Diagnosis is by testing the urine,urethra in males,vagina orcervix in females. It can be diagnosed by testing a sample collected from the throat or rectum of individuals who have had oral or anal sex, respectively.[1] Testing all women who are sexually active and less than 25 years of age each year as well as those with new sexual partners is recommended;[3] the same recommendation applies inmen who have sex with men (MSM).[3]Gonorrhea can be prevented with the use ofcondoms, having sex with only one person who is uninfected, and bynot having sex.[1][3] Certain vaccines originally designed to protect against infection caused by related bacteria,meningococcus serotype B, have been found to provide some protection against gonorrhea.[4][5][6] Treatment is usually withceftriaxone by injection andazithromycin by mouth.[7][8]Resistance has developed to many previously usedantibiotics and higher doses of ceftriaxone are occasionally required.[7][8]
Signs and symptoms
Gonorrhea infections ofmucosal membranes can cause swelling, itching, pain, and the formation ofpus.[16] Thetime from exposure to symptoms is usually between two and 14 days, with most symptoms appearing between four and six days after infection, if they appear at all. Both men and women with infections of the throat may experience asore throat, though such infection does not produce symptoms in 90% of cases.[17][18] Other symptoms may include swollen lymph nodes around the neck.[16] Either sex can become infected in the eyes or rectum if these tissues are exposed to the bacterium,[19] which can lead to pain with bowel movements, rectal discharge, or constipation.[20]
If left untreated, gonorrhea can spread from the original site of infection and infect and damage the joints, skin, and other organs. Indications of this can include fever, skin rashes, sores, and joint pain and swelling.[24] In advanced cases, gonorrhea may cause a generalfeeling of tiredness similar to other infections.[29][25] It is also possible for an individual to have anallergic reaction to the bacteria, in which case any appearing symptoms will be greatly intensified.[25] Very rarely it may settle in the heart, causingendocarditis, or in the spinal column, causingmeningitis. Both are more likely among individuals with suppressed immune systems, however.[18]
Cause
Neisseria gonorrhoeae in pus from a case of gonorrhoea in a man (Gram stain)Gram-stained pus from a urethral discharge showing Gram-negative, intracellular diplococci
Gonorrhea is caused by the bacteriumNeisseria gonorrhoeae.[22] Previous infection does not confer immunity – a person who has been infected can become infected again by exposure to someone who is infected. Infected persons may be able to infect others repeatedly without having any signs or symptoms of their own.[30]
Spread
The infection is usually spread from one person to another throughvaginal,oral, oranal sex.[22][31] Men have a 20% risk of getting the infection from a single act of vaginal intercourse with an infected woman. The risk formen who have sex with men (MSM) is higher.[32] Insertive MSM may get a penile infection from anal intercourse, while receptive MSM may get anorectal gonorrhea. Women have a 60–80% risk of getting the infection from a single act of vaginal intercourse with an infected man.[33]
A mother may transmit gonorrhea to her newborn during childbirth; when affecting the infant's eyes, it is referred to asophthalmia neonatorum.[22] It may be able to spread through the objects contaminated with body fluid from an infected person.[34] The bacteria typically does not survive long outside the body, typically dying within minutes to hours.[35]
Risk factors
It is discovered that sexually active women younger than 25 and men who have sex with men are at increased risk of getting gonorrhea.[36]
Other risk factors include:
Having a new sex partner
Having a sex partner who has other partners
Having more than one sex partner
Having had gonorrhea or another sexually transmitted infection[37]
Complications
Untreated gonorrhea can lead to major complications, such as:
Infertility in men. Gonorrhea can cause a small, coiled tube in the rear portion of the testicles where the sperm ducts are located (epididymis) to become inflamed (epididymitis). Untreated epididymitis can lead to infertility.
Infection that spreads to the joints and other areas of the body. The bacterium that causes gonorrhea can spread through the bloodstream and infect other parts of the body, including the joints. Fever, rash, skin sores, joint pain, swelling and stiffness are possible results.
Complications in babies. Babies who contract gonorrhea from their mothers during birth can develop blindness, sores on the scalp and infections.[29][30]
Diagnosis
Traditionally, gonorrhea was diagnosed withGram stain andculture; however, newerpolymerase chain reaction (PCR)-based testing methods are becoming more common.[23][38] If initial treatment fails, a culture should be done to determine the sensitivity of the bacteria to antibiotics.[39]
Tests that use PCR (aka nucleic acid amplification) to identify genes unique toN. gonorrhoeae are recommended for screening and diagnosis of gonorrhea infection. These PCR-based tests require a sample of urine, urethral swabs, or cervical/vaginal swabs. Culture (growing colonies of bacteria in order to isolate and identify them) and Gram-stain (staining of bacterial cell walls to reveal morphology) can also be used to detect the presence ofN. gonorrhoeae in all specimen types except urine.[40][41] Studies of the swab sample method for gonorrhea infections have not shown any difference in the number of patients treated, whether the sample was collected at home or in the clinic. The implications for number of patients cured, reinfection rates, partner management, and safety are unknown.[42]
If Gram-negative, oxidase-positive diplococci are visualized on direct Gram stain of urethral pus (male genital infection), no further testing is needed to establish the diagnosis of gonorrhea infection.[43][44] However, direct Gram stain of cervical swabs is not useful because theN. gonorrhoeae organisms are less concentrated in these samples. The chance of a false positive test is also higher for a cervical swab, as Gram-negative diplococci native to the normal vaginal flora cannot be distinguished fromN. gonorrhoeae in that context. Thus, cervical swabs must be cultured under the conditions described above. If oxidase positive, Gram-negative diplococci are isolated from a culture of a cervical/vaginal swab specimen, then the diagnosis is made. Culture is especially useful for diagnosis of infections of the throat, rectum, eyes, blood, or joints—areas where PCR-based tests are not well established in all labs.[44][45] Culture is also useful for antimicrobial sensitivity testing, analyzing treatment failure, and epidemiological purposes (outbreaks, surveillance).[44]
In patients who may have disseminated gonococcal infection (DGI), all possible mucosal sites should be cultured (e.g., pharynx, cervix, urethra, rectum).[45] Three sets of blood cultures should also be obtained.[46]Synovial fluid should be collected in cases ofseptic arthritis.[45]
All people testing positive for gonorrhea should be tested for other sexually transmitted infections such aschlamydia,syphilis, andhuman immunodeficiency virus.[39] Studies have found co-infection with chlamydia ranging from 46 to 54% in young people with gonorrhea.[47][48] Among persons in the United States between 14 and 39 years of age, 46% of people with gonorrheal infection also have chlamydial infection.[49] For this reason, gonorrhea and chlamydia testing are often combined.[40][50][51] People diagnosed with gonorrhea infection have a fivefold increase risk of HIV transmission.[52] Additionally, infected persons who are HIV positive are more likely to shed and transmit HIV to uninfected partners during an episode of gonorrhea.[53]
Screening
TheUnited States Preventive Services Task Force (USPSTF) recommends screening for gonorrhea in women at increased risk of infection, which includes all sexually active women younger than 25 years. Extragenital gonorrhea and chlamydia are highest inmen who have sex with men (MSM).[54] Additionally, the USPSTF also recommends routine screening in people who have previously tested positive for gonorrhea or have multiple sexual partners and individuals who use condoms inconsistently, provide sexual favors for money, or have sex while under the influence of alcohol or drugs.[21]
As with most sexually transmitted infections, the risk of infection can be reduced significantly by the correct use ofcondoms,not having sex, or can be removed almost entirely by limiting sexual activities to a mutually monogamous relationship with an uninfected person.[56][57]
Those previously infected are encouraged to return for follow up care to make sure that the infection has been eliminated. In addition to the use of phone contact, the use of email and text messaging have been found to improve the re-testing for infection.[58]
Newborn babies coming through the birth canal are givenerythromycin ointment in the eyes to prevent blindness from infection. The underlying gonorrhea should be treated; if this is done then usually a good prognosis will follow.[59]
Vaccines
As of 2014, a vaccine for gonorrhea had been developed that was effective in mice.[60] Development of a vaccine has been complicated by the ongoing evolution of resistant strains andantigenic variation (the ability ofN. gonorrhoeae to disguise itself with different surface markers to evade the immune system).[61]
AsN. gonorrhoeae is closely related toN. meningitidis and they have 80–90% homology in their genetic sequences, some cross-protection is feasible withmeningococcal vaccines. A study published in 2017 showed that theMeNZB group B meningococcal vaccine provided partial protection against gonorrhea,[4] with vaccine efficiency calculated to be 31%.[62] In June 2023,GlaxoSmithKline won fast-track designation from theFood and Drug Administration for its vaccine candidate against gonorrhea.[63]
In August 2025 theNHS began a gonorrhea vaccine program in England to provide4CMenB (brand name Bexsero) to high-risk populations, marking the first time that a vaccine has been available specifically to prevent gonorrhea infections. Bexsero is primarily used to protect againstmeningococcal B disease but has also been shown to provide up to 40% protection against gonorrhea.[5][6] The vaccination program is expected to prevent up to 100,000 cases of gonorrhea over ten years and save the NHS more than £7.9m.[64]
Treatment
Antibiotics
Penicillin entered mass production in 1944 and revolutionized the treatment of several venereal diseases.
Antibiotics are used to treat gonorrhea infections. As of 2016, bothceftriaxone by injection andazithromycin by mouth are most effective.[7][65][66][67] However, due to increasing rates ofantibiotic resistance, local susceptibility patterns must be taken into account when deciding on treatment.[39][61]Ertapenem is a potential effective alternative treatment for ceftriaxone-resistant gonorrhea.[68][69]
Adults may have eyes infected with gonorrhea and require proper personal hygiene and medications.[59] Addition of topical antibiotics have not been shown to improve cure rates compared to oral antibiotics alone in treatment of eye infected gonorrhea.[70] For newborns,erythromycin ointment is recommended as a preventative measure for gonococcal infantconjunctivitis.[71]
Infections of the throat can be especially problematic, as antibiotics have difficulty becoming sufficiently concentrated there to destroy the bacteria. This is amplified by the fact that pharyngeal gonorrhoea is mostly asymptomatic, and gonococci and commensalNeisseria species can coexist for long time periods in the pharynx and share anti-microbial resistance genes. Accordingly, an enhanced focus on early detection (i.e., screening of high-risk populations, such as men who have sex with men,PCR testing should be considered) and appropriate treatment of pharyngeal gonorrhea is important.[7]
Sexual partners
It is recommended that sexual partners be tested and potentially treated.[39] One option for treating sexual partners of people infected ispatient-delivered partner therapy (PDPT), which involves providing prescriptions or medications to the person to take to his/her partner without the health care provider's first examining him/her.[72]
The United States'Centers for Disease Control and Prevention (CDC) currently recommend that individuals who have been diagnosed and treated for gonorrhea avoid sexual contact with others until at least one week past the final day of treatment in order to prevent the spread of the bacterium.[73]
Many antibiotics that were once effective includingpenicillin,tetracycline, andfluoroquinolones are no longer recommended because of high rates of resistance.[39] Resistance tocefixime has reached a level such that it is no longer recommended as a first-line agent in the United States, and if it is used a person should be tested again after a week to determine whether the infection still persists.[65] Public health officials are concerned that an emerging pattern of resistance may predict a global epidemic.[74][75] In 2016, theWHO published new guidelines for treatment, stating "There is an urgent need to update treatment recommendations for gonococcal infections to respond to changing antimicrobial resistance (AMR) patterns ofN. gonorrhoeae. High-level resistance to previously recommended quinolones is widespread and decreased susceptibility to the extended-spectrum (third-generation) cephalosporins, another recommended first-line treatment in the 2003 guidelines, is increasing and several countries have reported treatment failures."[76]
Gonorrhea if left untreated may last for weeks or months with higher risks of complications.[22] One of the complications of gonorrhea is systemic dissemination resulting in skinpustules orpetechia,septic arthritis,meningitis, orendocarditis.[22] This occurs in between 0.6 and 3% of infected women and 0.4 and 0.7% of infected men.[22]
About 88 million cases of gonorrhea occur each year, out of the 448 million new cases of curable STI each year – that also includes syphilis, chlamydia andtrichomoniasis.[14] The prevalence was highest in theAfrican region, theAmericas, and WesternPacific, and lowest inEurope.[78] In 2013, it caused about 3,200 deaths, up from 2,300 in 1990.[79]
In the United Kingdom, 196 per 100,000 males 20 to 24 years old and 133 per 100,000 females 16 to 19 years old were diagnosed in 2005.[22] In 2013, the CDC estimated that more than 820,000 people in the United States get a new gonorrheal infection each year. Fewer than half of these infections are reported to CDC. In 2011, 321,849 cases of gonorrhea were reported to the CDC. After the implementation of a national gonorrhea control program in the mid-1970s, the national gonorrhea rate declined from 1975 to 1997. After a small increase in 1998, the gonorrhea rate has decreased slightly since 1999. In 2004, the rate of reported gonorrheal infections was 113. 5 per 100,000 persons.[80]
The World Health Organization warned in 2017 of the spread of untreatable strains of gonorrhea, following analysis of at least three cases in Japan, France and Spain, which survived all antibiotic treatment.[84]
History
During World War II, the U.S. government used posters to warn military personnel about the dangers of gonorrhea and othersexually transmitted infections.
Some scholars translate the biblical termszav (for a male,Hebrew:זָב) andzavah (for a female,זָבָה) as gonorrhea.[85]
It has been suggested[by whom?] thatmercury was used as a treatment for gonorrhea.[when?] Surgeons' tools on board the recovered English warship theMary Rose included asyringe that, according to some, was used to inject the mercury via theurinary meatus into crewmen with gonorrhea. The name "the clap", in reference to the disease, is recorded as early as the sixteenth century, referring to a medievalred-light district in Paris, Les Clapiers. Translating to "The rabbit holes", it was so named for the small huts in which prostitutes worked.[86][61]
Silver nitrate was one of the widely used drugs in the 19th century. However, it became replaced byProtargol.Arthur Eichengrün invented this type ofcolloidal silver, which was marketed byBayer from 1897 onward. The silver-based treatment was used until the first antibiotics came into use in the 1940s.[87][88]
The exact time of onset of gonorrhea as prevalent disease or epidemic cannot be accurately determined from the historical record. One of the first reliable notations occurs in the Acts of theEnglish Parliament which, in 1161, passed a law to reduce the spread of "the perilous infirmity of burning".[89] The symptoms described are consistent with, but not diagnostic of, gonorrhea. A similar decree was passed byLouis IX in France in 1256, replacing regulation with banishment.[90] Similar symptoms were noted at thesiege of Acre byCrusaders.
Coincidental to, or dependent on, the appearance of a gonorrhea epidemic, several changes occurred in European medieval society. Cities hiredpublic health doctors to treat affected patients without right of refusal.Pope Boniface VIII rescinded the requirement that physicians complete studies for the lower orders of theCatholic priesthood.[91]
Medieval public health physicians in the employ of their cities were required to treat prostitutes infected with the "burning", as well aslepers and other epidemic patients.[92] After Pope Boniface completely secularized the practice of medicine, physicians were more willing to treat a sexually transmitted infection.[91]
^Zakher B, Cantor AG, Pappas M, Daeges M, Nelson HD (December 2014). "Screening for gonorrhea and Chlamydia: a systematic review for the U.S. Preventive Services Task Force".Annals of Internal Medicine.161 (12):884–893.CiteSeerX10.1.1.691.6232.doi:10.7326/M14-1022.PMID25244000.S2CID207538182.
^abCaini S, Gandini S, Dudas M, Bremer V, Severi E, Gherasim A (August 2014). "Sexually transmitted infections and prostate cancer risk: a systematic review and meta-analysis".Cancer Epidemiology.38 (4):329–338.doi:10.1016/j.canep.2014.06.002.PMID24986642.
^Howard Brown Health Center: STI Annual Report, 2009
^National Institute of Allergy and Infectious Diseases; National Institutes of Health, Department of Health and Human Services (20 July 2001). "Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention". Hyatt Dulles Airport, Herndon, Virginia. pp14
^Goodyear-Smith F (November 2007). "What is the evidence for non-sexual transmission of gonorrhoea in children after the neonatal period? A systematic review".Journal of Forensic and Legal Medicine.14 (8):489–502.doi:10.1016/j.jflm.2007.04.001.PMID17961874.
^abcdeDeguchi T, Nakane K, Yasuda M, Maeda S (September 2010). "Emergence and spread of drug resistant Neisseria gonorrhoeae".The Journal of Urology.184 (3):851–8, quiz 1235.doi:10.1016/j.juro.2010.04.078.PMID20643433.
^Levinson, Warren (1 July 2014).Review of Medical Microbiology and Immunology (Thirteenth ed.). New York: McGraw-Hill Education.ISBN978-0-07-181811-7.OCLC871305336.
^Datta SD, Sternberg M, Johnson RE, Berman S, Papp JR, McQuillan G, Weinstock H (July 2007). "Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002".Annals of Internal Medicine.147 (2):89–96.doi:10.7326/0003-4819-147-2-200707170-00007.PMID17638719.S2CID16507728.
^Meyers D, Wolff T, Gregory K, Marion L, Moyer V, Nelson H, et al. (March 2008). "USPSTF recommendations for STI screening".American Family Physician.77 (6):819–824.PMID18386598.
^abSadowska-Przytocka A, Czarnecka-Operacz M, Jenerowicz D, Grzybowski A (2016). "Ocular manifestations of infectious skin diseases".Clinics in Dermatology.34 (2):124–128.doi:10.1016/j.clindermatol.2015.11.010.PMID26903179.
^Petousis-Harris H, Paynter J, Morgan J, Saxton P, McArdle B, Goodyear-Smith F, Black S (September 2017). "Effectiveness of a group B outer membrane vesicle meningococcal vaccine against gonorrhoea in New Zealand: a retrospective case-control study".Lancet.390 (10102):1603–1610.doi:10.1016/S0140-6736(17)31449-6.PMID28705462.S2CID4230156.
^abCenters for Disease Control Prevention (CDC) (August 2012). "Update to CDC's Sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections".MMWR. Morbidity and Mortality Weekly Report.61 (31):590–594.PMID22874837.
^de Vries HJ, de Laat M, Jongen VW, Heijman T, Wind CM, Boyd A, et al. (May 2022). "Efficacy of ertapenem, gentamicin, fosfomycin, and ceftriaxone for the treatment of anogenital gonorrhoea (NABOGO): a randomised, non-inferiority trial".The Lancet. Infectious Diseases.22 (5):706–717.doi:10.1016/S1473-3099(21)00625-3.PMID35065063.S2CID246129045.
^"Gonorrhea – CDC Fact Sheet".U.S. Centers for Disease Control and Prevention. 14 July 2014.Archived from the original on 16 December 2016. Retrieved17 October 2014.
^Groopman J (1 October 2012)."Sex and the Superbug".The New Yorker. Vol. LXXXVIII, no. 30. pp. 26–31.Archived from the original on 9 October 2012. Retrieved13 October 2012....public-health experts [see]...the emergence of a strain of gonorrhea that is resistant to the last drug available against it, and the harbinger of a sexually transmitted global epidemic.
^abKumar, Vinay; Abbas, Abul K.; Fausto, Nelson; & Mitchell, Richard N. (2007).Robbins Basic Pathology (8th ed.). Saunders Elsevier. pp. 705–706ISBN978-1-4160-2973-1
.png)
