The clap - male

Alternative names
Gonorrhea - male

Definition

Gonorrhea is a sexually transmitted disease (commonly known as “the clap”) caused by the bacterium Neisseria gonorrhoeae.

Causes, incidence, and risk factors

Gonorrhea is one of the most common infectious bacterial diseases and is most frequently transmitted during sexual intercourse, including vaginal, oral and anal sex.

Gonorrhea is a reportable disease and all state governments require that cases of diagnosed gonorrhea be reported to the health authorities (the State Board of Health). This allows for adequate follow-up and testing of sexual contacts. This is important because an estimated 90% of an infected male’s sex contacts are or will become infected. In the male, the risk of acquiring gonorrhea following one episode of vaginal intercourse with an infected female is approximately 20% (1 in 5).

There are almost 400,000 cases of gonorrhea a year reported to the CDC (Centers for Disease Control). There are probably many cases that are diagnosed and treated that are not reported as required (the total number of cases is thought to approach 1,000,000. If unreported cases are included, some estimates reach 2,000,000). However, a rate of 400,000 cases per year means that 1 in every 687 Americans has gonorrhea (a rate of 2 million means that 1 in every 130 Americans are infected).

There is a higher prevalence in large metropolitan areas, inner city areas, populations with lower overall levels of education and people with a lower socioeconomic status. Gonorrhea is most prevalent in people 15 to 29 years old. Risk factors include having multiple sexual partners, a partner with a past history of any STD and unprotected sex (sex without the use of a condom or the female condom).

The causative organism can infect the throat, producing a severe sore throat (gonococcal pharyngitis). Infection of the urethra may cause urethritis with burning, painful urination, and a discharge. It may also infect the anus and rectum, producing a condition called proctitis. In addition, the organism may spread from the urethra to other portions of the reproductive tract producing epididymitis (infection of the epididymis, a structure attached to the testicle), prostatitis (inflammation of the prostate gland), and various other conditions such as periurethral abscess (a collection of pus around the urethra).

Untreated gonorrhea may lead to urethral stricture (narrowing of the urethra caused by scarring), which can result in decreased urine flow, incomplete emptying of the bladder, urinary tract infection and ultimately kidney failure.

The average incubation for gonorrhea is approximately 2 to 5 days following sexual contact with an infected partner. However, symptoms may appear as late as 2 weeks. The most common initial symptom is a discharge from the urethra that is either mucus-like (clear or whitish discharge) or purulent (thick, yellowish, pus-like discharge). It appears at the opening of the penis and may stain the underwear. Other initial symptoms include painful urination and urethral burning. A small number of men will be without symptoms (asymptomatic).

Other sites of infection are relatively common. Gonorrhea infection of the rectal area (anorectal gonorrhea) may occur in men who have anal intercourse (it is also found in approximately 50% of women with gonorrhea). A majority of people with anorectal gonorrhea are symptom-free, but when symptoms are present they are typical of proctitis. A small percentage of people with gonorrhea have only a throat infection (gonococcal pharyngitis). Ten to 25% of homosexual men with gonorrhea also have pharyngeal infection, while 10 to 20% of women with gonorrhea have pharyngeal gonorrhea.

Gonococcal conjunctivitis (eye infection) is very rare in adults. It is normally seen only in infants delivered to mothers with gonorrhea, and is called ophthalmia neonatorum.

Gonorrhea can be transmitted simultaneously with other sexually transmitted diseases.

Symptoms

     
  • Increased urinary frequency or urgency  
  • Incontinence  
  • Urethral discharge  
  • Pain on urination  
  • Red or swollen opening of penis (urethra)  
  • Tender testicles

Signs and tests

A preliminary diagnosis of gonorrhea can be made at the time of examination. A smear of urethral discharge may be taken, stained and examined under the microscope. Neisseria gonorrhoeae organisms appear within the cells present in the discharge.

Cultures provide absolute proof of infection. Neisseria gonorrhoeae organisms may grow on any of the mucous membranes. Culture sites are determined depending on the person’s gender and sexual practices. Generally, cultures are obtain from the urethra, anus or throat. Laboratories can give a preliminary diagnosis often within 24 hours and a confirmed diagnosis within 72 hours.

Tests include:

     
  • Gram stain of urethral discharge  
  • Urethral discharge culture for gonorrhea  
  • Rectal culture  
  • Throat culture

Treatment
There are two aspects of treating a sexually transmitted disease, especially one as easily spread as gonorrhea. The first aspect is to cure the affected person. The second is to locate and test all of the other sexual contacts and to treat them to prevent further spread of the disease. Mandatory reporting has, until recently, held the number of cases of gonorrhea at a low level. However, the incidence is rising.

Beginning about the time of the Vietnam war, antibiotic-resistant strains of gonorrhea appeared in the United States. These resistant strains have been increasing over the last few years. Because of this, new treatments have now been recommended by the Centers for Disease Control (CDC). Instead of the standard penicillin treatment, gonorrhea is now treated by a large number of new and very potent antibiotics. More recently, resistance to antibiotics such as ciprofloxacin, ofloxacin (or levofloxacin) and enoxacin has started to become a problem.

This treatment regimen includes using one of the following:

     
  • Ceftriaxone, 125 mg (milligrams) injected into a muscle, one time  
  • Cefixime, 400 mg by mouth, one time  
  • Ciprofloxacin - oral, 500 mg by mouth, one time  
  • Ofloxacin - oral, 400 mg by mouth, one time  
  • Cefuroxime Axotal, 1 gram by mouth, one time  
  • Cefpodoxime proxetil, 200 mg by mouth, one time  
  • Enoxacin, 400 mg given by mouth, one time

It is important to see your health care provider for a follow-up visit 7 days after treatment to recheck cultures and confirm the cure of infection.

Expectations (prognosis)
When gonorrhea is treated immediately upon onset, the outcome is likely to be good, meaning that no permanent scarring of the urethra will take place and spread of the infection to other areas of the body will not occur. When treatment is delayed, there is a greater likelihood of complications.

Complications

     
  • Disseminated infection, which can be very serious  
  • Periurethral abscess (collection of pus around the urethra)  
  • Gonococcal arthritis (joint infection)  
  • Gonococcal pharyngitis (sore throat)  
  • Gonococcal conjunctivitis (eye infection)  
  • Infection or inflammation of the male reproductive system

Calling your health care provider
If you have symptoms suggestive of gonorrhea you should call your health care provider immediately. If you are short of funds or uninsured, state-sponsored Sexually Transmitted Disease Clinics will diagnose and treat STDs without charge. Using a state-sponsored clinic enables the state to keep accurate statistics on the number of cases, and to treat other infected contacts who would otherwise spread the disease.

If you have engaged in high-risk sexual practices (multiple partners, unknown partners, high-risk partners, unprotected sex), you should be periodically examined to detect the presence of asymptomatic disease and for STDs other than gonorrhea.

Prevention
Sexual abstinence is the only way to completely prevent gonorrhea. Safer sex behaviors can reduce risk. The use of condoms - both male and female types - markedly decrease the likelihood of contracting a sexually transmitted disease, but they must be used properly. The condom should be in place from the beginning to the end of sexual activity and should be used every time the person engages in sexual activity. Condoms are inexpensive considering the consequences of contracting a sexually transmitted disease.

Treatment of all sexual partners is essential to prevent reinfection, and is a primary reason that the government has implemented mandatory reporting. Gonorrhea is still relatively easily cured.

Johns Hopkins patient information

Last revised: December 8, 2012
by Brenda A. Kuper, M.D.

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