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 Centers for Disease Control and Prevention (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. 1.Concomitant serologic testing for syphilis for all patients
  2. 2.Concomitant Chlamydia testing for all patients
  3. 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 intramuscular (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. GI symptoms, primarily vomiting within 1 h 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) for guidance in clinical management, and report the case to the CDC through state and local public health authorities within 24 h. 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 intravenous (IV) every 24 h plus azithromycin 1 g orally as a single dose
• •Alternative regimens: Cefotaxime 1 g IV every 8 h or ceftizoxime 1 g IV every 8 h plus azithromycin 1 g orally in a single dose

• •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.
• •Doxycycline PEP has demonstrated benefit in reducing incident syphilis, chlamydia, and gonorrhea in certain populations and represents a new approach to addressing STI prevention in MSM and TGW at increased risk for these infections. The CDC recommends that providers should counsel gay, bisexual, and other MSM and TGW with a history of at least one bacterial STI (specifically syphilis, chlamydia, or gonorrhea) during the past 12 mo about the benefits and harms of using doxy PEP (Table 2). Although the pharmacokinetics of doxycycline and experience in treating bacterial STIs suggest that doxy PEP should be effective in some populations, clinical data to support doxy PEP in other populations (i.e., cisgender women, cisgender heterosexual men, transgender men, and other queer and nonbinary persons assigned female at birth) are limited. As a result, providers should use their clinical judgement and shared decision-making to inform use of doxycycline PEP with populations that are not part of CDC recommendations. If doxy PEP is prescribed, the provider should write the prescription for self-administration of the recommended dose of 200 mg of doxycycline (any formulation) to be taken as soon as possible within 72 h after having oral, vaginal, or anal sex with a maximum dose of 200 mg every 24 h. The prescription should account for enough doses on the basis of the person’s anticipated sexual activity until their next visit. Ongoing need for doxycycline PEP should be assessed every 3 to 6 mo. Doxy PEP, when offered, should be implemented in the context of a comprehensive sexual health approach (Box 1), including risk reduction counseling, STI screening and treatment, recommended vaccination and linkage to HIV PrEP, HIV care, and other services as appropriate. Persons who are prescribed doxy PEP should undergo bacterial STI testing at anatomic sites of exposure at baseline and every 3 to 6 mo thereafter.

• Gonorrhea (Patient Information)
• Cervicitis (Related Key Topic)
• Chlamydia Genital Infections (Related Key Topic)
• Pelvic Inflammatory Disease (Related Key Topic)
• Urethritis, Gonococcal (Related Key Topic)