Gonorrhea

Gonorrhea is a venereal disease caused by gonococcus. It is transmitted mainly by the priest's way. An out-of-the-way path of infection is rare (in children when using a towel and linen shared with the sick mother). The causative agent affects mainly the urogenital system, lined with single-layered epithelium: urethral mucosa, excretory ducts of the bartholin glands, cervical canal, uterine body, fallopian tube. Often, the process involves paraurethral throat, ovarian integument epithelium, rectal mucosa, pelvic peritoneum. Inflammation of the vaginal mucosa (gonorrhea colpitis) is possible with special conditions of the female body: in childhood, during pregnancy and during menopause. Inflammatory exudate contains a large amount of fibrinogen, rapidly falling into fibrin and thus contributing to the delimitation of the inflammatory process with the formation of numerous adhesions. The spread of infection occurs mainly through pre-existing channels. The incubation period is 3-4 days. Immunity to the gonorrhea is practically not produced.

Distinguish the following forms of the disease: fresh gonorrhea (acute, subacute, torpid); Chronic and latent. Thorpid (asymptomatic) form is characterized by insignificant clinical manifestations upon detection of pathogens in patients. For latent gonorrhea, it is typical that gonococci in smears and cultures are not detected, there are practically no symptoms of the disease, and the woman is nevertheless an obvious source of infection.

Gonorrheal urethritis. In acute stage, patients complain of pain and pain when urinating, in a chronic stage of the complaint there are no complaints. When gynecological examination - redness and swelling in the area of ​​the external hole of the urethra and mucopurulent discharge from the urethra. In the inflammatory process, the paraurethral passages are often involved.

With chronic urethritis, only the thickening of the urethral wall is noted (with palpation through the front wall of the vagina).

Gonorrheal endocervicitis, along with urethritis, is the most frequent localization of the disease. In the acute stage - mucopurulent leucorrhoea and a small pain in the lower abdomen. When examining the cervix with the help of vaginal mirrors, reddening and loosening of the mucous membrane in the area of ​​the exudate uterine pharynx, cervical muco-purulent leucorrhoea, hanging in the form of a tape, is found. In the chronic stage, the discharge becomes mucous, the patients are not presented with complaints. Around the outer throat of the uterus is often erosion.

Gonorrheal bartholinitis. Inflammation always begins with an excretory duct of the gland (canaliculitis); It is expressed by hyperemia in the area of ​​the outer holes of the excretory ducts (gonorrhea spots). When joining a secondary infection, a pseudoabsence of the gland with a characteristic clinical picture appears (see Bartholinitis).

Gonorrheal proctitis is relatively rare, with leakage of infected secretions from the prenatal organs. The acute stage is characterized by a burning sensation in the rectum and tenesmus; In the chronic stage, these symptoms are not expressed.

Gonorrheal endometritis. The infection (for the area of ​​the internal uterine throat) is promoted by menstruation, abortion, labor, intrauterine intervention (diagnostic curettage, hysterosalpingography, etc.). In the inflammatory process with gonorrheal endometrium, both basal and functional endometrial layers are involved. During the next menstruation, rejection of the mucous membrane is prolonged, which is manifested by a typical hyperpolymenomenia (menorrhagia). Acute stage: pain in the lower abdomen, subfebripic temperature, serous-purulent discharge. With vaginal examination, the uterus is slightly painful on palpation. For chronic-gonorrheal endometritis, only a symptom of menorrhagia is typical.

Gonorrheal salpingo-oophoritis is usually bilateral, while in salpingo-oophoritis caused by other microbes, the inflammatory process is more often one-sided. In the acute stage of the process, patients are concerned with abdominal pain, fever, dysuric disorders, menstrual irregularities (see Bleeding uterine dysfunctions). With vaginal examination, there are enlarged, swollen appendages of the uterus, sharply painful on palpation. The phenomena of pelvic peritonitis are often associated. In a chronic stage, patients complain of recurrent pain in the abdomen, often - its recurrence under the influence of nonspecific factors (hypothermia, influenza, etc.). Typically tubal infertility (primary or secondary).

Gonorrheal pelvioperitonitis is the result of the transition of the inflammatory process from the uterine appendages to the peritoneum of the pelvis. Inflammation has a pronounced tendency to differentiate (diffuse peritonitis - an exception). The onset of the disease is often acute. Characterized by severe abdominal pain, dyspepsia, tachycardia, fever, symptoms of irritation of the peritoneum in the lower abdomen. Delimitation of the process occurs quickly, as evidenced by a furrow located above the pelvic area (a conglomerate of intestinal loops and an omentum). With vaginal examination, the phenomena of bilateral salpingo-oophoritis and bulging of the posterior vaginal foramen, sharply painful upon palpation, are determined. When puncture the posterior fornix in the acute stage of the process, a serous effusion is obtained. In the chronic stage: pain caused by cicatrical-adhesive changes in the pelvic organs; Often infertility due to endo- and perisalpingitis.

Symptoms and diagnosis of gonorrhea. Recognition contributes to anamnesis: the disease soon after the onset of sexual activity, casual sex. During the examination, urethritis, endocervicitis in a primarily infertile woman, bilateral salpingo-oophoritis, proctitis are detected. Bacteriological and bacterioscopic diagnostics - smears and sowings from the urethra, cervical canal, vagina (before antibiotics!). In chronic stages provocation is shown: 1) lubrication of the mucous membrane of the urethra and the cervical canal with a solution of silver nitrate (for the urethra 0.5% solution, for the cervix 2% solution); 2) IM injection of gonovaccine (500 million microbial bodies); 3) physiotherapeutic procedures (diathermy, etc.). Bacteriological and bacterioscopic examination is carried out on the third day after the provocation. Menstruation is a provocation, so you can take smears and make sowing on the 2-3rd day of menstruation. Serological reactions with antibodies and antigen are of great diagnostic importance. In the cytobacteriological study of smears, the following patterns are distinguished: C., - in the smear a large number of leukocytes, there is no flora, intraocular and extracellular gonococcus is located (gram-negative); K2-large number of leukocytes, no flora, gonococci absent (smear suspected of gonorrhea); K3 - a small number of leukocytes and a diverse microbial flora (a smear is not characteristic for gonorrhea).

Treatment. With fresh and ascending gonorrhea treatment is carried out in a hospital. Bed rest, antibacterial and symptomatic treatment. Assign antibacterial therapy, with the treatment depends on the stage and localization of the inflammatory process. The course doses of antibiotics for gonorrhea of ​​the lower part of the genito-urinary organs should be 2 times lower than with ascending gonorrhea (with ascending gonorrhea, antibacterial therapy is carried out for 5-7 days). Penicillin and semisynthetic penicillins are prescribed in the following doses:

1) benzylpenicillin or potassium salt thereof, a single dose from 500,000 to 2,000,000 units IM in / m, daily from 2,000,000 to 20,000,000 units IM;

2) oxacillin 0.5 g 4 times per day IM;

3) ampicillin 0.4 g 6 times per day IM; Ampiox on 1 g 3-4 times a day in / m. Of the other antibiotics, cephalosporins are used (kefzol - 0.5-1 g 2-4 times a day IM), tetracycline (0.25 g 4 times a day inwards), erythromycin (0.5 g3- 4 times a day inwards). Sulfanilamidam appointed with intolerance of antibiotics (1 g 5 times a day for 4 days). Vaccinotherapy is carried out in the chronic course of the disease (IM / 200-300 million microbial bodies in 2-3 days or in the lesion of 50-100 million microbial bodies only in the hospital).

Local treatment is used for chronic gonorrhea of ​​the lower part of the genital organs (in the acute stage these procedures are contraindicated). With urethritis: washing the urethra with a solution of potassium permanganate 1: 5000-1: 10,000; Instillation of 1-2% protargol solution, lubrication of the urethral mucosa with a 1% solution of silver nitrate. In cervicitis: lubrication of the cervical canal with a 2% solution of silver nitrate; Vaginal baths with 3-5% protargol solution. With Bartholinitis: in the acute stage - sessile tubs, UHF; With suppuration, opening of the abscess; In the chronic stage, enucleation of the gland (in the case of pseudo-abscess formation).

Criteria of cure for gonorrhea. After the end of treatment, a gynecological examination of the patient is made and the smears are taken for 3 months. Smears from the urethra, cervix and vagina are taken after medication and physiological (menstruation) provocation (see above). The absence of gonococci during this period allows us to consider a woman cured of gonorrhea.