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Sexually transmitted diseases

Gonorrhea and Chlamydia

As we have learned more and more about chlamydia, we have come to recognize that gonorrhea and chlamydia are not only often transmitted together but also very, very difficult to differentiate in terms of the syndromes they produce. They are the two most common bacterial sexually transmitted diseases in the United States.

Interestingly, it has been a race, with gonorrhea way ahead and that was because the methods for detecting chlamydia were not nearly as good. Then chlamydia started catching up and as our methodology has gotten better and better, chlamydia has become more common than gonorrhea. It probably always was, but we just weren't able to demonstrate it. They produce similar syndromes. They can both produce urethritis, mucopurulent cervicitis, anorectal infections, conjunctivitis, epididymitis, pelvic inflammatory disease, the Fitz-Hugh-Curtis syndrome, or perihepatitis and they both can produce arthritis, although the arthritis with chlamydia is not a true infectious arthritis, it is Reiter's syndrome or host chlamydial infection arthritis.

I always think very hard in terms of making up test exam questions and so on about how they differ. What does one do that the other doesn't do? I used to count arthritis as one of them, because truly the Reiter's syndrome is not an infectious arthritis, but that gets blurred because arthritis can follow both. So all I can come up with is that chlamydia causes pneumonia in the newborn and the gonococcus does not. That is the differentiating factor in terms of syndromes produced.

Gonorrhea is a disease of the young - 15 to 25 years as defined by the CDC. It is more common in urban blacks of low socioeconomic status. This is somewhat interesting. We see a lot more gonorrhea in people in lower socioeconomic groups and more chlamydia in people of upper socioeconomic groups - college students, for example. Females who develop gonorrhea are usually asymptomatic and males are usually symptomatic. As a matter of fact, the figure is that after contracting the gonococcus, over ninety percent of males will become symptomatic within five days; the others will not become symptomatic at all, ever. Rectal infection is common in women and in male homosexuals. Twenty percent of male homosexuals who practice anal receptive intercourse develop gonorrhea. Rectal infection is usually asymptomatic. Pharyngeal infection is common.

Females are less effective transmitters of gonorrhea than male. One-third of males will be infected by one exposure, sixty percent by three exposures and in males it is fifty percent of females who will be affected by one exposure and ninety percent of females will be affected by three exposures. So males are far more effective in terms of transmission; it is thirty-three percent.

With regard to gonorrhea, you must treat the partners because of not, the partner will re-infect the individual you are treating in the first place and is free to go around infecting other people in the community. Much of the approach to sexually transmitted diseases is to prevent further spread of infection, not only to treat the patient that you are dealing with but also to prevent further spread. With melas there is urethritis, dysuria, discharge. Spread can occur to the prostate, seminal vesicles and epididymis.

With females, there is cervicitis, discharge and an inflamed, nontender cervix. Spread can occur to the rectum, which is usually totally asymptomatic. Then spread can occur beyond the mucosa of the urethra, of the cervix, of the rectum and of the pharynx. These can be totally asymptomatic and then spread can occur either via the bloodstream or by direct extension. In the female, contiguous spread can occur and produce pelvic inflammatory disease, salpingitis or can actually go all the way through the fallopian tube into the peritoneal cavity and produce the syndrome called Fitz-Hugh-Curtis syndrome.

Pelvic inflammatory disease may be gonococcal, may be chlamydial or may be mixed aerobic and anaerobic organisms. What seems to happen is that the initial infection is usually either gonococcal or chlamydial and then the recurrent infections tend to be caused by genital organisms that are found normally in the vagina, mixed aerobes and anaerobes. Sometimes that first episode is barely symptomatic, so the first truly symptomatic episode that comes to the attention of the physician.