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As we have learned more and more about clamidia, we have come to recognize that gonorrhea and clamidia are not only often transmitted together but also very, very difficult to differentiate in terms of the syndromes they produce clamidia. 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 clamidia were not nearly as good. Then clamidia started catching up and as our methodology has gotten better and better, clamidia has become more common than gonorrhea. It probably always was, but we just weren't able to demonstrate it.

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 clamidia is not a true infectious arthritis, it is Reiter's syndrome or host clamidial infection arthritis, which at one time was also attributed to the gonococcus. This is just like what we spoke about yesterday in terms of gastrointestinal infections. This is a post infectious arthritis and is presumably immunologic and one of the things that can trigger it is clamidial infection. It is most commonly seen in people with HLAB27 tissue type, but can be seen with other tissue types also.

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 clamidia causes pneumonia in the newborn and the gonococcus does not. That is the differentiating factor in terms of syndromes produced. Co-infection is very common and serves to further confuse the issue.

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 clamidia 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 in women practicing fellatio.

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 one exposure versus fifty percent and sixty percent with one exposure versus ninety. This is a repetitive theme that you will see with HIV infection, with clamidia infection and probably, if the studies were done appropriately, with virtually any sexually transmitted disease.

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 and produce epididymitis. With epididymitis, you usually have unilateral pain and swelling of the testicle. I want to point out that much of what was attributed to gonococcal prostatitis in the past and to gonococcal epididymitis was not caused by the gonococcus. Epididymitis is caused by Enterobacteriaceae as well as by clamidia and prostatitis is usually not a gonococcal infection.

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 clamidial or may be mixed aerobic and anaerobic organisms. What seems to happen is that the initial infection is usually either gonococcal or clamidial 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, seemingly the first episode, is actually caused by aerobic and anaerobic organisms. But the state is set by an initial gonococcal or clamidial infection. There are greater than one million cases per year in the United States. One-third of these cases require admission to the hospital, which means that two-thirds of them can clearly be treated at home and ten percent.