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Gonorrhea

by J. Allen McCutchan, MD, MSc

Gonorrhea is a sexually transmitted disease caused by the bacteria Neisseria gonorrhoeae, which infect the lining of the urethra, cervix, rectum, and throat or the membranes that cover the front part of the eye (conjunctiva and cornea).

  • Gonorrhea is usually spread through sexual contact.

  • People usually have a discharge from the penis or vagina and may need to urinate more frequently and urgently.

  • Rarely, gonorrhea infects the joints, skin, or heart.

  • Microscopic examination, culture, or DNA tests of a sample of the discharge or DNA tests of urine can detect the infection.

  • Antibiotics can cure the infection.

In the United States, the number of gonorrhea cases reported each year has decreased since it peaked at nearly 900,000 in 1985. However, the number appears to have leveled off for about the last 10 years, with about 334,000 cases reported in 2012.

Gonorrhea is almost always spread through sexual contact. After one episode of vaginal intercourse with an infected person, the chance of spread from women to men is about 20%. The chance of spread from men to women may be higher.

If pregnant women are infected, the bacteria can spread to the eyes of the fetus during birth. However, in most developed countries, infection is prevented because all newborns are routinely treated after delivery with medicated eye ointment.

Many people with gonorrhea have other sexually transmitted diseases (STDs), such as chlamydial infection, syphilis, or human immunodeficiency virus (HIV) infection.

Did You Know...

  • If pregnant women have gonorrhea, the eyes of the fetus may become infected during birth, so newborns are routinely treated to prevent this infection.

Symptoms

Usually, gonorrhea causes symptoms only at the sites of initial infection. In some people, infection spreads through the bloodstream to other parts of the body, especially to the skin, joints, or both.

In men , symptoms begin within about 2 to 14 days after infection. Men feel mild discomfort in the urethra, followed a few hours later by mild to severe pain during urination, a yellow-green discharge of pus from the penis, and a frequent urge to urinate. The opening at the tip of the penis may become red and swollen. The bacteria sometimes spread to the epididymis (the coiled tube on top of each testis), causing the scrotum to swell and feel tender to the touch.

Some women (about 10 to 20%) have minimal or no symptoms. Thus, the infection may be detected only during routine screening or after diagnosis of the infection in their male partner. Symptoms typically do not begin until at least 10 days after infection. Some women feel only mild discomfort in the genital area and have a puslike discharge from the vagina. However, other women have more severe symptoms, such as a frequent urge to urinate and pain during urination. These symptoms develop when the urethra is also infected.

Bacteria commonly spread up the genital tract and infect the tubes that connect the ovaries to the uterus (fallopian tubes). This infection, called salpingitis, causes severe lower abdominal pain, especially during intercourse. In some women, the infection spreads to the lining of the abdominal cavity (peritoneum), causing peritonitis or pelvic inflammatory disease (see Pelvic Inflammatory Disease (PID)), which may cause severe pain in the lower abdomen. Women who have had pelvic inflammatory disease have an increased risk of infertility and mislocated (ectopic) pregnancies (see Ectopic Pregnancy), which can cause dangerous internal bleeding.

Occasionally, infection in the abdomen concentrates around the liver. This infection, called perihepatitis or Fitz-Hugh-Curtis syndrome, causes pain in the upper right part of the abdomen.

Anal sex with an infected partner may result in gonorrhea of the rectum, which makes bowel movements painful. Other symptoms include constipation, itching, bleeding, and a discharge from the rectum. The area around the anus may become red and raw, and stool may be coated with mucus and pus. When a doctor examines the rectum with a viewing tube (anoscope), mucus and pus may be visible on the wall of the rectum.

Oral sex with an infected partner may result in gonorrhea of the throat (gonococcal pharyngitis). Usually, these infections cause no symptoms.

If infected fluids come into contact with the eyes, gonococcal conjunctivitis may develop, causing swelling of the eyelids and a discharge of pus from the eyes. In adults, often only one eye is infected. Newborns usually have infection in both eyes. Blindness may result if the infection is not treated early.

Gonorrhea in children usually results from sexual abuse. In girls, the genital area (vulva) may be irritated, red, and swollen, and they may have a discharge from the vagina. If the urethra is infected, children, mainly boys, may have pain during urination.

Rarely, the infection spreads through the bloodstream to other parts of the body, especially the skin and joints. Joints become swollen, tender, and extremely painful, limiting movement. The skin over infected joints may be red and warm. If the bloodstream is infected, people may have a fever, feel generally ill, and develop arthritis in one or more joints. Small, red spots may appear on the skin, usually on the arms and legs. The spots are slightly painful and may be filled with pus. This infection is called disseminated gonococcal infection or arthritis-dermatitis syndrome. Joint, bloodstream, and heart infections can be treated, but recovery from arthritis may be slow.

Diagnosis

  • Examination of the discharge under a microscope or in a laboratory

In more than 90% of infected men, gonorrhea may be diagnosed within an hour by identifying the bacteria (gonococci) in samples of the discharge examined under a microscope. The sample is usually obtained by inserting a small swab a few centimeters into the urethra. However, identifying bacteria in a sample of discharge from the cervix is more difficult. The bacteria can be seen in only about half of infected women.

The sample of discharge is also sent to a laboratory for tests. Such tests are very reliable in both sexes but take longer than a microscopic examination. If a doctor suspects an infection of the throat, rectum, or bloodstream, samples from these areas are sent for testing in a laboratory.

Highly sensitive tests can be done to detect the DNA of gonococci and of chlamydia (which are often also present). Laboratories can test for both infections in a single specimen. For some of these tests, urine samples can be used. Thus, these tests are convenient for screening men and women who have no symptoms or who are unwilling to have fluid samples taken from their genitals.

Because many people have more than one STD, doctors may test samples of blood and genital fluids for other STDs, such as syphilis and HIV infection.

If a joint is red and swollen, doctors draw fluid from the joint using a needle. The fluid is sent for culture (to grow the organisms) and other tests.

Screening

Certain people who have no symptoms are screened for gonorrhea. For example, women who are not pregnant are screened if they

  • Are age 24 or younger and are sexually active

  • Have had a previous STD

  • Participate in risky sexual activities (such as having many sex partners, not using condoms regularly, or engaging in sex work)

  • Have a sex partner who participates in risky sexual activities

Pregnant women are screened at their first prenatal visit and, if they have risk factors for infection, again during the 3rd trimester.

Heterosexual men are not screened. Men who have sex with men are screened only if they have been sexually active within the last year.

Treatment

  • The antibiotic ceftriaxone plus either azithromycin or doxycycline

  • Testing and treatment of sex partners

Doctors give a single injection of the cephalosporin antibiotic ceftriaxone into a muscle, plus either a single dose of azithromycin or a 1-week course of doxycycline by mouth. Although ceftriaxone cures most people in the United States, azithromycin or doxycycline is given with ceftriaxone because theses drugs may help keep gonococci from becoming resistant to treatment. These drugs also kill chlamydiae, which are often also present in people with gonorrhea. Some antibiotics (such as penicillin, ciprofloxacin, levofloxacin, ofloxacin, and cefixime) are no longer used because some strains of gonococci have developed resistance to them.

If gonorrhea has spread through the bloodstream, people are usually treated in the hospital and given antibiotics intravenously or by injection into a muscle.

If symptoms recur or persist after treatment, doctors may take samples for culture to make sure people are cured and do tests to determine whether the gonococci are resistant to the antibiotics used.

People with gonorrhea should abstain from sexual activity until treatment is completed to avoid infecting sex partners. All sex partners who have had sexual contact with infected people in the past 60 days should be tested for gonorrhea and other STDs and, if the tests are positive, should be treated. People who were exposed to gonorrhea within 2 weeks are treated for it without waiting for test results.

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  • IQUIX, LEVAQUIN, QUIXIN
  • FLOXIN OTIC
  • CILOXAN, CIPRO
  • ZITHROMAX
  • PERIOSTAT, VIBRAMYCIN
  • ROCEPHIN
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