Gonorrhea is caused by the bacteria 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. Several oral or injectable antibiotics can be used, but drug resistance is an increasing problem.
(See also Overview of Sexually Transmitted Diseases.)
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 about 20%, but from men to women, it may be higher.
Neonates can acquire conjunctival infection during passage through the birth canal, and children may acquire gonorrhea as a result of sexual abuse.
In 10 to 20% of women, cervical infection ascends via the endometrium to the fallopian tubes (salpingitis) and pelvic peritoneum, causing pelvic inflammatory disease (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.
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.
Coinfection with Chlamydia trachomatis occurs in 15 to 25% of infected heterosexual men and 35 to 50% of women.
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 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 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 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) 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
- Gram staining and culture
- Nucleic acid–based testing
Gonorrhea is diagnosed when gonococci are detected via microscopic examination using Gram stain, culture, or a nucleic acid–based test of genital fluids, blood, or joint fluids (obtained by needle aspiration).
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.
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 nucleic acid amplification tests 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.
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.
In the US, confirmed cases of gonorrhea, chlamydial infection, and syphilis must be reported to the public health system. Serologic tests for syphilis (STS) and HIV and NAAT to screen for chlamydial infection should also be done.
Men with urethritis
Men with obvious 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 genital symptoms or signs
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 (either sex)
Swabs of the affected area are sent for culture or NAAT.
Arthritis, DGI, or both
An affected joint should be aspirated, and fluid should be sent for culture and routine analysis (see arthrocentesis). 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).
Asymptomatic patients considered at high risk of sexually transmitted diseases (STDs) can be screened by NAAT of urine samples, thus not requiring invasive procedures to collect samples from genital sites.
Nonpregnant women (including women who have sex with women) are screened annually if they
- Are sexually active and ≤ 24 years
- Have a history of a prior STD
- Engage in high-risk sexual behavior (eg, have a new sex partner or multiple sex partners, engage in sex work, use condoms inconsistently)
- Have a partner who engages in high-risk behavior
Pregnant women are screened during their initial prenatal visit and again during the 3rd trimester if they are ≤ 24 years or have risk factors.
Heterosexually active men are not routinely screened unless they are considered at high risk (eg, those with multiple sex partners, patients at adolescent or STD clinics, men entering correctional facilities).
Men who have sex with men are screened 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). Those with HIV infection, multiple sex partners, or whose partner has multiple partners should be screened more frequently, at 3- to 6-month intervals.
(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 plus azithromycin
- For DGI with arthritis, a longer course of parenteral antibiotics
- Concomitant treatment for chlamydial infection
- Treatment of sex partners
Uncomplicated gonococcal infection of the urethra, cervix, rectum, and pharynx is treated with the following:
- Preferred: A single dose of ceftriaxone 250 mg IM plus azithromycin 1 g orally
- Alternative: A single dose of cefixime 400 mg orally plus azithromycin 1 g orally
Patients who are allergic to cephalosporins are treated with one of the following:
- Gemifloxacin 320 mg orally plus azithromycin 2 g orally once
- Gentamicin 240 mg IM plus azithromycin 2 g orally once
Monotherapy and previous oral regimens of fluoroquinolones (eg, ciprofloxacin, levofloxacin, ofloxacin) or cefixime are no longer recommended because of increasing drug resistance. Test of cure is recommended only for patients treated with an alternative regimen for pharyngeal infections.
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. A single dose of azithromycin 1 g is also always given for adjunctive therapy for the gonococcal infection and for possible co-infection with C. trachomatis (1).
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.
Pearls & Pitfalls
All sex partners who have had sexual contact with the patient within 60 days should be tested for gonorrhea and other STDs 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 drugs 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 drug allergies and to screen for other STDs.
- 1. Centers for Disease Control and Prevention: 2015 Sexually Transmitted Diseases Treatment Guidelines: Gonococcal Infections: A source of clinical guidance emphasizing treatment of STDs and discussing prevention strategies and diagnostic recommendations
- Gonorrhea 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 asymptomatic, high-risk patients using NAAT.
- Treat uncomplicated infection with a single dose of ceftriaxone 250 mg IM plus azithromycin 1 g orally once.
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
- US Preventive Services Task Force: Chlamydia and Gonorrhea: Screening: A review of evidence that screening tests can accurately detect chlamydia and gonorrhea
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