GONORRHOEA (gonorrhea; Greek gonorrhoia, from gonos the birth, a seed + rhoe the expiration; synonym: perely, gonorrhea) — the venereal disease of the person with preferential damage of mucous membranes of urinogenital bodies caused gonokokky.
- 1 History
- 2 the Aetiology
- 3 A pathogeny
- 4 Pathological anatomy
- 5 Immunity
- 6 Classification
- 7 The incubation interval
- 8 Influence of various factors on the course of gonorrhea
- 9 Laboratory diagnosis
- 10 Gonorrhea at men
- 11 Gonorrhea at women
- 12 Gonorrhea at girls
- 13 The forecast
- 14 Prevention
is known to G. from far antiquity. Unlike syphilis G. did not give heavy outside manifestations and epid, flashes therefore it did not draw special attention. Apparently, the fact that it is a little told about G. in the remained written monuments is explained by it. Hippocrates (5 century BC) for the first time emphasized that the expirations from an urethra at men — result of its inflammation. He also reported about belyakh at women. In 2 century K. Galen described a wedge, a picture of a disease and entered the term «gonorrhoea». Within 15 — 17 centuries in Europe syphilis and G. considered various stages of the same disease. Emergence of the doctrine about identity of causative agents of syphilis and G. was promoted by the known experience of J. Gunter which imparted to itself(himself) a discharge from sick G.'s urethra on a balanus and a prepuce. On unfortunate combination of circumstances of the patient, at to-rogo Gunter took a discharge, it was at the same time the carrier and a syphilitic infection. As a result of on site inoculations ulcers were formed, inguinal glands swelled up, and in several months ulcers on almonds and rash on a trunk developed; all these phenomena disappeared under the influence of treatment by drugs of mercury.
The doctrine about identity of the activators causing syphilis and G. was shaken thanks to works F. Rikora. Conducting inadmissible experiments in public (1831 — 1838), Rikor infected G. of 667 people; at 7 of them the phenomena of syphilis developed. He managed to prove that purulent discharges from an urethra can depend on the syphilitic ulcer which is in it and that inoculations of such pus cause formation of a hard ulcer, but not. Thanks to these researches various nature of a syphilitic and gonorrheal infection was proved.
The activator G. was opened by A. Neisser who in 1879 found the special micrococcus called by it gonokokky in sick G.' pus. The offer E is of great importance for recognition of gonokokk. Ru to use method of coloring across Gram. A certain role in recognition and treatment hron, a gonorrheal urethritis was played by the urethroscope invented in 1853 Mr. of A. J. Desormeaux. The treatment of a gonorrheal urethritis offered in 1892 by Zh. Zhane and Reverdin plentiful washings of an urethra solution of potassium permanganate considerably reduced terms of treatment and reduced quantity of complications. Progress in treatment was introduction of vaccinotherapy, and then and a proteinotherapy. For the first time in Europe at gonorrheal diseases V. E. Dembskaya began to apply vaccinotherapy (1909). Since then the specific and nonspecific immunotherapy of G. was widely adopted. With the advent of streptocides, and then antibiotics (penicillin, streptomycin, levomycetinum, biomycin, etc.) development of a new stage of treatment begins. The significant contribution to studying of various problems G. was made by domestic scientists V. E. Dembskaya, A. I. Vasilyev, P.F. Bogdanov, P. M. Fronshtein, A. G. Kan, G. N. Lisovskaya, M. A. Zaigrayev, I. M. Porudominsky, etc.
the Activator G. — gonokokk (Neisseria gonorrhoeae) in pure growth is hit by E. Bumm in 1885 by its inoculation in an urethra of the healthy woman. It was so proved etiol, value of a gonokokk that then it is confirmed by a number of authors. Gonokokk treats the sort Neisseria, serological distinguish several types of gonokokk (see. Neisseria ).
Gonokokk — the pair coccus (diplococcus), in a form has looking alike the coffee grains or kidneys put by the concave parties inside. Length of its 1,25 — 1,6 microns, width is 0,7 — 0,8 microns. Gonokokk gramotritsatelen, is not mobile. The optimum of growth, and reproduction is observed at t ° 37 °. At a submicroscopy of a gonokokk (fig. 1) the three-layered outside wall, under it a three-layered cytoplasmic membrane, a nuclear vacuole, ribosomes and mesosom is visible. Find fibers (pili) in the gonokokk allocated directly from patients, with to-rymi Swanson, Grimbl, Armitidzh (J. Swanson, A. Grimble, L. R. Armitage, 1975), etc. connect distinctions in pathogenicity of different strains. In separated at an acute urethritis of a half of a gonokokk have approximately identical size (fig. 2).
At chronic G. after antibacterial therapy, especially in insufficient doses, polymorphism is observed, the relation to coloring across Gram changes, L-forms with reduced sensitivity to penicillin and other antibiotics can be formed. However in crops it is possible to receive growth of typical gram-negative gonokokk again. Gonokokk breeds by transverse fission, at patol, conditions possibly budding. In drugs from pus the intracellular arrangement of the activator is characteristic. Gonokokk in neutrophilic leukocytes is viable (endotsitobioz).
Gonokokk badly grows on a beef-extract agar, breeds at addition of complete human protein much better; aerobe; does not form gas and a pigment, does not give hemolysis; from carbohydrates decomposes only a dextrose; does not form exotoxin. In crops of material from cavities (an exudate from joints and so forth) grows under a liquid paraffin or in the atmosphere with the increased content of carbonic acid better. On external signs distinguish 5 main types of colonies of gonokokk, and only colonies of the 1st and 2nd types consist of virulent microorganisms whereas gonokokk in colonies of the 3rd, 4th and 5th types are mutants with the weakened pathogenicity.
At immunization of animals cultures of a gonokokk in blood there are agglutinins (see. Agglutination ), pretsipitina (see. Precipitation ), opsonins (see) and complement-linked antibodies (see). In sick G.' serum a nek-swarm only the last have diagnostic value, other contain in a small amount. Antigenic properties of different strains of gonokokk can vary.
Gonokokk is a little steady out of a human body and perishes in process of drying; in the wet environment there is viable longer time; in mains water it is viable from 1 to 52 hour; in soap water perishes very quickly. Antiseptic agents (silver salts, mercury etc.) and many antibiotics perniciously affect gonokokk of in vitro in small concentration. However at the gonokokk which are grown up on mediums to the Crimea gradually add the increasing concentration of antibiotics or streptocides, resistance to them is quickly developed.
For testing to lay down. effect of medicines use model of a gonoseptitsemiya on mice, the Crimea intraperitoneally enter culture of gonokokk with mucin and a dextrose, and also infection of a horionallantoisny cover of chicken embryos. These models are suitable also for testing of virulence of various strains of gonokokk. However similar on a wedge, to a picture and a current with G. of the person the pilot model of G. is received only at infection of subhuman primates.
Urinogenital human organs are surprised gonokokky variously depending on a type of the epithelium covering them. The gentle cylindrical epithelium of an urethra, neck of uterus, conjunctiva most often is surprised gonokokky; the multilayer flat epithelium of a mucous membrane of a vagina, bladder is a barrier to penetration of a gonokokk into depth of a mucous membrane. However cases of detection of gonokokk in the paraurethral courses covered by a flat epithelium are known. The vagina and a vulva which are also covered with a multilayer flat epithelium at children's age are especially susceptible to a gonorrheal infection; at the same time the gonorrheal colpitis at the woman — the phenomenon exclusively rare also arises only when the mucous membrane of a vagina owing to loss of activity of ovaries loses the resilience (at senile age, at the castrated women and at pregnant women) as a result of a razrykhlennost of covers of a uterus.
The main way of distribution of G. — sexual. At men of a gonokokka initially affect an urethra. If allocations from an urethra of the man are insignificant, then generally gonokokk are allocated outside from urethral (littreevsky) glands, a prostate or seed bubbles together with an ejaculate. In these cases at the woman the neck of uterus is usually infected in the beginning, and an urethra, glands, crypts of an entrance of the vagina and a rectum are surprised for the second time owing to flowing purulent separated from a neck of uterus. At considerable allocations from an urethra of the man, and also at a narrow vagina at the woman the entrance of the vagina and an urethra are surprised more often.
The infection can be transmitted also in the vnepolovy way — through the fingers and household goods contaminated by allocations. Extra sexual infection of G. at adults, especially at men, meets exclusively seldom. At little girls the extra sexually transmitted infection can take place. Infections as anatomo-fiziol, features of an organism (a wide outside opening of an urethra, Epi - and a hypospadias, etc.), and properties of the activator (virulence of a gonokokk) favor.
Ways of spread of a gonococcal infection in an organism. Gonokokki, getting on the unimpaired epithelial surface, extend on a mucous membrane of urinogenital bodies for an extent (per continuitatem). Breeding, they gradually pass to new sites of a mucous membrane and, being implemented between separate epithelial cells, get into subepithelial connecting fabric. Speed of emergence of the inflammatory process in an urethra reaching in the first days of a disease of an outside sphincter, an ochagovost of defeat, localization of inflammatory process around urethral glands (see) where the network limf is well developed, vessels, availability of infiltrates in interstitial tissue of a prostate gland and seed bubbles in the absence of changes in gland, etc. — all this allows to consider that gonokokk get in limf, cracks and vessels also, therefore, are quickly transferred to the departments of urinogenital bodies remote from primary place of penetration of an infection. A tubular structure of urinogenital bodies at men and women, their reductions and stretching, peristaltic, and in patol, cases and the antiperistaltic movements as a result of erections and ejaculations at sexual excitements and the intercourses also promote that the infection quickly extends to sites of a mucous membrane of an urethra, remote from primary place of penetration. Gonokokki can get into blood and be the cause of a gonohemia (gonosepsis) with metastasises in various bodies and gonoseptitsemiya (see. Sepsis ).
Penetration of gonokokk into blood is more often observed at damage of a prostate gland, seed bubbles and uterine (fallopian) tubes that is promoted by an anatomic structure of these bodies. Plentiful network krovo-and the limfosnabzheniya, a hyperemia of these bodies at the sexual intercourses (and at women and in the period of periods) create favorable conditions for penetration of gonokokk into a blood flow. The gonohemia can take place already during the earliest period of G. of an urethra and neck of uterus. Owing to bactericidal properties of blood and antibody formation of a gonokokka in blood quickly perish, and therefore usually in it do not find them.
At disintegration of gonokokk in glands of an urethra and neck of uterus, a prostate gland and seed bubbles, and also in appendages of a uterus a significant amount of toxin is released. Getting into a blood channel and circulating on an organism, gonotoxin can cause a number of the general phenomena: headaches, breakdown, loss of appetite, etc. Usually at acute uncomplicated G. it is not possible to note some considerable deviations in a picture of blood. Intradermal reaction with gonococcal antigen at an acute gonorrheal urethritis becomes positive in most cases in 8 — 10 days after the beginning of a disease. Such early emergence of positive intradermal reaction indicates that in the first days of a disease of G. the sensitization of an organism gonotoxin takes place.
Morfol. substrate of gonorrheal defeat of various bodies of urinogenital system is generally identical. The inflammatory changes caused by gonokokka develop both in an epithelium, and in subepithelial fabric. Changes of an epithelium come down to penetration between cells of polynuclear leukocytes, to dystrophic processes in epithelial cells up to their final fracture on certain sites. Further there occurs proliferation and a metaplasia of a cylindrical epithelium with its transformation into multilayer flat. The metaplasia of an epithelium can sometimes be observed in an acute stage of gonorrheal damage of a mucous membrane of an urethra. Idiosyncrasy of a proliferating epithelium — its disorganization and destruction. Layers of the changed epithelium are located randomly, loosened; cells places sharply of a vakuolizirovana, kernels are extended, the uneven size and a form, a piknotichna (see. Pycnosis ). The reinforced epithelial cover is penetrated by the leukocytes which emigrated from expanded vessels and subepithelial infiltrates. As a result of it in certain places of border between an epithelium and connecting fabric are erased.
Changes in subepithelial fabric come down to a hyperemia, hypostasis and formation of inflammatory infiltrate. In early stages of a disease subepithelial infiltrate has diffusion and focal character, is often located around vessels. Vessels of submucosal fabric are expanded, around them and limf, cracks inflammatory infiltrates in the form of the separate centers are located. Quite often numerous glands of an urethra and neck of uterus are involved in inflammatory process. The gleam of glands is filled with the torn-away epithelium and leukocytes. Mouths of glands are often squeezed by inflammatory infiltrate that leads to partial or their full obstruction. Pus, without having an exit outside, collects in a gleam of gland therefore small pseudoabscesses are formed (e.g., at a bartholinitis). Sometimes inflammatory infiltrate is located in a circle of glands.
In the acute period of G. inflammatory infiltrates have diffusion character and hl consist. obr. from the polinuklear which are located preferential in hyperemic subepithelial departments. From here leukocytes migrate in a gleam of glands of an urethra through the loosened and deskvamirovanny epithelial cover, being a part of purulent exudate.
In inertly current and hron, G.'s cases the nature of inflammatory process considerably changes. Inflammatory infiltrates become focal, in their structure also plasmocytes begin to prevail lymphoid. Also dominance of a productive component of an inflammation over alteration and exudation is noted. Gonokokki in infiltrate is found directly under an epithelium inside - and vnekletochno; when gonokokk get on considerable depth, they are located vnekletochno. Phagocytosis is observed more often in surface layers of sub epithelial fabric.
To draw a sharp distinction between acute and hron, gonorrheal process in morfol, the relation it is not always possible since transition of one state to another happens slowly and gradually. In the absence of treatment inflammatory infiltrates in a mucous membrane and a submucosa are gradually replaced with connecting fabric and reach a limit with scarring and wrinkling. These changes can exert impact on function of those bodies where they were formed: disturbance of an urination at cicatricial narrowings of an urethra, impassability for spermatozoa and an ovum at stenotic changes in epididymes or uterine tubes, etc. At timely begun treatment by effective drugs deep hems in the struck bodies are formed much less than before — at use only of local therapy.
Some differences in a pathoanatomical picture at G. are connected with anatomic and fiziol, features of urinogenital bodies at men, women and girls.
At men at acute G. the epithelium of a mucous membrane of an urethra on certain sites completely collapses and deeper layers are bared. Inflammatory infiltrate in the back urethra which is not possessing unlike front well developed cellulose is located more superficially and evenly. Limited infiltrates are formed only around output channels of a prostate and deep vessels of a back urethra.
At hron. Depending on extent of development of connecting fabric from inflammatory infiltrate distinguish uretrita with the soft infiltrate which is characterized by dominance of cellular elements (lymphoid, plasmocytes and histiocytes) at insignificant amount of connecting fabric, and an uretrita with solid infiltrate, in Krom again formed cicatricial fabric prevails (see. Urethritis ). Along with formation of infiltrates in an urethra also granulyatsionny changes (a granulyatsionny urethritis) can develop. The metaplasia and keratinization of an epithelium which are not corresponding to intensity of inflammatory process in a subepithelial layer is in certain cases observed. Such urethritis which is followed by the expressed desquamation of a metaplazirovanny epithelium (a desquamative urethritis) is most often localized in the forefront of an urethra. Usually at hron. There is a combination of the listed versions hron, an urethritis.
At women at a gonorrheal endocervicitis (see. Cervicitis ) almost always glands of a neck of uterus are surprised. Inflammatory infiltrate in a stroma is replaced further with cicatricial fabric, edges quite often is exposed to hyalinization.
Gistol, a picture of a gonorrheal endometritis is various depending on a phase of a menstrual cycle. At infection in the intermenstrual period of a gonokokka breed on a surface of an endometria and through interepithelial cracks get into subepithelial layers and glands. The acute inflammation of a functional layer of an endometria is shown by exudation and alteration of fabrics; vessels are expanded, focal perivascular and periglandulyarny kruglokletochny infiltration is often observed. With rejection of a functional layer during periods of a gonokokka settle on a wound surface of a basal layer where the infiltrates consisting of leukocytes, lymphocytes and plasmocytes are formed. Inflammatory process detains regeneration and proliferation of a functional layer that is shown by lengthening of menstrual bleeding (menorrhagia). At hron, a metroendometritis infiltration from a basal layer sometimes gets deeply into a muscular layer with development on site of infiltrate of connecting fabric.
Gistol, a picture of a gonorrheal salpingitis is various depending on a form: at catarral process the serous cover is hyperemic, edematous. In epithelial cells signs of muddy swelling, vacuolation, desquamation with formation of erosion. In subepithelial fabric infiltration is noted by neutrophils and eosinophils, plasmocytes. The ampullar end of a pipe remains open, fimbrias of a uterine tube are edematous. From a cavity of a pipe the moderate amount of serous and purulent exudate is distinguished. Microscopically at a deep (purulent) salpingitis infiltrate gets into a submucosa and a muscular layer of a pipe; erozirovanny sites of folds of a pipe stick together, forming the cavities filled with serous liquid or pus (fig. 3). Further infiltrate gets into a submucosa and a muscular layer of a pipe. It can resolve or be replaced with connecting, and then cicatricial fabric. Under the influence of gonococcal toxin the transudate containing a large amount of fibrin which covers the inflamed pipes is emitted and forms at the organization of commissure with surrounding bodies. At a hydrosalpinx a muscular part of a pipe wall usually the atrofichna, is thin, its stroma is stretched while at a pyosalpinx in connection with availability of the granulyatsionny fabric which is exposed to a sclerosis, suppurative focuses and muscular hems of a dense consistence the wall is thickened (fig. 4).
Strike with Gonokokki in an ovary a germinal epithelium, and during an ovulation and formation of a yellow body sometimes get into depth of an ovary, causing false follicular or true abscess of a yellow body (fig. 5). The cover of abscess consists of granulyatsionny fabric, lymphocytes, plasmocytes. In an ovum opacification of protoplasm and disintegration of a kernel is found. The ovary is increased in the beginning, then there can occur wrinkling of neogenic connecting fabric that leads to an atrophy.
At a pelviperitonitis of a gonokokka, having got on a surface of a peritoneum, cause inflammatory reaction; leukocytes accumulate under the moved apart mesothelial cells, and gonokokk get under cells of a serous cover. The plentiful fibrinous exudate leading at its organization to formation of conglomerates of tumors with dense commissures is as a result emitted.
In an acute stage of a gonorrheal proctitis the mucous membrane is hyperemic and edematous, in the thickness of it — focal small-celled infiltrates with plasmocytes. Affected areas are more often covered with a purulent plaque on the hyperemic basis. In a subacute stage on a mucous membrane there are centers of ulcerations. At hron, process there is an atrophy of a cylindrical epithelium or his full death. On site the destroyed intestinal crypts (liberkyunovy glands) there is a defect and cavities with irregular edges. In prolonged cases the local mucosal atrophy and glands, and also the centers of kruglokletochny infiltrates is observed.
At girls, unlike adults, the areas of genitalias covered by a multilayer flat or transitional epithelium — a vulva, a threshold, a vagina are surprised. Inflammatory infiltrate differs in almost total absence of plasmocytes in what age feature of reaction of a children's organism affects. Diffusion infiltrate from lymphocytes and polynuclear leukocytes (neutrophils and in smaller quantity of eosinophils) at acute G. affects a vagina throughout, breaking at an entrance to the cervical channel. Changes in anticipation of, the paraurethral courses, big glands of a threshold and an urethra are less expressed. At hron. In a vagina the expressed proliferation of an epithelium and histiocytic infiltration of a submucosa is found. In an urethra small histiocytic infiltrates are subepitelialno located. The uterus and appendages usually are not involved in inflammatory process.
an organism of the patient reacts To implementation of a gonokokk development of specific antibodies. They do not provide immunity to a gonorrheal infection therefore the person who transferred G. can catch it repeatedly and besides many times (reinfection). The congenital immunity to this infection, as a rule, does not exist.
Numerous observations testify, however, about immunobiol. the processes happening in sick G. Tsiklichnost's organism of a current of G. passing like any infectious disease, a number of stages (from an incubation and gradual increase of the inflammatory phenomena before their gradual subsiding and total disappearance), speaks about acquisition by an organism of relative immunity to the implemented strain of a gonokokk. Emergence of complications (an epididymite, an adnexitis) exerts impact on gonorrheal process in an urethra (at men) or a neck of uterus. It is shown by the sudden termination of allocations from an urethra or a neck of uterus, disappearance of gonokokk, and also an enlightenment of urine that testifies to an immunitas non sterilisans. Obsolescence of the acute inflammatory phenomena at a gonorrheal urethritis and its transition in hron, a stage, at a cut subjective feelings and objective symptoms are insignificant, are also explained by the fact that the organism gains immunity to this strain of a gonokokk. It is confirmed by numerous observations so-called family G. Muzhchina, suffering hron. With the low-expressed subjective and objective symptoms, can infect the wife with an acute Form. Breeding on a mucous membrane of generative organs of the infected woman, gonokokk get others biol, properties, other degree of virulence and at the subsequent sexual intercourses can cause new infection of the husband. Further in the absence of treatment the inflammatory phenomena at spouses gradually decrease, external displays of a disease disappear, despite existence of gonokokk in generative organs. If the third party enters cohabitation to one of spouses, it gets sick with acute G. and at the subsequent sexual intercourses transfers the activated gonokokk again to the partner therefore at spouses the picture of an acute disease develops again.
Thus, owing to fight of an organism against the implemented infection there is a reorganization of reactivity of an organism eventually, the cut results nonsensitivity from it to a homologous strain of a gonokokk. These can explain also cases when in an urinogenital path of a gonokokka long time do not show the pathogenicity. If under the influence of any reasons endo-and exogenous character reactive properties of an organism change, gonokokk, appearing from any closed center on a mucosal surface of a cover of an urethra, can cause a recurrence of an urethritis.
the Basis G.'s classifications make intensity of reaction of an organism to implementation of the infectious agent, expressiveness a wedge, displays of a disease and duration from the moment of infection. According to the international classification of G. it is accepted to divide into two main forms: acute and chronic. In the USSR acute G. call fresh, to-ruyu subdivide on acute, subacute and torpid. It is reasonable to carry to hron. Inertly proceeding disease with prescription is more than 2 months or cases when duration of a disease does not manage to be established (that quite often happens at women). At hron. Aggravations are sometimes observed.
The incubation interval
From the moment of infection of G. before emergence a wedge, symptoms passes an incubation interval. Existence its number of authors explains with inability of gonokokk to get through the multilayer flat epithelium covering a navicula into submucosal fabric and to cause there inflammatory reaction. Only after 2 — 3 days of a gonokokka manage to breed so that reach a part of the urethra covered with a cylindrical epithelium; they not only extend on its surface, but also get between epithelial cracks into a submucosa where cause inflammatory reaction. However during sexual intercourse as a result of spasmodic reductions and expansions of an urethra at the time of an ejaculation of a gonokokka stick to it and can directly get to the forefront of an urethra covered by a cylindrical epithelium. But even in this case the known term is necessary for emergence in fabrics of the inflammatory changes sufficient for a wedge, displays of a disease.
Duration of an incubation interval at G. fluctuates of one day to 2 — 3 weeks and more (usually 3 — 5 days) that generally depends on the general reactivity of an organism and on virulence of the activator. At insufficient reaction of an organism to the implemented infection the incubation interval is more long, at small virulence of a gonokokk it is also extended. However it can depend and from other reason — gonokokk get sometimes not directly into an urethra, and into the paraurethral courses from where the mucous membrane of an urethra is already consistently infected. The wrong conclusion about brevity of an incubation interval can arise when patients mistakenly carry G.'s infection to later sexual intercourse.
Influence of various factors on the course of gonorrhea
In development and formation patol, process at G. takes part both micro, and a macroorganism, but the dominating role is played by a macroorganism. In the weakened organism even the small and virulent activator usually causes a picture of a serious illness; in an organism with high reactivity at very pathogenic gonokokk the disease proceeds easier. The course of gonorrheal process depends also on age of the patient. At women at senile age of G. proceeds more inertly, than at young women, and causes damage to appendages of a uterus less often that is caused by the lowered reactivity of an organism and fading of hormonal function of ovaries. Emergence of complications of G. is promoted by sexual excitements, emissions, the sexual intercourses, and also deviations from normal sex life (excesses, the severed sexual relations and so forth). Periods (that is connected with the changes of the general condition of an organism occurring at this time, change of a basal layer of a mucous membrane of a uterus), abortion, childbirth, concussions of bodies of a small pelvis, their accidental injury, heavy physical are the most frequent origins of the ascending G. at women. work. Usual physical. work does not exert an adverse effect on a current uncomplicated. The adverse course of gonorrheal process at women is promoted also by abnormal position of a uterus, especially its bends (retropositio, retroflexio). Men have specific features of an anatomic structure and anomaly of an urethra (narrowness of an outside opening, abundance of urethral glands and crypts, the paraurethral courses), a prostate and seed bubbles can complicate outflow of pus and to promote heavier course of inflammatory process.
the Main diagnostic method of G. is a bacterioscopy (see. Bacteriological techniques ). At men investigate a discharge of an urethra, women have a discharge of an urethra, neck of uterus and rectum, girls have a discharge of a vagina, urethra, rectum. Less often at patients study a discharge from the paraurethral courses, a prostate, seed bubbles, big glands of a threshold and so forth. At a disease of joints investigate synovial fluid. If separated from the affected urethra it is not enough, it is possible to investigate the threads caught from urine directly after an urination. In a puerperal period investigate lokhiya. At a disease of eyes (see. Blennorey ) investigate pus of a conjunctiva.
Material for a research is taken after washing of outside urinogenital bodies the cotton plug moistened sterile fiziol, solution. It is the best of all to take freely pus which is flowing down from an urethra. If at men pus from an urethra independently does not flow down, press a finger on webby and spongy speak rapidly urethras and the easy movement squeeze out a drop of pus. The edge of microscope slide or bacterial, a loop take pus and smear on a slide plate. From women the discharge from an urethra after its massage is taken a stupid spoon or bacterial, a loop, from the cervical channel — ginekol. tweezers, from a rectum — method of rinsing waters. If do not find gonokokk, then take material from a neck of uterus, it is 2 better — the 3rd day of periods; in this case gonokokk are found much more often. From other bodies material for a research is taken according to indications.
Material for a bakterioskopichesky research is applied on two glasses. Drugs dry up on air and fix over a flame. Coloring is made across Gram (see. Grama method ). For orientation it is possible to paint smears methylene blue or eosine and methylene blue at the same time to reveal also eosinophils, whose quantity at hron. It is often raised.
The most characteristic signs of a gonokokk — a form of a bean, an intracellular arrangement and gram-negative coloring. However these signs are characteristic only of acute uncured G. V drugs from patients, treated sulfanamide drugs and antibiotics, they can change or be absent absolutely. The form and size of gonokokk are various: often they take spherical shape, reach the big sizes, but along with it very small — powdered gonokokk meet. The intracellular arrangement is observed short time and is characteristic not only of a gonokokk, but also of other diplococcuses and cocci which are available in urinogenital ways. In particular, staphylococcus is located sometimes in cells and in a stage of reproduction has the form similar with gonokokky, and at times is painted gramotritsatelno. During the coloring across Gram the gonokokk which were affected by chemotherapeutic drugs can become gram-positive while other gram-positive microbes under the same conditions sometimes become gram-negative that should be considered at interpretation of a microscopic picture. The Bakterioskopichesky diagnosis is made on the basis of identification only of typical gonokokk.
Cultural diagnosis is necessary in all cases when at a bacterioscopy of a gonokokka are not found. Crops allow to reveal gonokokk by 1,2 — 4 times more often than a method of direct microscopy. Crops are especially shown at hron, forms, a gonorrheal proctitis and control on treatment. Within a week do not carry out antigonorrheic treatment. Before capture for the crops separated from an urethra of the patient shall abstain 3 — 4 hours from an urination.
The best environment for growth of a gonokokk — 2,5% the beef-extract agar prepared on rabbit meat or Bailey's circle pH 7,4 — 7,6 with addition of ascitic liquid.
Widely use bezastsitny environments (e.g., the KDS-1 environment with a hydrolyzate of casein, barmy autolysate and native serum). They not only do not concede ascites agar, but in many cases surpass it. Addition on Wednesday of the antibiotics suppressing the accompanying flora (Ristomycinum and polymyxin M) raises a vysevayemost of gonokokk and facilitates recognition of their colonies. At cultivation of a gonokokk in the atmosphere with the partial content of carbonic acid the quantity of positive takes increases. Environments for crops shall be fresh.
In 24 hours after crops gonokokk grows in the form of transparent risovidny colonies, slightly yellowish, with a plain, smooth, brilliant surface. The size of colonies depends on quality of the environment. Gradually the colony increases and darkens, its center becomes yellowish-brownish. Sometimes in 72 — 96 hours on a circle the roller or affiliated colonies appears.
For bystry approximate selection of colonies of gonokokk in crops use reaction to cytochrome oxydase (see. Tsitokhroma ), etc.
Gonokokki in culture in 24 hours of growth have almost identical size and take the form of a diplococcus or a coccus; in 72 — 96 hours the culture becomes polymorphic and is painted across Gram unevenly. Biochemical, features of a gonokokk are an accessory sign for its difference from similar diplococcuses, but also this sign is not always constant. Sometimes gonokokk, except a dextrose, decomposes also others of sugar, but in certain cases does not decompose any. At bacterial, diagnosis gonokokk should differentiate with other diplococcuses of a sort Neisseria (see) and representatives of the M irnea group.
Immunobiological diagnostic methods of G. have only auxiliary value. Reaction of definition of gonococcal antigen and an intracutaneous test with a gonococcal vaccine completely lost the value. RSK (in particular, Borde's reaction — Zhangu) at acute G. do not apply * since it becomes positive usually only in 3 — 4 weeks after a disease i.e. when G. already recovers. Borde's reaction — Shangu is unsuitable and for establishment of an izlechennost since it can be positive within 10 years after the postponed G. Odnako it can matter a nek-swarm for clarification of the etiology complicated and hron. (In doubtful cases).
Gonorrhea at men
at the beginning of a disease appear small burning in an urethra and insignificant mucous allocations in which at microscopic examination find gonokokk. In the next 3 — 4 few days the inflammatory phenomena continue to accrue and the picture of an acute urethritis develops.
At an acute front urethritis of a sponge of an outside opening of an urethra are sharply hyperemic, edematous, as if vyvorochena. The urethra of an infiltrirovan, at palpation is painful, the plentiful purulent discharge from its outside opening is noted. At microscopic examination of separated find almost exclusively multinuclear neutrophils, separate epithelial cells, and also the numerous, mostly intracellularly located gonokokk. The urine produced consistently in two glasses in the first portion of a mutn owing to impurity of a significant amount of pus, and in the second — is transparent (see. Stakanny tests ). The urination is painful. There is pain at erections.
From a typical picture of an acute gonorrheal urethritis there can be deviations. Sometimes the disease develops torpidno after the incubation interval extended to 2 — 3 weeks, subjective feelings are expressed poorly, allocations are insignificant, sometimes they remain unnoticed patients. Gonokokki in separated is possible to find only after repeated bakterioskopichesky researches. Inflammatory process in an urethra from the very beginning accepts as if hron, a current (urethritis recens torpida). Much less often violently proceeding form of an urethritis meets. The inflammatory phenomena in such cases are expressed extremely sharply. The penis swells up and is in a semi-stressed state, taking slightly bent form (chorda venerea), allocations from an urethra plentiful, with impurity of blood; the urethra at palpation is dense, sharply painful. Such form G. can sometimes be followed by moderate disturbances of the general state, subfebrile condition.
Symptoms of an acute back urethritis are the speeded-up, imperative desires on an urination which in hard cases of a disease arise each 15 — 20 min. By the end of the act of an urination there is pain, several drops of blood (a terminal hamaturia) quite often appear. Patients complain of frequent and painful erections and emissions, sometimes with impurity of blood in sperm. Temperature increase usually is not observed. Separated from an urethra, unlike a front urethritis, it is much less or it is absent absolutely. Pus from a back urethra flows into a bladder. The urine produced consistently in several glasses, a mutn in all portions (a total pyuria). The back urethritis also from the very beginning can proceed torpidno. Subjective frustration in such cases are insignificant. The second portion of urine is transparent, or muddy and transparent urine alternate depending on duration of intervals between urinations. At timely and rational treatment gonorrheal process is limited to the forefront of an urethra. The inflammatory phenomena gradually decrease, painful feelings and allocations stop, gonokokk from allocations disappear.
At overdue or irrational therapy, the lowered body resistance or disturbance by the patient of the mode G. extends further, causing various complications, or passes into a chronic form. Symptoms at hron, a gonorrheal urethritis are various and depend on character and features patol, process, and also on a psychological condition of the patient. In most cases subjective frustration at hron, an urethritis insignificant. The patient is disturbed only by allocations from an urethra, mostly in the form of a drop in the mornings or in the afternoon after long abstention from an urination. However this sign can be absent. In such cases the discharge remains in that place of an urethra where it is produced, and is washed away outside by a stream of urine in the form of threads and flakes. Proceeding inertly, hron, the urethritis under the influence of various reasons (alcohol intake, sexual excitements, etc.) is followed by periodic aggravations and can simulate a picture of an acute gonorrheal urethritis.
Complications. After opening of antibiotics of a complication of G. are registered by 8 — 10 times less than before. They arise usually at prolonged forms of a disease, and also at the infection mixed with trichomonads or chlamydias. The opened and closed urethral adenites, an inflammation of bulbouretralny (kuperovy) glands can develop (see. Bulbous and urethral glands ) and additional gonads. Gonorrheal damages of a bladder and kidneys arise only as an exception. The most frequent complication of G. — damage of a prostate gland (see. Prostatitis ), in a cut of a gonokokka can remain a long time and cause a recurrence of an urethritis. Other complication — an inflammation of an epididymis (see. Epididymite ); there can be one - or bilateral. The inflamed appendage is usually accurately delimited from clinically not changed small egg. However at gistol, a research in fabric of externally healthy small egg find signs of a reactive inflammation, and in some cases from its parenchyma gonokokk (Ya. I. Pevzner) allocate. Clinically expressed symptoms of an orchitis (orchiepididymitis), sometimes even with existence of an exudate in covers of a small egg, are observed only at multi-infection (see. Orchitis ). The inflammation of a prostate and an epididymis is quite often accompanied by an inflammation of one or both seed bubbles (see. Vesiculitis ). Heavy complication — cicatricial urethrostenoses which at an early treatment of G. began to meet less than before opening of antibiotics. Severe forms of complications of G. at men (an acute or Subacute gonohemia with metastatic defeats of an endocardium, a liver, kidneys, joints, eyes, skin etc.) at the used methods of treatment represent an extreme rarity.
Diagnosis. The diagnosis of an acute urethritis can be established only by laboratory methods. Klien, inspection aims to establish degree of prevalence and expressiveness patol, process (topical diagnosis), considering that G. quite often accepts multifocal character. At poll of the patient it is necessary to find out data on an estimated source of infection and other sexual contacts. After that it is necessary to examine carefully area of an outside opening of an urethra, a prepuce and a balanus to find out whether there is no simultaneous infection of the paraurethral and preputial courses. Inspection of an urethra allows to establish whether the urethral glands which in case of defeat are defined in the form of scattered small knots are involved in inflammatory process. Dvukhstakanny test gives an opportunity to judge a condition of the tail of an urethra. At a total pyuria (see. Leukocyturia ) it is necessary to make inspection of a prostate and seed bubbles to exclude their defeat. Massage of these bodies for the purpose of receiving their secret for a research at a pyuria is contraindicated. At the differential diagnosis it is necessary to remember existence of different types of not gonorrheal uretrit of an infectious and noninfectious etiology (see. Urethritis ), and also about diseases at which there can be allocations from an urethra (nonspecific prostatitises and vesiculites, the allocations caused by chemical means, a tool injury and disturbances of exchange — an uretrita at diabetes, an uraturia, an oksaluriya). Besides, the differential diagnosis with the uretrita caused by implementation of Trichomonas vaginalis is necessary (see. Trichomoniasis ), yeast-like fungi, mycobacteria of tuberculosis. In all these cases lack of gonokokk shall be confirmed with a research of smears or crops on mediums.
The diagnosis hron, a gonorrheal urethritis is put on the basis of the anamnesis (duration of a disease of St. 2 months), a wedge, pictures of a sluggish inflammation of an urethra also surely confirm with an obnarusheniye of activators. Gonokokki at hron, a gonorrheal urethritis are in more thickly mucous membrane, in sacculated the centers and are seldom taken out outside with scanty separated urethras. Also bacterial, researches separated are necessary therefore repeated bakterioskopichesky. For judgment of a condition of the tail of an urethra at hron, a gonorrheal urethritis dvukhstakanny test of urine has relative value. In view of the insignificant quantity separated in a back urethra it does not flow into a bladder, and is washed away by the first portion of urine; therefore the second portion of urine can remain transparent.
Is of great importance for establishment of localization and the nature of inflammatory process uretroskopiya (see). In the presence of soft infiltrate the mucous membrane of an urethra is hyperemic, loosened, vessels are not visible; the central figure is closed, irregular shape, a skladchatost rough, unevenly expressed. In case of solid infiltrate the mucous membrane in the place of its stay is pale, has no characteristic radiarnost, a skladchatost its rough, uneven or absolutely is absent. Between these two ureteroscopic pictures many transitional forms, depending on dominance in inflammatory infiltrate of kruglokletochny elements or connecting fabric are had. At an urethral adenitis the inflamed mouths of urethral glands and crypts are hyperemic, tower over the level of a surrounding mucous membrane or are expanded, gape like craters. Sometimes it is possible to note allocation from them purulent contents. At palpation of an urethra on a tube of the urethroscope it is possible to find more or less large dense small knots, slightly painful with a pressure (the closed urethral adenitis). At a granulyatsionny urethritis the mucous membrane of an urethra is sharply hyperemic, loosened, easily bleeds and is covered various size with growths. Uretroskopiya at a desquamative urethritis reveals round islands of whitish or pearl gray color. Process of a metaplasia or keratinization can be observed not only in the form of separate islands, but also extend diffuzno, affecting an urethra on a considerable extent. In all cases hron. At men it is necessary to investigate a state prostatic, bulbouretralny glands, seed bubbles which inflammation can be subjectively asymptomatic.
Treatment. The nature of therapy depends on a form of a disease (acute or chronic), the topical diagnosis, existence of complications and a condition of an organism of the diseased. The list of the recommended drugs and their dose are defined by periodically updated instructions of M3 of the USSR. From these schemes («The instruction for treatment and prevention of gonorrhea». The m3 of the USSR, 1976) choose the most suitable for this patient taking into account portability of medicines, stability of activators etc.
At acute and subacute G. usually use drugs of penicillin. Topical treatment at the same time is not carried out. Benzylpenicillin is entered intramusculary for 0,5% solution of novocaine; an initial dose 600 OOO ED, the subsequent on 300 000 PIECES every 4 hour; course dose of 3 000 000 PIECES. In out-patient conditions for the purpose of reduction of quantity of injections it is recommended to enter for the night benzylpenicillin with blood of the patient. Ekmonovotsillin-1 appoint 600 000 PIECES (each 12 hours) in a single dose or 1 200 000 PIECES (each 24 hours), enter intramusculary in the double-stage way. Bicillinum-1, Bicillinum-3 and Bicillinum-5 enter in the same way bucketed at a single dose into 600 000 PIECES at 24 o'clock, at a dose of 1 200 000 PIECES — the 48th hour. Course dose of 3 000 000 PIECES. Ampicillin is given inside on 0,5 g in 4 hours to the general dose of 3 g.
Other antibiotics, as a rule, apply at intolerance of drugs of penicillin, and also at failure of treatment by penicillin. From antibiotics of a reserve use drugs of tetracycline (a hydrochloride of tetracycline, a dihydrate Oxytetracyclinum, a hydrochloride of chlortetracyclin) on 0,3 g of 5 times a day during the first 2 days, and then on 0,2 g of 5 times a day to a course dose of 5 g. 4 times a day in the next days (a course dose of 4 000 000 PIECES) give Oletetrinum inside on 500 000 PIECES on the first reception, then 3 more times on 250 000 PIECES during the first day and on 250 000 PIECES. Erythromycin is appointed inside by 2 days on 400 000 PIECES of 6 times a day, then on 400 000 PIECES of 5 times a day (a course dose of 8 800 000 PIECES). Levomycetinum is appointed inside on 0,5 g during the first 2 days of 6 times a day, in the next days on 4 times pass. Monomycinum and Kanamycinum enter intramusculary on 500 000 PIECES in 12 hours to the general dose of 3 000 000 Units Trobitsin (spektinomitsin) enter intramusculary once in a dose 2 g. Sulfanamide drugs (sulfamonometokein, sulfadimethoxine) give inside 1,5 g 3 times a day the first 2 days, then on 1 g 3 times a day to the general dose of 15 g.
As a result of treatment by antibiotics the inflammatory phenomena usually within 5 — 7 days sharply decrease, allocations become scanty, mucous; gonokokk in them are not found. In case of successful treatment it is necessary to start after 7 — 10 days establishment of an izlechennost.
If after 5 — 7 days after the end of treatment by penicillin, despite disappearance of gonokokk, the inflammatory phenomena (allocations, threads in urine, etc.) remain, the patient needs to be inspected and according to the topical diagnosis to begin topical treatment. It is reasonable to start local influence if at an uretroskopiya find the expressed inflammatory changes which are not tending to spontaneous return permission. If gonokokk after treatment finally did not disappear, then the wedge, the wellbeing which came after an antibioticotherapia is short-term. In 3 — 5 days, and sometimes more, after the end of introduction of antibiotics of allocation from an urethra increase and in them gonokokk are found again. In such cases it is necessary to make additional inspection. Relative stability of activators to the applied antibiotics, the infection mixed with trichomonads or existence of complications can be the cause of failure. After laboratory and the Urals, inspections by antibiotics repeat treatment, having replaced drug. But at failure of a penicillin therapy it is impossible to appoint repeatedly other antibiotic of this group since decrease in sensitivity of gonokokk extends to different drugs of penicillin. Same concerns also failures at treatment by tetracyclines. In the presence of complications and in prolonged cases the course dose of an antibiotic is increased by 1,5 — 2 times, and the immunotherapy (on epid, to indications simultaneous carrying out immune and chemotherapy is allowed) shall precede introduction of antibiotics or streptocides. At the infection mixed with trichomonads antimecotic drugs (metronidazole, etc.) appoint to or during antigonorrheic treatment.
At hron, the complicated G., and also fresh torpid, treatment comes down to a specific or nonspecific immunotherapy and to local impact on the struck body. After such treatment in the conditions of a hospital it is necessary to appoint penicillin or other antibiotic in the general dose exceeding by 1,5 — 2 times course at treatment acute G. Chem the prescription of gonorrheal process is more, than connective tissue changes (solid infiltrate) are expressed more considerably and the more sharply vascularization of the struck fabric is broken, the more intensively there have to be a preliminary immunotherapy and topical treatment. In out-patient conditions antibiotics are appointed along with an immunotherapy. At especially hard proceeding complications (as well as at multi-infection and at failures from consecutive purpose of several antibiotics) apply simultaneous treatment by two antibiotics. Course doses and technique at the combined prescription of antibiotics same, as well as at their separate appointment. After improvement of the general state and considerable reduction of the inflammatory phenomena start to immune, fizio-and local therapy.
The immunotherapy can be specific (gonovaccine) and nonspecific (pyrogenal, lakto-and an autohemotherapy). The last stimulates natural resistance of an organism, increases efficiency of medical drugs, promotes more bystry and full rassasyvaniye of inflammatory infiltrates. Apply a gonovaccine more often, to-ruyu enter intramusculary in 1 — 2 day, since 150 — 300 million microbic bodies and increasing each subsequent dose by 100 — 150 million microbic bodies. At very rough reaction (temperature increase more than on 1,5 — 2 °, the expressed aggravation in the centers of defeat) it is necessary to wait 2 — 3 days and to enter same or even a little smaller dose. At weak reaction the following injection is done in 1 — 2 day, having doubled a dose of a vaccine. The maximum single dose — 2 billion microbic bodies; the course consists of 6 — 8 injections.
The lactotherapy is especially shown at prostatitises, paraprostatites and periurethrites. In out-patient conditions the lactotherapy is not applied. The initial dose of milk (1 — 2 ml) depends on sharpness of inflammatory process. At rather expressed temperature reaction (38 — 38,5 °) the dose of milk should not be raised. Usually the subsequent dose applied in 3 days is increased by 2 — 3 ml and then gradually brought to 10 ml. At the patients with a torpid form G. who are poorly reacting to a vaccine and milk the combined treatment can be applied with success: the vaccine and milk are gathered in one syringe and injected intramusculary. Initial dose of 1 ml of milk + 100 million microbic bodies of a vaccine. Further increase in a dose depends on reaction of an organism.
Pyrogenal is entered intramusculary in 1 — 2 day, by 10 — 15 injections on a course. Initial dose 50 — 75 MPD (minimum pyrogenic doses). Depending on reaction the subsequent doses increase by 1,5 — 2 times; maximum single dose of 1 000 MPD.
Contraindications to an immunotherapy: active pulmonary tuberculosis, organic lesions of cardiovascular system, disease of kidneys and liver.
Widely apply various chemical, mechanical and thermal irritants to topical treatment. The choice of this or that method depends on intensity and character patol, process in an urethra and individual ability of an organism to react to this or that irritation. At prolonged and hron, uretrita washings are shown by weak solutions of potassium permanganate (see. Zhane method ). In the presence of soft infiltrate or granulations appoint instillations in an urethra of solutions of a lyapis (0,25 — 1%) or protargol (1 — 2%) of 1 times in 2 — 3 days. Limited sites of damage of a mucous membrane grease 10 — 20% with solution of a lyapis via the urethroscope with intervals in 5 — 6 days. At a desquamative urethritis 2 times in day of 1% solution of zinc sulfate or mix of the following structure apply syringings: Zinci sulfatis, Plumbi acetatis aa 1,0, Aq. dest. 200,0. At infiltrate and an urethral adenitis the tamponade of an urethra across Vashkevich is useful: to an outside sphincter enter an ureteroscopic tube into a front urethra (No. 25 — 27), take out the obturator, and through a tube enter a cotton plug, poorly navernuty on the smooth round probe, impregnated 2% protargol-glycerin. Holding the probe, take a tube of the urethroscope, then take out the probe from a tampon. The tampon is left in an urethra for 2 — 3 hours then he is brought from an urethra by a stream of urine at an urination. Tamponades do 2 times a week, only 6 — 8 times. Bougieurage (as well as a tamponade) is most shown at solid infiltrate, but it with success is applied also at soft infiltrate when instillations of a lyapis do not give sufficient effect. Buzh leave in an urethra for 5 min. After extraction of a buzh it is necessary to wash out an urethra solution of oxymercuric cyanide (1: 6000) or lyapisa (1: 10 000).
At an inflammation of urethral glands (the closed urethral adenitis) the good effect renders warming up of an urethra diathermic current, a cut make daily 15 — 20 min. In the presence of expanded mouths of the crypts or glands emitting pus and also at the limited growths of a mucous membrane which are not disappearing from greasing lyapisy it is necessary to destroy these centers via the urethroscope by electrothermic coagulation (see. Diathermocoagulation ).
The main methods of physical therapy of gonorrheal diseases — thermal procedures: compresses, local bathtubs, microclysters, paraffin, ozokerite, diathermy, etc. Contraindications to use of a diathermy — acute inflammatory processes and a hyposensitivity of the patient to heat (tabes, a myelosyringosis, etc.). Apply an electrophoresis (drugs of iodine) to a rassasyvaniye of inflammatory infiltrate, a softening and stretching of the hems which remained after gonorrheal process in epididymes, a prostate, seed bubbles and other bodies, and also fonoforez (see. Ultrasonic therapy ).
Curability and criteria of an izlechennost. Usually antibiotics promote elimination of an infection in rather short terms. But at a part of patients, despite permanent disappearance of gonokokk (no methods did found), a wedge, recovery does not occur: it is long there are inflammatory phenomena in the urinogenital device which are not showing a tendency to spontaneous treatment (a post-gonorrheal urethritis). Such post-gonorrheal diseases can be caused by various reasons and demand additional inspection and treatment. Since wedge, manifestations of a post-gonorrheal urethritis and hron. Completely match, attach that special significance to comprehensive repeated laboratory examination (microscopy and crops), including it is obligatory after attempt of an artificial exacerbation of a disease (provocation).
It is necessary to consider cured the patient when after long observation it is not possible to find gonokokk in an organism, and the patient stops being a source of an infection. For provocation use various methods: chemical (instillation in an urethra of 0,5% of solution of a lyapis), mechanical (massage of an urethra to Bougie), biological (intramuscular introduction of a gonovaccine in number of 500 million microbic bodies), alimentary (salty, spicy food and beer), thermal (warming up by diathermic current of generative organs). Since the combination of all listed ways of an aggravation of an inflammation gives the largest frequency of identification of gonokokk, it is necessary in 7 — 10 days from the moment of the last manipulation to carry out the combined provocation. In 24, 48 and 72 hours after provocation investigate allocations, at their absence — scraping from an urethra, threads from urine and a secret of a prostate and seed bubbles on gonokokk. If after provocation of a gonokokka in smears and crops do not find and there is no post-gonorrheal process, the patient is left for dispensary observation. In a month after the first provocation of the patient inspect after the combined provocation again, then do an uretroskopiya. Uretroskopiya is obligatory since patol, changes of a mucous membrane and glands of an urethra can remain, despite the absence of a wedge, symptoms of an urethritis. The general duration of dispensary observation for the men who transferred G. makes 2 months. If during this term activators and a wedge, G.'s symptoms were not found, then such persons are considered as cured and are struck off the register in venerol. establishment. If the source of infection was not revealed, patients shall be under observation of 6 months for an exception of other latent venereal disease (syphilis).
Gonorrhea at women
Gonorrhoea at women is characterized by nek-ry features: the gonorrheal infection quite often affects almost all departments of urinogenital system of the woman, differing in a mnogoochagovost; the disease happens subjectively asymptomatic at most of patients; Often proceeds as the multi-infection caused by gonokokka and other activators (most often gonokokk in association with a vulval trichomonad, are more rare with chlamydias, fungi Candida, pyogenic cocci, hemophilic vaginal sticks etc.); quite often (in 30 — 40%) the gonorrheal proctitis is observed.
Distinguish G. of a lower part of the urinogenital device (the urethritis, a vulvitis, vestibulit, a bartholinitis, an endocervicitis, a colpitis, a paraurethritis) and the ascending G. (an endometritis, a salpingitis, an oophoritis, a pelviperitonitis).
The urethritis takes place almost at 90% sick. At acute G. about 30% of patients complain of pains or gripes during an urination, at other patients of the complaint are absent. This results from the fact that the female urethra is very short (3 — 4 cm), easily the rastyazhima also does not create obstacles to outflow of pus. At acute G. the mucous membrane of an urethra is edematous, hyperemic, sometimes on it find the dot hemorrhages and erozirovanny sites covered with a purulent plaque (see. Urethritis ). Gonokokkam the paraurethral courses are quite often infected. Owing to a delay of pus in these courses the small abscesses which are opened in an urethra can develop.
Patients hron, a gonorrheal urethritis, as a rule, have no complaints. Only after massage of an urethra there are noticeable scanty serous purulent discharges. Puffiness and infiltration of an urethra are expressed, the channel is palpated in the form of a dense tyazh.
The vulvitis meets seldom; generally at pregnant women and at women in a menopause. The mucous membrane of a vulva is covered with a multilayer flat epithelium and is the adverse soil for development of gonokokk. Patients complain of burning sensation, plentiful allocations, the irritating skin of a crotch and hips. The mucous membrane of a vulva is edematous, hyperemic, easily bleeds. On big vulvar lips purulent crusts are quite often formed, under to-rymi find erosion and ulcerations (see. Vulvovaginitis ).
Vestibulit at G. of usually secondary origin and the same as the vulvitis, differs in nothing from a nonspecific vestibulit.
The bartholinitis occurs at 20% sick. Process can be limited only to an output channel, take a gleam of gland and extend out of its limits. At acute defeat only of mouths of channels the last act over a surface of a threshold in the form of red spots. However it is not specific to G. and occurs at patients trichomoniasis (see). The struck channel of gland is palpated in the form of a painful tyazh or an oblong swelling of a pasty consistence. During the pressing on the course of an output channel from its mouth pus can appear. In cases of disturbance of outflow the retentsionny cyst or false abscess develops. Quite often the bartholinitis is allowed independently, the discharge gradually gains mucous character, the swelling decreases. Some patients have insignificant increase in a channel of gland in the form of a dense small knot.
The colpitis caused only by gonokokka meets extremely seldom; more often it arises owing to the infection mixed with trichomonads or for the second time because of decrease in resistance of a mucous membrane of a vagina, matserirovanny is long the existing allocations from a neck and a body of the womb. The discharge is plentiful, purulent character.
The cervicitis and an endocervicitis are observed at 95% of patients. The main complaints at acute G. — bleach (see). Acute process without treatment quickly passes in subacute and hron., bleach become muddy, mucous. At survey of the woman in the acute period of a disease note puffiness and a hyperemia of a mucous membrane of a neck of uterus. Around an outside opening of the cervical channel the bright red, easily bleeding erosion is visible, sometimes it has a granular appearance (a follicular erosion). Mucopurulent allocations from the channel flow down in the form of a tape. At uncured or insufficiently treated process the disease gets hron, a current, at Krom of the complaint at patients are absent, and at survey find an erosion of a neck of uterus (see) and mucopurulent allocations (see. Cervicitis ).
Owing to partial obstruction of glands of a neck of uterus on a mucous membrane of a vulval part of a neck of uterus sometimes there are belovatozhelty grains (ovula Nabothi) in the depth of which can is long to remain gonokokk.
Penetration of gonokokk for an isthmus of a uterus (in an internal pharynx) causes so-called ascending. This process is promoted by periods, abortion, childbirth, intrauterine interventions etc. By data A. V. Chastikova (1967) and E. N. Turanova (1972), the ascending G. is diagnosed for 6 — 7% of patients in an acute stage, and at hron. — at 28 — 30%. Almost at 1/4 patients the ascending G. proceeds subjectively asymptomatically that complicates diagnosis of this disease.
Endometritis. Involvement in process of a uterus can proceed gradually, imperceptibly or suddenly. In the latter case the disease gets an acute current. Appear liquid bleach, the menorrhagias considerably increasing upon termination of periods, quite often, pains irradiating in a sacrum, feeling of weight in the bottom of a stomach, small sensitivity of a uterus at vulval survey. If there comes the delay of a secret in a cavity of the uterus, there are pains of skhvatkoobrazny character. At acute process are observed, in addition to local, and the general phenomena: delay of a chair, general weakness, pallor of integuments, etc. At hron, a current note pains in the bottom of a stomach, the uterus is a little increased, dense, is sometimes sensitive. Since at hron. Of a gonokokka get into a stroma and a muscular layer of a uterus, process has character metroendometritis (see).
Salpingitis. At spread of an infection on uterine tubes in a fresh stage of a disease there is a gonorrheal salpingitis (see. Adnexitis ). Patients note colicy pains in the bottom of a stomach, moderate fever, disturbance of appetite, sometimes rise in temperature to 38 °, a headache. These frustration rather quickly weaken. At a long delay of pus in a uterine tube the pyosalpinx forms. Bilateral defeat of pipes is characteristic of G. (at 70% of patients). At hron. Of the complaint quite often are absent.
The oophoritis arises at spread of an infection on pipes on an ovary or a hematogenous way. Ferruterous fabric or a parenchyma inflames. Patients complain of abdominal pains and bleeding (like a metrorrhagia). At vaginal examonation define the increased and sharply painful ovary; the same general frustration, as at a salpingitis (see. Adnexitis ).
A pelviperitonitis — a consequence of further spread of an infection and involvement in process of a pelvic peritoneum that, as a rule, does not go beyond a small pelvis (see. Pelviperitonitis ). At an acute inflammation there are severe pains in the bottom of a stomach, temperature increases, the headache, weakness, sometimes vomiting, a liquid chair are noted. The stomach is blown up, at a palpation reveal sharp morbidity in the bottom of a stomach, a muscle tension of a front abdominal wall and symptoms of irritation of a peritoneum. Treatment conservative: antibiotics, Disintoxication therapy, cold on a bottom of a stomach, sublime position of a body.
At hron, the ascending G. only at 1/3 patients take place of the complaint to dull aches in the bottom of a stomach, disturbance of a menstrual cycle on type meno-, metrorrhagias, bleach. At the same time at a bimanual research find bilateral tumorous formations of an inflammatory origin (a pyosalpinx, an adneks-tumor) in patients that can be the cause of infertility.
Hron, inflammatory process of appendages of a uterus of a gonorrheal etiology proceeds with the frequent aggravations leading to extensive unions. The noticeable role in it belongs to the gonococcal endotoxin promoting strengthening of release of fibrin. Plastic exudate which quickly leads to adhesion of surfaces not only a pipe and an ovary, but also loops of intestines, an epiploon is as a result formed. Further the picture of an adhesive desease can develop (see).
The proctitis is usually combined with defeat of urinogenital bodies, developing more often for the second time, as a result of flowing of pus from a genital tract, but can be primary and isolated (see. Proctitis ). Process strikes 3 — 4 cm of a lower part of a rectum. Complaints usually are absent; only in the presence of cracks or erosion on a mucous membrane of a rectum of some patients the itch or burning in the field of an anus, presence of pus in Calais, morbidity of defecation disturb. Folds of a mucous membrane of the anal channel are edematous, sometimes between them there are cracks and a purulent discharge. At survey by means of a rectal speculum the ochagovogiperemirovanny and edematous mucous membrane in places covered with a purulent plaque is visible.
At hron, a gonorrheal proctitis symptoms are almost not expressed.
Gonorrhea at pregnant women
the Developments of stagnation in bodies of a small pelvis developing in time of pregnancy define G.'s originality at pregnant women. In the first 3 — 4 months of pregnancy of G. of a lower part of urinogenital ways can easily pass in ascending when covers of fetal egg still insufficiently densely close an isthmus of a uterus. The ascending G. quite often leads to abortions and premature birth. E. N. Turanova, R. D. Ovsyannikov (1973) among sick G. of pregnant women spontaneous abortions (see. Misbirth ) noted in 7% of cases, premature births (see) — in 3%. In a puerperal period gonorrheal process quickly progresses. The open channel of a neck of uterus promotes penetration of an infection into a cavity of the uterus where there is a favorable environment for development of an inflammation. Usually ascending G. is shown on 7 — the 9th day after the delivery.
The diagnosis at women shall be surely confirmed with identification of activators bakterioskopichesky or bacterial, methods since a wedge, a picture not the patognomonichna for G. and can be caused by other microorganisms. In the absence of gonokokk in allocations from genitals and a rectum G.'s diagnosis (even if on the patient it is specified as a source of an infection) cannot be put to registration, in a registration form (281) such patients are not subject though they should carry out preventive antigonorrheic treatment.
At hron. Provocation facilitates identification of gonokokk. The best results observe at the combined provocation: once intramusculary enter 500 million microbic bodies of a gonococcal vaccine (biol, provocation); the urethra and a rectum are greased with solution of Lugol on glycerin or 1% solution of a lyapis, the channel of a neck of uterus — 4% solution of a lyapis (chemical provocation); carry out a vaginalno-sacral diathermy (thermal provocation) within 20 — 30 min. Within three next days take smears and in 4 — 5 days crops on gonokokk. A menstrual phase — one of the brightest forms of provocation. Material for a research is taken in time of periods and in the first 2 — 3 days after it.
Treatment is, as a rule, carried out in a complex using the general antibacterial drugs, local therapy and methods of specific and nonspecific stimulation of defense reactions of an organism. A dosage and a technique of administration of drugs of penicillin and its derivatives (an ekmonovotsillin, Bicillinums, ampicillin), and also other antibiotics same, as well as at treatment of the corresponding forms G. at men. At hron. At women it is regionarno reasonable to enter along with intramuscular injections into a neck of uterus 200 000 PIECES of benzylpenicillin. The combination of several antibiotics is shown only to patients with severe forms ascending. Detection in smears of gonokokk after treatment is the indication for change of antibiotics with preliminary use of an immunotherapy. At impossibility of use of antibiotics (allergic reactions, antibiotic-resistant forms) it is possible to recommend treatment by sulfadimethoxine or Sulfamonomethoxinum: the first 2 days on 1,5 g 3 times a day, in the next 2 days — on 1,0 g 3 times a day to the general dose of 15 g, plentiful alkaline drink.
Topical treatment is appointed by hl. obr. at fresh torpid process, hron, and the complicated Forms. At hron, an urethritis greasing of an urethra by pure Ichthyolum or 1% solution of Lugol is shown (8 — 12 sessions in 1 — 2 day depending on local reaction, alternating to instillations of solution of a lyapis). The inflamed paraurethral courses cauterize lyapisy, soldered on the probe, or coagulate a diathermocoagulator. A gonorrheal endocervicitis in a subacute stage treat vaginal trays with hydrogen peroxide after which the vagina is drained and put for 24 hours a tampon from 10% solution of protargol in glycerin; the channel of a neck of uterus is greased by 1% with solution of Lugol on glycerin or 2% solution of a lyapis on depth of 1,5 cm once in 3 — 4 days. At hron, an endocervicitis vulval trays from 2% solution of a lyapis are appointed in 3-4 days, the follicular erosion of a neck of uterus is cauterized 1 time crystals of potassium permanganate; retentsionny cysts of a neck of uterus open or coagulate. It is long the existing erosion of a neck of uterus after a preliminary biopsy subject diathermocoagulations, then enter into a vagina for 24 hours a tampon from 10% Ichthyolum glycerin. At a gonorrheal proctitis in an acute form do every other day microclysters with 1% solution of protargol and 2 times in day of a candle with a belladonna; in hron, stages — microclysters from 3% solution of protargol and cauterization of erosion of 5 — 10% solution of a lyapis.
Establishment of an izlechennost is carried out in 7 — 10 days upon termination of a course of treatment. After the combined provocation within 3 days take smears, in 4 days make crops. At favorable results the patient is called for capture of control smears during the next periods. Upon termination of periods — again combined provocation and a research of smears within 3 days. Similar inspection is made throughout 2 — 3 menstrual cycles. If the source of an infection is not revealed, the patient is under dispensary observation within 6 months for an exception of the latent syphilis.
Gonorrhea at girls
Girls get sick with G. most often at the age of 2 — 8 years. G.'s infection in 95% of cases occurs in the household way through objects of a toilet (a bast, a chamber-pot, the general bed) contaminated by allocations of the patient. In 75% of cases a source of an infection is mother, other relatives and the personnel which are looking after the child are more rare. Extremely seldom infection occurs sexually. In isolated cases of the girl can be infected during the passing in patrimonial ways of sick G. of mother. The pre-natal way of infection is described.
At G. of girls inflammatory process, as well as at adult women, is characterized by a mnogoochagovost (the vagina and its threshold, in 85% of cases — an urethra and in 50% — a rectum usually are surprised, and at girls 5 years — sometimes and big glands of a threshold are more senior). But internal generative organs suffer extremely seldom. Distinguish fresh G. of girls (lasting disease up to 2 months), edges there can be acute and torpid (sluggish) and chronic with a duration of St. 2 months Hron. Of girls usually proceeds malosimptomno, giving periodic aggravations under the influence of systemic infections and other reasons.
At acute process of the complaint to allocations and morbidity at an urination. Skin of big and small vulvar lips, a mucous membrane of a threshold, a clitoris and a hymen are edematous, hyperemic, covered is purulent - mucous allocations. On big vulvar lips, a crotch and the adjoining surfaces of hips purulent discharges shrink in the form of crusts. Covers of a vagina are edematous, hyperemic. Allocations are plentiful, mucopurulent character. As a rule, a front third of an urethra inflames, its sponges are edematous. If to press on a back wall of an urethra through a vagina, from an outside opening the purulent discharge appears. The mucous membrane of a rectum at patients with a gonorrheal proctitis is edematous, hyperemic, sometimes with purulent separated; the itch, pain at defecation is noted. Emergence of blood on fecal masses can simulate dysentery. At a rektoskopiya (see. Rektoromanoskopiya , in children) the focal hyperemia of a mucous membrane, an erosion with a purulent plaque is found. Cystitis at G. at girls happens extremely seldom.
Hron, G.'s current at girls is observed infrequently (in 6%) and diagnosed usually in the period of an aggravation when allocations from a genital tract appear. The mucous membrane ochagovo is hyperemic in the field of mouths of small glands of a threshold. On a vulva and a threshold sharp-pointed condylomas occasionally expand. At a vaginoskopiya find a focal hyperemia and puffiness of a neck of uterus and walls of a vagina.
Complications: the disease of a sust of the Second World War proceeding in the form of mono - and polyarthritis, the miozita proceeding the same as sometimes occur at adults, the defeat of a nervous system which is developing as a result of intoxication the gonotoxin which is emitted at death of gonokokk, and shown in the form of deterioration in a dream, irritability, slackness, a loss of appetite.
The diagnosis is made only at detection of typical gonokokk during the coloring across Gram, and also according to crops. The discharge from an urethra and a vagina is taken an ear spoon, from a rectum — it is better rinsing waters. In the absence of gonokokk it is necessary to make chemical provocation: through a rubber catheter enter 1% into a vagina solution of a lyapis or 1% solution of Lugol in glycerin, in an urethra dig in the same solution an eyedropper, and grease the lower piece (3 — 4 cm) of a rectum with solution of Lugol. To girls 3 years are more senior enter at the same time gonococcal vaccine (150 — 200 million bacterial bodies intramusculary). In 24,48 and 72 hours from all centers take material for smears which is applied in parallel on 2 glasses. In 4 — 5 days after chemical provocation take material for crops.
Bakteriol, identification of gonokokk is especially necessary when the source of infection since microorganisms, externally a little similar to Neisseria gonorrhoeae are found in girls rather often at microscopic examination is not revealed.
The differential diagnosis is carried out with not gonococcal colpitises which can develop both as a result of penetration of microbes from the environment, and at the general and local infectious diseases (scarlet fever, diphtheria, measles, a pyoderma, etc.). Quite often the colpitis develops at disbolism, chemical, mechanical and thermal irritation, in the presence of an enterobiosis, at an invasion of trichomonads, yeast-like fungi of a sort Candida. However at not gonococcal colpitis the rectum is not surprised and it is extremely rare — an urethra.
Treatment. The general principles of treatment of G. at girls do not differ from those at adults. The child is hospitalized. For introduction of an antibiotic appoint a bed rest, fortifying treatment. In sharply proceeding cases enter benzylpenicillin in a course dose from 2 000 000 to 3 000 000 PIECES, depending on age on 50 — 100 000 PIECES in isotonic solution of sodium chloride in 3 — 4 hours. It is possible to apply ekmonovotsillin on a course respectively 2 400 000 — 3 600 000 PIECES on 600 000 PIECES in 10 — 12 hours; Monomycinum — on a course 2 000 000 — 3 000 000 PIECES, on 500 OOO ED in 0,5% solution of novocaine in the 12th hour. Levomycetinum is appointed inside to a course 5 — 6 g depending on age: up to 3 years on 0,01 — 0,15 g on 1 kg of weight of the child on reception, 3 — 4 times a day; to children from 3 to 8 years on 0,2 g on reception, 8 years — 0,3 — 0,5 g on reception are more senior. The combined use of antibiotics is shown to patients with resistant forms G. and at hron, process. In case of failure of a penicillin therapy it is impossible to reappoint drugs of this group. Before a course of antibiotics it is necessary to carry out an immunotherapy. The gonococcal vaccine is entered intramusculary in a dose of 50 — 200 million microbic bodies depending on age of the child. The subsequent doses entered at an interval of 2 — 3 days increase, proceeding from extent of reaction. At an acute vulvovaginitis apply warm sedentary trays for 10 — 15 min. to topical treatment 2 — 3 times a day from infusion of a camomile or solution of potassium permanganate (1: 10 000); in hron, stages wash out a vagina through a rubber catheter solution of potassium permanganate with the subsequent instillation of 1 — 2% of solution of protargol or 0,25% — 1% of solution of a lyapis on 5 ml every other day. At hron, an urethritis of century the urethra is dug in a pipette by 3 — 4 drops of 2% of solution of protargol or 0,25 — 0,5% of solution of a lyapis. Apply microclysters from 20 — 30 ml of 1 — 2% of solution of colloid silver or 1 — 3% of solution of protargol to treatment of a proctitis.
The establishment cured by t and. All girls preschool * age after the end of treatment remain in a hospital for 1 month of Izlechennost at girls the wedge, pictures and favorable results of repeated laboratory researches separated (crops and smears), taken from an urethra, a vagina and a rectum before and after combined (chemical and biological) provocations is based on subsiding. Laboratory control is carried out twice at an interval of 7 — 10 days. Then the child is written out from a hospital. Visit of kindergartens, yasel and schools is allowed: right after the end of treatment.
At timely and correct treatment of acute G. the forecast usually favorable. Disturbance of terms of treatment, insufficient efficiency can lead it to transition in hron, a form and to various complications.
Effects insufficiently treated hron. At men can be an urethrostenosis, hron, prostatitis, infertility, sexual frustration, at women — hron, an adnexitis, infertility.
the Basis of fight against G. is made by the measures of public prevention which are closely connected with dispensary service of patients (identification and sanitation of sources of infection, control of completeness and quality of treatment etc.), active identification of G. among patients the Urals, institutions and husbands of the women having inflammatory diseases of female generative organs of an unspecified etiology, and also educational and a dignity. - a gleam. work among the population and other actions, the general for all venereal diseases.
Surely inspect all family members who got sick with G. Akushersko-ginekol. institutions carry out a dignity. - a gleam, work among the patients. The law prescribes punishment for evasion from treatment and notorious infection of other persons (see. Venereology ).
The revealed sick G. are subject to treatment according to the existing instructions of M3 of the USSR of N to the subsequent full control on treatment during an established period. Only after it they can be struck off the dispensary register. On everyone sick G. fill in the registration form, edges is in venerol. a clinic (see. Clinic, dermatovenerologic ) on territorial accessory. At the same time report data on an estimated source of infection and the persons which were in sexual contact with the patient or sick.
Personal prevention is recommended to the persons which had accidental sexual relations. She in most cases guarantees the man against infection of. The best prophylactic is the condom which is equally protecting from G.'s infection both the man, and the woman. For personal prevention it is recommended to urinate, wash immediately after the intercourse with soap a penis and at once to address on point of personal prevention which is available at each venerol. a clinic and in some other to lay down. institutions. For men the desinfectants applied after the sexual intercourse, hl are reasonable. obr. drugs of silver: lyapis, protargol. Directly after the sexual intercourse inject into an urethra by means of a pipette of 10 drops 2% of solution of a lyapis or 10% of solution of protargol in glycerin which is held 1 — 2 min.
The concentrated solutions of silver cause pain, burning and irritation of a mucous membrane of an urethra and at prolonged repeated use can lead to an urethritis.
The most efficient method of prevention of G. — plentiful washing of a front urethra the solution of potassium permanganate (1:6000) which is mechanically deleting from a mucosal surface of a cover of the gonokokk which got on it and creating unfavorable conditions for their reproduction. Potassium permanganate does not cause any painful feelings and irritation of a mucous membrane therefore it can be applied without any harm repeatedly during long term. Washings with the preventive purpose are effective during 12 hours after sexual intercourse. The more will pass time after the sexual intercourse, the it is more than a percent of failures.
Personal prevention at women is less reliable, than at men. For personal prevention it is possible to apply a condom. Before sexual intercourse it is possible to enter the gauze tampon impregnated with solution of corrosive sublimate into a vagina (1: 3000) or protargol (1: 100) to grease a threshold and an urethra with vaseline. Right after the intercourse the woman is recommended to remove a tampon, to urinate, wash generative organs with soap and to prosprintsevatsya by solution of potassium permanganate (1:5000). On points venerol. prevention, besides, to women in an urethra dig in 1 — 2% solution of a lyapis; the neck of uterus, a vagina and a vulva are greased by 2% with solution of a lyapis; in skin of the bottom of a stomach, hips, crotches, proctal area within 5 min. rub calomel ointment.
For the prevention of a disease of G. children shall sleep separately from parents, have separate objects of leaving (a sponge, a towel, a chamber-pot). The pediatrician shall examine the children coming to children's collective, and at suspicion on G. — the venereologist.
The service personnel before revenues to work in child care facility and in the subsequent also have each three months examination of the venereologist.
Bibliography Kaliner B. S. Bases of prevention and treatment of gonorrhea of the woman, L., 1970, bibliogr.; To and A. G. Gono-roynye N of a disease of a female body, M., 1950, bibliogr.; L I x about in and the Central Committee and y N. S. Uretroskopiya and vnutriuret-ralny interventions, M., 1969, bibliogr.; M and and A. M. Gonorey's c of women and its complication, L., 1968; Methodical materials on diagnosis, clinic, treatment and prevention of skin and venereal diseases, under the editorship of H. M. Turanova and A. A. Studnitsin, M., 1974; The Multivolume guide to a dermatovenereology, under the editorship of O. N. Podvysotskaya, t. 1, book 2, page 489, M., 1959, bibliogr.; The multivolume guide to pathological anatomy, under the editorship of S. T. Pavlov, t. 7, page 367, etc., M., 1964; Ovchinnikov H. M. Laboratory diagnosis of venereal diseases, M., 1969, bibliogr.; Porudominsky I. M. Gonorrhea, M., 1952; The Guide to clinical urology, under the editorship of. A. Ya. Pytelya, page 384, M., 1970, bibliogr.; Starostina 3. D. Cultural methods of a research in diagnosis of gonorrhea, Vestn, dermas, and veins., No. 11, page 41, 1975; Teokhar about in B. A. Gonorey, trichomoniasis and other urinogenital venereal diseases, M., 1968, bibliogr.; Turanova E. N., Skuratovich A. A. and Afanasyev B. A. Pirogenal in therapy of inflammatory diseases of urinogenital bodies of women, Vestn, dermas, and veins., No. 5, page 76, 1969, bibliogr.; Brown W. J., Lucas C. T. and. To u h n U. S. Gonorrhoea in the chimpanze, Brit. J. vener. Dis., v. 48, p. 177, 1972; G i 1 1 i e t F. u. S t o r with k H. Neues zur Therapie der Gonorrhoe, Schweiz, med. Wschr., S. 564, 1973, Bibliogr.; G r i m b 1 e A. S. Gonorrhoea, Practitioner, v. 209, p. 614, 1972, bibliogr.; G r i m b 1 e A. Armi-t a g e L. R. G. Surface structures of the gonococcus, Brit. J. vener. Dis., v. 50, p. 354, 1974; KilpatrickZ. M. Gonorrheal proctitis, New Engl. J. Med., v. 287, p. 967, 1972; King A. Nico 1C. Veneral diseases, L., 1975, bibliogr.; Schofield C. B.S. Sexually transmitted diseases, Edinburgh — L., 1975; Ser-sironD. RoironV. Urogenital gonococcal infection in young girls, Brit. J. vener. Dis., v. 43, p. 33, 1967; Swanson J. Studies on gonococcus infection, J. exp. Med., v. 136, p. 1258, 1972, bibliogr.
I. M. Porudominsky, I. I. Ilyin; H. M. Ovchinnikov (lab., etiol.), E. N. Turanova, L. V. Becker (gin., ped.).