dispensary observation, sexual contacts are allowed using a condom.
Modern venereology is armed with effective antibacterial drugs that can successfully fight gonorrhea. In the treatment of gonorrhea, the duration of the disease, symptoms, location of the lesion, the absence or presence of complications, concomitant infection are taken into account. With an acute ascending type of gonorrhea, hospitalization, bed rest, and therapeutic measures are necessary. In the event of purulent abscesses (salpingitis, pelvioperitonitis), emergency surgery is performed - laparoscopy or laparotomy. The main place in the treatment of gonorrhea is given to antibiotic therapy, while taking into account the resistance of some strains of gonococci to antibiotics (for example, penicillins). If the antibiotic used is ineffective, another drug is prescribed, taking into account the sensitivity of the causative agent of gonorrhea to it.
Gonorrhea of the genitourinary system is treated with the following antibiotics: ceftriaxone, azithromycin, cefixime, ciprofloxacin, spectinomycin. Alternative treatment regimens for gonorrhea include the use of ofloxacin, cefozidime, kanamycin (in the absence of hearing disorders), amoxicillin, trimethoprim.
Fluoroquinolones are contraindicated for children under 14 years of age in the treatment of gonorrhea, tetracyclines, fluoroquinolones, aminoglycosides are contraindicated for pregnant women and nursing mothers. Antibiotics that do not affect the fetus (ceftriaxone, spectinomycin, erythromycin) are prescribed, preventive treatment newborns in mothers with gonorrhea (ceftriaxone - intramuscularly, washing the eyes with a solution of silver nitrate or laying erythromycin eye ointment).
Gonorrhea treatment may be adjusted if there is a mixed infection. In torpid, chronic and asymptomatic forms of gonorrhea, it is important to combine the main treatment with immunotherapy, local treatment and physiotherapy.
Local treatment of gonorrhea includes the introduction into the vagina, urethra of 1-2% protorgol solution, 0.5% silver nitrate solution, microclysters with chamomile infusion. Physiotherapy (electrophoresis, ultraviolet radiation, UHF currents, magnetotherapy, laser therapy) is used in the absence of an acute inflammatory process. Immunotherapy for gonorrhea is prescribed without exacerbation to increase the level immune reactions and is divided into specific (gonovacin) and nonspecific (pyrogenal, autohemotherapy, prodigiosan, levamiosol, methyluracil, glyceram, etc.). Children under 3 years of age are not given immunotherapy. After treatment with antibiotics, lacto- and bifido drugs are prescribed (orally and intravaginally).
The successful result of the treatment of gonorrhea is the disappearance of the symptoms of the disease and the absence of the pathogen according to the results. laboratory tests(7-10 days after the end of treatment).
The need is currently being contested. various kinds provocations and numerous control examinations after the end of the treatment of gonorrhea, carried out by modern highly effective antibacterial drugs. One follow-up examination of the patient is recommended to determine the adequacy given treatment gonorrhea. Laboratory control is prescribed if they remain clinical symptoms, there are relapses of the disease, possibly re-infection with gonorrhea.