Gonorrhea

INTRODUCTION — Gonorrhea is a sexually transmitted infection that can affect both men and women. Approximately 700,000 people are infected with gonorrhea every year in the United States, although only about half of those people are tested and receive treatment. Gonorrhea has potentially serious consequences, particularly in women and newborns of infected mothers.

CAUSES — Gonorrhea is caused by a bacterium known as Neisseria gonorrhoeae. It is too tiny to be seen by the naked eye. Gonorrhea is usually spread from one person to another during sexual intercourse; it is not transmitted via inanimate objects, like toilet seats.

A person can become infected when the bacteria invades mucous membranes of the mouth, throat, anus, urethra (where urine exits), and vagina. Ejaculation is not necessary to spread the infection. Risk factors for infection include a new sexual partner or multiple sexual partners, and a previous history of gonorrhea.

SYMPTOMS — Symptoms of gonorrhea depend upon a person's gender and the area that is infected. However, some people have no symptoms at all. This potentially allows the disease to be spread from person to person before it is detected.

Both men and women can develop infection of the urethra (where urine exits), throat, and rectum. In women, infection can also occur in the cervix, uterus, fallopian tubes, and ovaries (show figure 1). Infection in men can affect the prostate and the epididymis (show figure 2). In both men and women, the infection can affect several areas at once.

Women — In women, the most common site of infection is the cervix. Cervical infection causes no symptoms in about 50 percent of cases. If symptoms do occur, a woman may notice vaginal itching, abnormal vaginal discharge, or vaginal bleeding between menstrual periods. Infection of the urethra can cause burning during urination.

The anus and rectum can also become infected, which causes no symptoms in most cases. When present, symptoms include anal itching, rectal discharge, rectal fullness, and painful defecation. Even women who do not engage in rectal intercourse can become infected in this area due to contact with vaginal secretions.

Rarely, a woman's Bartholin's glands and Skene's glands can become infected (show figure 3). The primary symptom is vaginal discomfort. Infection of the throat and mouth may cause a sore throat, but usually causes no symptoms at all.

Men — While women often have no symptoms of gonorrhea, 90 percent of men do experience symptoms, including painful urination and a milky penile discharge. Epididymal infection can develop, causing pain and swelling in one testicle.

Infection of the rectum can develop among men who have sex with men. Symptoms include a rectal discharge, rectal fullness, constipation, and pain. Symptoms usually develop within four to eight days of infection, although it can be up to 30 days in some men.

DIAGNOSIS — Gonorrhea can be identified using several methods, all of which require that the person visit a healthcare provider's office or clinic. Testing may be done because the person has symptoms or as a part of a general check up.

The usual method of testing for gonorrhea gives results within hours. Testing can be done with a swab of the cervix or urethra, as well as with a urine sample.

Other sexually transmitted infections — A person who is found to have an STI, or has a partner with an STI, should consider testing for other STIs, including HIV, Chlamydia, hepatitis B, trichomoniasis, and syphilis. (See "Patient information: Testing for HIV", see "Patient information: Chlamydia" and see "Patient information: Hepatitis B").

Women are advised to have an annual cervical cancer screening (Pap smear), which can detect precancerous or abnormal changes related to a sexually transmitted virus, the human papilloma virus. (See "Patient information: Screening for cervical cancer").

Men or women who use intravenous drugs or have sexual intercourse with a partner who is at risk for hepatitis C should consider testing for this infection. (See "Patient information: Hepatitis C").

Testing is also available for herpes simplex virus, although this is not usually performed unless there are symptoms or risk factors for infection. (See "Patient information: Genital herpes").

COMPLICATIONS — If untreated, gonorrhea can lead to serious complications in both men and women, including joint infections and arthritis. Women can develop pelvic inflammatory disease while men can develop epididymitis. People with gonorrhea are also at higher risk of becoming infected with HIV. (See "Patient information: Joint infection" and see "Patient information: Symptoms of HIV infection").

Pelvic inflammatory disease (PID) occurs in women when gonorrhea spreads from the cervix to the uterus and fallopian tubes. This can cause abdominal or pelvic pain, pain during intercourse, and occasionally, chronic pelvic pain. PID occurs in 10 to 40 percent of women with cervical gonorrhea, which can scar the fallopian tubes and lead to infertility and an increased risk of ectopic pregnancy. (See "Patient information: Chronic pelvic pain in women").

Epididymitis can occur in men with untreated gonorrhea, and can lead to infertility as a result of scarring of the epididymis. The epididymis collects sperm after it leaves the testis.

Infants infected with gonorrhea during birth can develop a serious eye infection, which can potentially cause blindness. As a result, pregnant women are routinely tested for gonorrhea during pregnancy and infants are routinely given a one-time eye treatment with antibiotic ointment immediately after birth.

TREATMENT — Treatment of gonorrhea is the same for women and men. Most experts recommend a one-time antibiotic treatment, such as an injection of ceftriaxone, or an oral dose of cefixime. This is a new recommendation, made in 2007, due to increasing rates of resistance to another type of antibiotic called quinolones (for example, ciprofloxacin, ofloxacin). Pregnant women with uncomplicated gonorrhea can be safely treated with either ceftriaxone or cefixime.

Alternate medications are available for persons who are allergic to the above medications, including an oral medication called azithromycin. Resistant strains of gonorrhea are increasing in some areas of the world (including the United States). The Centers for Disease Control and Prevention (CDC) monitors drug resistance rates (www.cdc.gov/std/gisp).

Patients infected with gonorrhea are sometimes also infected with Chlamydia. For this reason, some clinicians will recommend treatment for both infections at once. (See "Patient information: Chlamydia").

Treatment of sexual partners — Current or recent sexual partners of a person diagnosed with gonorrhea should also be treated, especially since that person may not have any symptoms. Furthermore, an untreated partner can reinfect the patient. The traditional approach has been for the patient to notify their partner that a clinic visit is necessary, where the partner can be tested and treated if needed. In contrast, some clinics have a policy of offering two prescriptions - one for the patient and one for the partner.

In order to prevent reinfection, sexual contact should be avoided until both partners have been treated and all symptoms have resolved. It is possible to become infected with gonorrhea more than once.

Test of cure — Patients who finish the recommended treatment regimen do not need to be retested. However, a person who continues to have symptoms should be reevaluated; further testing may be recommended.

PREVENTION — The most effective way to prevent gonorrhea is to avoid sexual intercourse. Because this is not practical for many people, the following tips are recommended: Use a latex condom with every act of sexual intercourse. Discuss routine testing for sexually transmitted infections with a healthcare provider. Persons in a long-term, mutually monogamous relationship are at a lower risk of infections than those with multiple sexual partners or multiple short-term relationships. See a healthcare provider if there are signs or symptoms of gonorrhea. Avoid sexual intercourse if either partner notes abnormal genital discharge, burning with urination, or a genital rash or sore.

SUMMARY Gonorrhea is a sexually transmitted infection that can be spread during sexual intercourse. A man does not have to ejaculate to spread the infection (see "Causes" above). Some people have symptoms (pain while urinating, discharge from the penis or vagina), while others have no symptoms at all. The infection can be spread from one person to another before it is diagnosed (see "Symptoms" above). Testing for gonorrhea is done in a medical office or clinic. Testing can be done with a swab of the penis or cervix or with a urine sample (see "Diagnosis" above). If untreated, gonorrhea can lead to serious complications in both men and women. In addition, people with gonorrhea are at higher risk of becoming infected with HIV (see "Complications" above). Gonorrhea can be cured with an antibiotic. Sexual partners of a person with gonorrhea should also be treated. Sex should be avoided until both partners have been treated. (see "Treatment" above). Using a latex condom reduces the risk of becoming infected with gonorrhea. Regular testing for sexually transmitted infections is recommended, especially before having sex with a new partner. Sex should be avoided if either partner has abnormal discharge from the penis or vagina, burning with urination, or a genital rash or sore (see "Prevention" above).

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases

(www.niaid.nih.gov/factsheets/stdgon.htm)
Centers for Disease Control and Prevention

(www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm)
American Social Health Association

(www.ashastd.org/stdfaqs/gonorrhea.html)


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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Choudhury, B, Risley, CL, Ghani, AC, et al. Identification of individuals with gonorrhoea within sexual networks: a population-based study. Lancet 2006; 368:139.
2. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
3. Cook, RL, Hutchison, SL, Ostergaard, L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med 2005; 142:914.