Merck Manual

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Sheldon R. Morris

, MD, MPH, University of California San Diego

Full review/revision Jan 2021 | Modified Sep 2022
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Gonorrhea is a sexually transmitted infection 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, but resistance to the antibiotics used to treat gonorrhea is becoming more common.

Gonorrhea is a very common infectious disease. The Centers for Disease Control and Prevention (CDC) estimates that about 1.14 million new infections occur in the United States each year. In 2018, 583,405 cases of gonorrhea were reported to the CDC.

Gonorrhea is almost always spread through vaginal, oral, or anal sexual contact. After one episode of vaginal intercourse without a condom, the chance of spread from an infected woman to a man is about 20%. The chance of spread from an infected man to a woman and from a man to a man may be higher.

If pregnant women are infected, the bacteria can spread to the eyes of the fetus during birth, causing conjunctivitis in the newborn Conjunctivitis in Newborns Conjunctivitis is inflammation of the conjunctiva, the membrane that lines the eyelid and covers the white of the eye. Conjunctivitis is caused by bacteria, viruses, or a reaction to chemicals... read more Conjunctivitis in Newborns . However, in most developed countries, infection is prevented because all newborns are routinely treated after delivery with medicated eye ointment.

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 of Gonorrhea

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

Some men (about 25%) have minimal symptoms. Symptoms begin within about 2 to 14 days after infection. Men feel mild discomfort in the urethra (the tube that carries urine from the bladder out of the body). This discomfort is 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, gonorrhea 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.

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. It occurs mainly in women.

Anal sex with an infected partner may result in gonorrhea of the rectum. This infection usually causes no symptoms, but it may make 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, but the throat may be sore.

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.

In children, gonorrhea 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, disseminated gonococcal infection (arthritis-dermatitis syndrome) develops. It occurs when 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. People typically 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. Joint, bloodstream, and heart infections can be treated, but recovery from arthritis may be slow.

Gonococcal septic arthritis is a form of disseminated gonococcal infection that causes painful arthritis. Usually, it affects one or two large joints, such as the knees, ankles, wrists, or elbows, Symptoms often begin suddenly. People usually have a fever. Infected joints are painful and swollen, and movement is limited. The skin over the infected joints may be warm and red.

Diagnosis of Gonorrhea

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

In more than 95% of infected men with a discharge, gonorrhea may be diagnosed within an hour by identifying the bacteria (gonococci) in samples of the discharge examined under a microscope. If a discharge is obvious, doctors touch a swab or slide to the end of the penis to collect the sample. If there is no obvious discharge, doctors insert a small swab a half inch or more into the urethra to collect a sample. Men are asked to refrain from urinating for at least 2 hours before the sample is collected.

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 (from the urethra or cervix) is also sent to a laboratory for culture (to grow the organisms) and for other 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 chlamydiae (which are often also present). Laboratories can test for both infections in a single sample. For some of these tests (called nucleic acid amplification tests, or NAATS), techniques that increase the amount of the bacteria's genetic material are used. Because these techniques make the organisms easier to detect, 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 samples of fluid taken from their genitals.

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

Screening for gonorrhea

Certain people who have no symptoms are screened for gonorrhea because they have characteristics that increase their risk of this infection.

For example, women who are not pregnant are screened if they

  • Are age 24 or younger and are sexually active

  • Have had a previous STI

  • 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 routinely screened unless they are considered at high risk of infection—for example, when they have several sex partners, are patients at an adolescent or STI clinic, or are admitted into a correctional facility.

Men who have sex with men are screened only if they have been sexually active within the last year. Those with HIV infection Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection is a viral infection that progressively destroys certain white blood cells and can cause acquired immunodeficiency syndrome (AIDS). HIV is transmitted... read more Human Immunodeficiency Virus (HIV) Infection , multiple sex partners, or whose partner has multiple partners are screened more frequently.

Prevention of Gonorrhea

The following general measures can help prevent gonorrhea (and other STIs):

Not having sex (anal, vaginal, or oral) is the most reliable way to prevent STIs but is often unrealistic.

Treatment of Gonorrhea

  • The antibiotics ceftriaxone plus azithromycin

  • Testing and treatment of sex partners

Doctors usually give people with gonorrhea a single injection of the antibiotic ceftriaxone into a muscle, plus a single dose of azithromycin by mouth. Although ceftriaxone cures most people in the United States, azithromycin is given with ceftriaxone because this drug may help keep gonococci from becoming resistant to treatment. Also, azithromycin kills chlamydiae, which are often present in people with gonorrhea.

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 determine whether people are cured and may 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.

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 STIs and, if the tests are positive, should be treated. If sex partners were exposed to gonorrhea within the past 2 weeks, they are treated for it without waiting for test results.

Expedited partner therapy is an option doctors sometimes use to make it easier for sex partners to be treated. This approach involves giving people with gonorrhea a prescription or drugs to give to their partner. Thus, the sex partner does not need to see a doctor before being treated. Seeing a doctor is better because then the doctor can check for drug allergies and the presence of other STIs. However, if the partner is unlikely to see a doctor, expedited partner therapy is useful.

More Information about Gonorrhea

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Ceftrisol Plus, Rocephin
Azasite, Zithromax, Zithromax Powder, Zithromax Single-Dose , Zithromax Tri-Pak, Zithromax Z-Pak, Zmax, Zmax Pediatric
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