The symptoms of acute gonorrhea of the vulva may appear from 1 day to several days after contact, are often mild or transitory, and may be overlooked. The patient may experience burning on urination, urinary frequency, leukorrhea, and itching in the vestibule. Occasionally, however, the ﬁrst suggestive manifestation of disease is not apparent until the following menses or shortly thereafter, when the ascending infection has resulted in an acute salpingitis. Examination of the external genitalia may reveal a congested vestibule bathed in pus and an inﬂammation of the urethra and Skene and Bartholin ducts. The acute infection ascends via the mucosa and epithelium of the urogenital tract and may give rise to an endometritis, peritonitis (pelvic inﬂammatory disease), and tuboovarian abscess. By lymphatic absorption and hematogenous spread, it may result in septicemia, endocarditis, arthritis and tenosynovitis. Although if untreated, gonorrheal infection may, at times, be uncomplicated and self-limited, the tendency for establishment of deep-seated chronic foci is strong. These occur particularly within compound tubular glands and structures lined by columnar epithelium, such as the periurethral and Bartholin glands and the endocervix.
In acute urethritis, the mucosa of the external urethral meatus is reddened and edematous. On gentle stripping of the urethra, a few drops of thick yellow pus escape. The inﬂammatory reaction results in urinary frequency, urgency, and dysuria.
Acute skenitis is evident in the swollen, slightly raised, injected ostia of Skene ducts, which expel pus when milked. The ducts may harbor gonorrheal organisms over long periods of time. Thickened ducts and conspicuous oriﬁces from which beads of pus can be expressed suggest a chronic infection.
In acute bartholinitis, the openings of the Bartholin ducts, normally inconspicuous, become more apparent because of the surrounding inﬂammation. On palpation, the Bartholin gland may be enlarged and tender. The infection can progress rapidly, resulting in an extremely painful swelling of the lower half of the labia. Eventually, a tender, red ﬂuctuant abscess may develop, with taut, congested overlying skin, edema of the labia, and regional lymphadenopathy. This abscess may persist or may lead to a chronic infection, evidenced by enlargement of the gland, recurrent abscesses, and cyst formation.
Chronic urethritis may be manifested by a palpable induration of the posterior urethral wall mainly due to a persistence of infection within the shallow posterior urethral glands, seen endoscopically as small granular areas on the urethral ﬂoor. The only symptom may be a burning sensation on urination.
In vulvovaginitis of childhood gonorrhea, the vagina and the vestibule of the vulva are inﬂamed and edematous and are covered by a creamy, yellow-green discharge. The profuse leukorrhea results in secondary irritation of the labia and perineum. The adult vaginal mucosa, by virtue of its thickness and acidic environment, is more resistant to the gonococcus, but in child-hood and after menopause the vagina is far more susceptible to infection because of its thin epithelial layer and its alkaline environment.
Culture on Thayer-Martin agar plates kept in a CO2- rich environment may be used to document the infection. Cervical cultures provide 80% to 95% diagnostic sensitivity. Cultures should also be obtained from the urethra and anus, although these additional cultures do not signiﬁcantly increase the sensitivity of testing. A Gram stain of any cervical discharge for the presence of gram-negative intracellular diplococcus supports the presumptive diagnosis but does not establish it (sensitivity 50% to 70%, speciﬁcity 97%). A solid-phase enzyme immunoassay may also be used. Even when the diagnosis is established by other methods, all cases of gonorrhea should have cultures obtained to assess antibiotic susceptibility, although therapy should not be delayed pending the results.