Gonorrhea (aka "the clap," or "the drip") is caused by sexually transmitted Neisseria gonorrhoeae--a Gram-negative diplococcus. One of the most common reportable diseases in the United States, gonorrhea frequently affects sexually active adolescents. Approximately 30% of the 350,000 annual cases involve 15- to 19-year-olds. (That percentage is thought to be an underestimate!) Those most often infected are young women 15 to 24 years old. Recent data suggest that infection rates are higher among teens who are homeless or pregnant, and in those from a minority group or an economically disadvantaged background.¹

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Chlamydia trachomatis is the most common cause of sexually transmitted disease (STD) worldwide. The obligate intracellular bacterium has a predilection for columnar epithelium (found in the cervix) and the cells of the urethra. Like gonorrhea, rates of chlamydialinfection are highest in females aged 15 to 24. Infection is associated with new sexual partners, pregnancy, homelessness, and being from an economically disadvantaged minority group.

Here I review the magnitude of the problem and the consequences of undiagnosed infection. I also discuss new diagnostic tests and current treatment regimens.

GENITOURINARY TRACT INFECTIONS

Figure 1 – Symptomatic gonococcal urethritis typically presents with penile discharge and dysuria within 2 weeks of exposure. (Courtesy of the Public Health Agency of Canada)

When most physicians consider gonorrhea or chlamydial infection, painful, purulent urethritis or cervicitis comes to mind. Many clinicians believe that if their patient has no pain, dysuria, or genital discharge, then a pelvic examination or a male urethral swab is unnecessary. This misconception has contributed to the current epidemic of gonorrhea and chlamydial infection.

Both gonorrhea and chlamydial infection are usually asymptomatic; they are often discovered during routine screening, or when a partner becomes symptomatic. In one screening series, up to 84% of adolescent boys infected with N gonorrhoeae had no symptoms.² Other school-based screenings for C trachomatis revealed that chlamydial infection was diagnosed in 2% to 4% of boys and in 8% to 16% of girls who were asymptomatic.^3,4

Why are these infections so common among teenagers? The reasons are varied. From a biologic perspective, the adolescent girl's cervix has an increased amount of ectropion (columnar epithelium that extrudes over the exocervix and into the vaginal vault) that makes her more susceptible to these infections. In addition, adolescents tend to use condoms incorrectly and inconsistently. Serial monogamy--involving multiple sexual partners--is also associated with increased risk of STD exposure. Finally, some populations have higher rates of STDs, sexual abuse, and prostitution; these factors--combined with inadequate access to medical care--increase the risk of acquiring an infection during adolescence.

Because rates of asymptomatic gonorrhea and chlamydial infection are so high, most adolescent medicine providers recommend an annual pelvic examination with screening cultures in sexually active girls. Sexually active boys should provide a yearly first-morning void urine sample to screen for leukocyte esterase. If results are positive, more specific testing via urethral swab or urine DNA tests is indicated.

GONORRHEA

Figure 2 – Gonococcal urethritis is among the most common causes of Bartholin gland abcesses, which cause pain and labial swelling. (Courtesy of the CDC/Susan Lindsley)

In boys, symptomatic gonococcal urethritis typically occurs from 1 to 14 days after exposure. Patients may complain of dysuria and penile discharge initially (Figure 1). In approximately one third of patients, untreated infection progresses to involve the epididymis and surrounding structures along the genitourinary tract. Typically, patients with epididymitis present with unilateral scrotal pain, warmth, and swelling, with particular discomfort around the spermatic cord and epididymis. Prostatitis is an uncommon complication of gonococcal urethritis. Nevertheless, the diagnosis should be considered when lower back pain, urinary retention or frequency, and chills or fever accompany urethritis.

In girls, N gonorrhoeae infection can cause symptoms at any point between the outer and inner genitourinary tract. Itis one of the most common causes of Bartholin gland abscesses, which typically present as pain and swelling of the labia minora (Figure 2). If the patient complains of dysuria and/or urinary frequency, suspect gonococcal urethritis. Consider gonococcal cervicitis (Figure 3) in a girl with purulent vaginal discharge or with pelvic discomfort secondary to cervical edema.

Endocervical infections can progress to pelvic inflammatory disease (PID) when organisms spread through the cervical os into the uterus and/or fallopian tubes. It is not uncommon for PID to spread into the peritoneum and cause ovarian abscesses or even inflammation of the hepatic visceral capsule (Fitz-Hugh and Curtis syndrome).

 

CHLAMYDIAL INFECTION

Figure 3 – Purulent vaginal discharge or pelvic discomfort secondary to cervical edema suggests gonococcal cervicitis. (Courtesy of the Public Health Agency of Canada)

Chlamydial urethritis is usually asymptomatic in boys, but it can produce a watery penile discharge 1 to 3 weeks after sexual exposure. Like gonorrhea, this infection can progress to epididymitis in young men. It rarely causes prostatitis;however, this diagnosis should be considered when prostate symptoms (described earlier) accompany known chlamydial urethritis

 

Chlamydial cervicitis can present with purulent discharge and vaginal blood spotting but is usually asymptomatic. Almost half of all cases of PID are caused by chlamydial infection. As with gonorrhea, this infection can spread to the ovaries and hepatic visceral capsule.