Gonorrhea is a sexually transmitted bacterial infection with a predilection for columnar and transitional epithelial cells. It commonly manifests as urethritis, cervicitis, or salpingitis. Infection may be asymptomatic. It differs between males and females in course, severity, and ease of recognition.

Gonococcal urethritis

Gonococcal vulvovaginitis

Gonococcal cervicitis

Gonococcal bartholinitis

GC

• The disease is common worldwide, affects both sexes and all ages, especially younger adults; highest incidence is in inner-city areas. Per CDC reports, approximately 1.6 million new cases were found in the U.S. in 2018, with more than half found in young people ages 15 to 24 yr. Gonorrhea is the second most-commonly reported communicable disease.
• Asymptomatic anterior urethral carriage may occur in 12% to 50% of cases in men.
• Asymptomatic in 50% to 80% of cases in women. Most common dissemination is by mucosal passage to fallopian tubes, resulting in pelvic inflammatory disease (PID) in 10% to 15% of infected women. Hematogenous spread may result in septic arthritis and skin lesions. Conjunctivitis rarely occurs but may result in blindness if not rapidly treated. Infection can occur in both men and women in oropharynx and anorectally.
• The World Health Organization (WHO) reported 78 million new cases of gonorrhea worldwide among adults in 2012.

• Males: Purulent discharge from anterior urethra (Fig. E1), with dysuria appearing 2 to 7 days after infecting exposure. May have rectal infection causing pruritus, tenesmus, and discharge, or may be asymptomatic.
• Females: Initial urethritis or cervicitis may occur a few days after exposure, frequently mild. Infections may be asymptomatic or may not produce recognizable symptoms until complications have occurred. In approximately 20% of cases, uterine invasion occurs after menstrual period with signs and symptoms of endometritis, salpingitis, or pelvic peritonitis. The patient may have purulent discharge or inflamed Skene or Bartholin glands.
• Classic presentation of acute gonococcal PID is fever, abdominal and adnexal tenderness, and, often, absence of purulent discharge. Physical examination may be normal if asymptomatic. Disseminated gonococcal infection (DGI) may manifest with petechial or pustular acral skin lesions (Fig. E2), asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic arthritis. The infection is occasionally complicated by perihepatitis and, rarely, endocarditis or meningitis.

• Neisseria gonorrhoeae is also known as gonococcus. Plasmids coding for β-lactamase render some strains resistant to penicillin or tetracycline. There is an increasing frequency of chromosomally mediated resistance to penicillin, tetracycline, fluoroquinolones, and cefoxitin. In the Far East, high-level resistance to spectinomycin is endemic.
• There are a rising number of cases of quinolone-resistant N. gonorrhoeae worldwide, with the expected number to rise in the U.S. from importation.
• Men who have sex with men are vulnerable to the emerging threat of antimicrobial-resistant N. gonorrhoeae.

• Nongonococcal urethritis (NGU)
• Nongonococcal mucopurulent cervicitis
• Chlamydia trachomatis
• Trichomonas vaginalis

Diagnosis depends on bacteriologic investigation. Culture and nucleic acid amplification tests (NAAT) are available for the detection of genitourinary infection with N. gonorrhoeae.

• NAATs are preferred testing modalities for the detection of genitourinary infection with N. gonorrhoeae. The performance of NAATs with respect to overall sensitivity, specificity, and ease of specimen transport is better than that of any other tests available for the diagnosis of gonococcal infections. NAATs should be used to detect gonorrhea except in cases of child sexual assault involving boys and rectal and oropharyngeal infections in prepubescent girls. When evaluating a potential gonorrhea treatment failure, case culture and susceptibility testing might be required. NAATs allow testing of the widest variety of specimen types, including endocervical swabs, vaginal swabs, urethral swabs (men), and urine (from both men and women).
• Culture: Gonorrhea culture on Thayer-Martin medium (organism is fastidious; requires aerobic conditions with increased carbon dioxide atmosphere; incubate ASAP). Culture has a sensitivity of 95% or more for urethral specimens from men with symptomatic urethritis and 80% to 90% for endocervical infection in women. Gram-negative intracellular diplococci are diagnostic in male urethral smears (Fig. E3). There is a false-negative rate of 60% to 70% in female cervical or urethral smears.
  1. Concomitant serologic testing for syphilis for all patients
  2. Concomitant Chlamydia testing for all patients
  3. Offer of HIV testing and counseling to all patients

• First-catch urine (or genital swab) sample NAAT is the preferred screening and diagnostic test for gonorrhea. These tests have largely replaced collecting culture in many settings where persons are screened for asymptomatic genital infection. These tests are not more sensitive than culture for detecting N. gonorrhoeae in cervical or urethral specimen; however, they have specificities >99% and retain sensitivity when used to test voided urine or self-collected vaginal swabs.
• Gonorrhea culture on Thayer-Martin medium (organism is fastidious; requires aerobic conditions with increased carbon dioxide atmosphere; incubate ASAP). Culture has a sensitivity of 95% or more for urethral specimens from men with symptomatic urethritis and 80% to 90% for endocervical infection in women.
• Nonamplified DNA probe tests are less sensitive than culture or NAATs and are not useful in the diagnosis of rectal or pharyngeal infection or for testing urine; however, they are inexpensive, readily available, and offered in many laboratories in combination assays for C. trachomatis.
• Concomitant serologic testing for syphilis on all patients.
• Concomitant Chlamydia testing on all patients.
• Offer of HIV testing and counseling to all patients.

For treatment of uncomplicated urogenital, rectal, or pharyngeal gonorrhea, the CDC recommends a single 500-mg IM dose of ceftriaxone. For persons weighing ≥150 kg (300 lbs), a single 1-g IM dose of ceftriaxone should be administered. If chlamydial infection has not been excluded, doxycycline 100 mg orally twice a day for 7 days is recommended. When ceftriaxone cannot be used for treating urogenital or rectal gonorrhea because of cephalosporin allergy, a single 240-mg IM dose of gentamicin, plus a single 2-g oral dose of azithromycin is an option. Gastrointestinal symptoms, primarily vomiting within 1 hr of dosing, have been reported among 3% to 4% of treated persons. If administration of IM ceftriaxone is not available, a single 800-mg oral dose of cefixime is an alternative regimen. However, cefixime does not provide as high or sustained bactericidal blood levels as does ceftriaxone, and demonstrates limited treatment efficacy for pharyngeal gonorrhea.

When gonococcal expedited partner therapy (provision of prescriptions or medications for the patient to give to a sex partner without the health care provider first examining the partner) is permissible by state law and the partner is unable or unlikely to seek timely treatment, the partner may be treated with a single 800-mg oral dose of cefixime, provided that concurrent chlamydial infection in the patient has been excluded. Otherwise, the partner may be treated with a single 800-mg oral dose of cefixime plus oral doxycycline 100 mg twice daily for 7 days.

In cases of suspected cephalosporin treatment failure, clinicians should obtain relevant clinical specimens for culture and antimicrobial susceptibility testing, consult an infectious disease specialist or STD clinical expert (https://www.stdccn.org/external icon) for guidance in clinical management, and report the case to the CDC through state and local public health authorities within 24 hr. Health departments should prioritize notification and culture evaluation for the patient’s sex partner(s) from the preceding 60 days for those with suspected cephalosporin treatment failure or persons whose gonococcal isolates demonstrate reduced susceptibility to cephalosporins.

A test-of-cure is unnecessary for persons with uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, for persons with pharyngeal gonorrhea, a test-of-cure is recommended, using culture or nucleic acid amplification tests 7 to 14 days after initial treatment, regardless of the treatment regimen. Because reinfection within 12 mo ranges from 7% to 12% among persons previously treated for gonorrhea, those who have been treated should be retested 3 mo after treatment, regardless of whether they believe their sex partners were treated. If retesting at 3 mo is not possible, clinicians should retest within 12 mo after initial treatment.

Treatment of arthritis and arthritis-dermatitis syndrome:

• Recommended regimen: Ceftriaxone 1 g IM or IV every 24 hr plus azithromycin 1 g orally as a single dose
• Alternative regimens: Cefotaxime 1 g IV every 8 hr or ceftizoxime 1 g IV every 8 hr plus azithromycin 1 g orally in a single dose

• Pregnant women infected with N. gonorrhoeae in whom chlamydia has been excluded should be treated with ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lbs) or 1 g of IM ceftriaxone for persons weighing ≥150 kg (300 lbs). If chlamydia has not been excluded, these patients should also receive azithromycin 1 g PO as a single dose. When cephalosporin allergy or other considerations preclude treatment and spectinomycin is not available, consultation with an ID specialist is recommended.

• All sexual partners should be identified, examined, tested, and receive presumptive treatment.
• Patients should be counseled to avoid unprotected intercourse with partners for 1 wk after all partners have completed treatment.
• Men or women who have been treated for gonorrhea should be retested in 3 mo because of risk of reinfection. If they are unable to be retested in 3 mo, then they should be retested when they next present to care within 12 mo of their care.

PID requiring hospitalization, disseminated gonococcal infection

• This is a reportable disease.
• The proportion of gonorrhea cases in heterosexual men who are fluoroquinolone resistant (QRNG) has reached 6.7%, an elevenfold increase from 0.6% in 2001. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the U.S.
• The use of azithromycin as the second antimicrobial is preferred over doxycycline in areas of high prevalence of tetracycline resistance.
• The U.S. Preventive Services Task Force (USPSTF) recommends screening for gonorrhea in sexually active females younger than 25 yr and in women 25 and over who are at increased risk for infection (multiple partners, new partner, partner who has concurrent partners). The USPSTF also concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gonorrhea in men.
• High-intensity counseling on sexual risk reduction has been shown to reduce sexually transmitted infections (STIs) in primary care and related settings.

Gonorrhea (Patient Information)

Cervicitis (Related Key Topic)

Chlamydia Genital Infections (Related Key Topic)

Pelvic Inflammatory Disease (Related Key Topic)

Urethritis, gonococcal (Related Key Topic)