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Gonorrhea

By

Sheldon R. Morris

, MD, MPH, University of California San Diego

Last review/revision Jan 2023
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Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent discharge. Dissemination to skin and joints, which is uncommon, causes sores on the skin, fever, and migratory polyarthritis or pauciarticular septic arthritis. Diagnosis is by microscopy, culture, or nucleic acid amplification tests (NAATs). Several oral or injectable antibiotics can be used, but drug resistance is an increasing problem.

N. gonorrhoeae is a gram-negative diplococcus that occurs only in humans and is almost always transmitted by sexual contact. Urethral and cervical infections are most common, but infection in the pharynx or rectum can occur after oral or anal intercourse, and conjunctivitis may follow contamination of the eye.

After an episode of vaginal intercourse, likelihood of transmission from women to men is approximately 22% (1 Reference Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more Reference ), but from men to women, it may be higher.

In 10 to 20% of women, cervical infection ascends via the endometrium to the fallopian tubes (salpingitis) and pelvic peritoneum, causing pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more (PID). Chlamydiae or intestinal bacteria may also cause PID. Gonorrheal cervicitis is commonly accompanied by dysuria or inflammation of Skene ducts and Bartholin glands. In a small fraction of men, ascending urethritis progresses to epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more Epididymitis .

Disseminated gonococcal infection (DGI) due to hematogenous spread occurs in < 1% of cases, predominantly in women. DGI typically affects the skin, tendon sheaths, and joints. Pericarditis, endocarditis, meningitis, and perihepatitis occur rarely.

Reference

  • 1. Holmes KK, Johnson DW, Trostle HJ: An estimate of the risk of men acquiring gonorrhea by sexual contact with infected females. Am J Epidemiol 91(2):170-174, 1970. doi:10.1093/oxfordjournals.aje.a121125

Symptoms and Signs of Gonorrhea

About 10 to 20% of infected women and very few infected men are asymptomatic. About 25% of men have minimal symptoms.

Male urethritis has an incubation period from 2 to 14 days. Onset is usually marked by mild discomfort in the urethra, followed by more severe penile tenderness and pain, dysuria, and a purulent discharge. Urinary frequency and urgency may develop as the infection spreads to the posterior urethra. Examination detects a purulent, yellow-green urethral discharge, and the meatus may be inflamed.

Epididymitis Epididymitis Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Scrotal pain and swelling usually occur unilaterally. Diagnosis is... read more Epididymitis usually causes unilateral scrotal pain, tenderness, and swelling. Rarely, men develop abscesses of Tyson and Littre glands, periurethral abscesses, or infection of Cowper glands, the prostate, or the seminal vesicles.

Cervicitis Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include vaginal discharge, vaginal bleeding, and cervical erythema and friability. Women are tested for infectious... read more Cervicitis usually has an incubation period of > 10 days. Symptoms range from mild to severe and include dysuria and vaginal discharge. During pelvic examination, clinicians may note a mucopurulent or purulent cervical discharge, and the cervical os may be red and bleed easily when touched with the speculum. Urethritis may occur concurrently; pus may be expressed from the urethra when the symphysis pubis is pressed or from Skene ducts or Bartholin glands. Rarely, infections in sexually abused prepubertal girls cause dysuria, purulent vaginal discharge, and vulvar irritation, erythema, and edema.

Pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more occurs in 10 to 20% of infected women. PID may include salpingitis, pelvic peritonitis, and pelvic abscesses and may cause lower abdominal discomfort (typically bilateral), dyspareunia, and marked tenderness on palpation of the abdomen, adnexa, or cervix.

Fitz-Hugh-Curtis syndrome is gonococcal (or chlamydial) perihepatitis that occurs predominantly in women and causes right upper quadrant abdominal pain, fever, nausea, and vomiting, often mimicking biliary or hepatic disease.

Rectal gonorrhea is usually asymptomatic. It occurs predominantly in men practicing receptive anal intercourse and can occur in women who participate in anal sex. Symptoms include rectal itching, a cloudy rectal discharge, bleeding, and constipation—all of varying severity. Examination with a proctoscope may detect erythema or mucopurulent exudate on the rectal wall.

Gonococcal pharyngitis is usually asymptomatic but may cause sore throat. N. gonorrhoeae must be distinguished from N. meningitidis and other closely related organisms that are often present in the throat without causing symptoms or harm.

Disseminated gonococcal infection (DGI), also called the arthritis-dermatitis syndrome, reflects bacteremia and typically manifests with fever, migratory pain or joint swelling (polyarthritis), and pustular skin lesions. In some patients, pain develops and tendons (eg, at the wrist or ankle) redden or swell. Skin lesions occur typically on the arms or legs, have a red base, and are small, slightly painful, and often pustular. Genital gonorrhea, the usual source of disseminated infection, may be asymptomatic. DGI can mimic other disorders that cause fever, skin lesions, and polyarthritis (eg, the prodrome of hepatitis B infection or meningococcemia); some of these other disorders (eg, reactive arthritis Reactive Arthritis Reactive arthritis is an acute spondyloarthropathy that often seems precipitated by an infection, usually genitourinary or gastrointestinal. Common manifestations include asymmetric arthritis... read more Reactive Arthritis ) also cause genital symptoms.

Gonococcal septic arthritis is a more localized form of DGI that results in a painful arthritis with effusion, usually of 1 or 2 large joints such as the knees, ankles, wrists, or elbows. Some patients present with or have a history of skin lesions of DGI. Onset is often acute, usually with fever, severe joint pain, and limitation of movement. Infected joints are swollen, and the overlying skin may be warm and red.

Diagnosis of Gonorrhea

  • Nucleic acid–based testing

  • Gram staining and culture

Gonorrhea is diagnosed when gonococci are detected via microscopic examination using a nucleic acid–based test, Gram stain, or culture of genital fluids, blood, or joint fluids (obtained by needle aspiration).

Nucleic acid amplification tests (NAATs) may be done on genital, rectal, or oral swabs and can detect both gonorrhea and chlamydial infection. NAATs further increase the sensitivity adequately to enable testing of urine samples in both sexes.

Gram stain is sensitive and specific for gonorrhea in men with urethral discharge; gram-negative intracellular diplococci typically are seen. Gram stain is much less accurate for infections of the cervix, pharynx, and rectum and is not recommended for diagnosis at these sites.

Meningococcal urethritis has been found as a cause of nongonococcal urethritis at some STI (sexually transmitted infection) centers in the US (1 Diagnosis reference Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more Diagnosis reference ). Neisseria meningitidis cannot be distinguished from N. gonorrhoeae on Gram stain and has similar colony morphology appearance on culture. The diagnosis of presumed gonococcal urethritis on the basis of Gram stain with gram-negative diplococci but negative NAAT for gonorrhea requires confirmation of the Neisseria species by culture.

Culture is sensitive and specific, but because gonococci are fragile and fastidious, samples taken using a swab need to be rapidly plated on an appropriate medium (eg, modified Thayer-Martin) and transported to the laboratory in a carbon dioxide–containing environment. Blood and joint fluid samples should be sent to the laboratory with notification that gonococcal infection is suspected. Because NAATs have replaced culture in most laboratories, finding a laboratory that can provide culture and sensitivity testing may be difficult and require consultation with a public health or infectious disease specialist.

Men with urethritis

Men with obvious urethral discharge may be treated presumptively if likelihood of follow-up is questionable or if clinic-based diagnostic tools are not available.

Samples for Gram staining can be obtained by touching a swab or slide to the end of the penis to collect discharge. Gram stain does not identify chlamydiae, so urine or swab samples for NAAT are obtained.

Women with cervicitis or pelvic inflammatory disease

A cervical swab should be sent for culture or NAAT. If a pelvic examination is not possible, NAAT of a urine sample or self-collected vaginal swab can detect gonococcal (and chlamydial) infections rapidly and reliably.

Pharyngeal or rectal exposures

Swabs of the affected area are sent for culture or NAAT.

Arthritis, disseminated gonococcal infection (DGI), or both

An affected joint should be aspirated, and fluid should be sent for culture and routine analysis (see arthrocentesis Arthrocentesis Some musculoskeletal disorders affect primarily the joints, causing arthritis. Others affect primarily the bones (eg, fractures, Paget disease of bone, tumors), muscles or other extra-articular... read more ). Patients with skin lesions, systemic symptoms, or both should have blood, urethral, cervical, and rectal cultures or NAAT. In about 30 to 40% of patients with DGI, blood cultures are positive during the first week of illness. With gonococcal arthritis, blood cultures are less often positive, but cultures of joint fluids are usually positive. Joint fluid is usually cloudy to purulent because of large numbers of white blood cells (typically > 20,000/microliter).

Diagnosis reference

  • 1. Bazan JA, Peterson AS, Kirkcaldy RD, et al. Notes from the field. Increase in Neisseria meningitidis–associated urethritis among men at two sentinel clinics — Columbus, Ohio, and Oakland County, Michigan, 2015. MMWR Morb Mortal Wkly Rep 65:550–552, 2016. doi: 10.15585/mmwr.mm6521a5external icon

Screening for Gonorrhea

Asymptomatic patients considered at high risk of sexually transmitted infections (STIs) can be screened by NAAT of urine samples, thus not requiring invasive procedures to collect samples from genital sites. The following are based on CDC's Sexually Transmitted Infections (STI) Treatment Guidelines, 2021.

Women are screened annually if they are sexually active and < 25 years of age or if they are ≥ 25 years of age, sexually active, and have one or more of the following risk factors:

  • Have a history of a prior STI

  • Engage in high-risk sexual behavior (eg, have a new sex partner or multiple sex partners; engage in sex work; have a history of incarceration; or use condoms inconsistently when not in a mutually monogamous relationship)

  • Have a partner who has an STI or engages in high-risk behavior (eg, a sex partner who has concurrent partners)

Pregnant women who are < 25 years or who are ≥ 25 years with one or more of the risk factors are screened during their first prenatal visit and again during their 3rd trimester for women who are < 25 or at high risk.

There is insufficient evidence for screening heterosexual men who are at low risk for infection.

Men who have sex with men are screened at least annually if they have been sexually active within the previous year (for insertive intercourse, urine screen; for receptive intercourse, rectal swab; and for oral intercourse, pharyngeal swab), regardless of condom use. Those at increased risk (eg, with HIV infection, receive preexposure prophylaxis with antiretrovirals, have multiple sex partners, or whose partner has multiple partners) should be screened more frequently, at 3 to 6-month intervals.

Transgender and gender diverse people are screened if they are sexually active on the basis of sexual practices and anatomy (eg, annual screening for all people with a cervix who are < 25 years old; if ≥ 25 years old, people with a cervix should be screened annually if at increased risk; rectal swab based on reported sexual behaviors and exposure).

(See also the US Preventive Services Task Force’s summary of recommendations regarding screening for gonorrhea.)

Treatment of Gonorrhea

  • For uncomplicated infection, a single dose of ceftriaxone

  • Concomitant treatment for chlamydial infection

  • Treatment of sex partners

  • For disseminated gonococcal infection (DGI) with arthritis, a longer course of parenteral antibiotics

Uncomplicated gonococcal infection of the urethra, cervix, rectum, and pharynx is treated with the following:

  • A single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥ 150 kg)

If ceftriaxone is not available, use cefixime 800 mg orally in a single dose.

If chlamydial infection has not been excluded, treat for chlamydia with doxycycline 100 mg orally twice a day for 7 days. In patients who have a doxycycline allergy, treat for chlamydia with a single dose of azithromycin 1 g orally.

Patients who are allergic to cephalosporins (including ceftriaxone) are treated with

  • Gentamicin 240 mg IM in a single dose plus azithromycin 2 g orally in a single dose

DGI with gonococcal arthritis is initially treated with IM or IV antibiotics (eg, ceftriaxone 1 g IM or IV every 24 hours, ceftizoxime 1 g IV every 8 hours, cefotaxime 1 g IV every 8 hours) continued for 24 to 48 hours once symptoms lessen, followed by oral therapy guided by antimicrobial susceptibility testing, for a total treatment course of at least 7 days. If chlamydial infection has not been excluded, add doxycycline 100 mg orally twice a day for 7 days (1 Treatment reference Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more Treatment reference ).

Gonococcal purulent arthritis usually requires repeated synovial fluid drainage either with repeated arthrocentesis or arthroscopically. Initially, the joint is immobilized in a functional position. Passive range-of-motion exercises should be started as soon as patients can tolerate them. Once pain subsides, more active exercises, with stretching and muscle strengthening, should begin. Over 95% of patients treated for gonococcal arthritis recover complete joint function. Because sterile joint fluid accumulations (effusions) may develop and persist for prolonged periods, an anti-inflammatory drug may be beneficial.

Posttreatment cultures are unnecessary if symptomatic response is adequate. However, for patients with symptoms for > 7 days, specimens should be obtained, cultured, and tested for antimicrobial sensitivity.

Patients 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 the patient within 60 days should be tested for gonorrhea and other STIs and treated if results are positive. Sex partners with contact within 2 weeks should be treated presumptively for gonorrhea (epidemiologic treatment).

Expedited partner therapy (EPT) involves giving patients a prescription or medications to deliver to their partner. EPT may enhance partner adherence and reduce treatment failure due to reinfection. It may be most appropriate for partners of women with gonorrhea or chlamydial infection. However, a health care visit is preferable to ascertain histories of medication allergies and to screen for other STIs (1 Treatment reference Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more Treatment reference ).

Treatment reference

Key Points

  • Neisseria gonorrhoeae infection typically causes uncomplicated infection of the urethra, cervix, rectum, pharynx, and/or conjunctivae.

  • Sometimes gonorrhea spreads to the adnexa, causing salpingitis, or disseminates to skin and/or joints, causing skin lesions or septic arthritis.

  • Diagnose using NAAT, but culture and sensitivity testing should be done when needed to detect antimicrobial resistance.

  • Screen high-risk patients using NAAT.

  • Treat uncomplicated infection with a single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥ 150 kg); add oral doxycycline (100 mg twice a day for 7 days) when chlamydial infection has not been excluded.

More Information

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

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