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Gonorrhea Last updated: October 5, 2020

Summary

Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae

that leads to genitourinary tract infections such as urethritis, cervicitis,
pelvic in ammatory disease (PID) and epididymitis. The disease primarily affects individuals
between 15–24 years of age and has an incubation period of 2–7 days. Gonorrhea is
commonly asymptomatic, especially in women, which increases the chance of further
spreading and complications. In symptomatic cases, typical clinical symptoms include
purulent vaginal or urethral discharge, dysuria, and signs of epdidymitis (e.g., scrotal pain) or
PID (e.g., pelvic pain, dyspareunia). Gonorrhea may also cause extragenitourinary
manifestations, such as proctitis and pharyngitis. Rarely, disseminated disease may occur,
which typically manifests with a triad of arthritis, pustular skin lesions, and tenosynovitis.

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Diagnostic tests include nucleic acid ampli cation testing, gram stains, and bacterial cultures
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from urine or swabs of the genitourinary tract as well as blood and synovial uid in
disseminated infection. Treatment consists of antibiotics, mainly ceftriaxone and
azithromycin, but may require different approaches in more severe cases. Without
treatment, prolonged infection may lead to complications, such as a hymenal and tubal
synechiae that lead to infertility in women.

Epidemiology
Second most commonly reported infectious disease in the US after chlamydia

Incidence: ∼ 820,000 cases per year in the US

Age: primarily individuals between 15–24 years of age

References:[1][2][3][4]

Epidemiological data refers to the US, unless otherwise speci ed.

Etiology
Pathogen

Neisseria gonorrhoeae (N. gonorrhoeae, gonococcus)

Gram-negative, intracellular, aerobic, diplococci

Transmission

Sexual contact (oral, genital, or anal) with an infected individual

Perinatal transmission

Risk factors

Multiple sexual partners

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Low socioeconomic status

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Lack of barrier protection (e.g., condomless sex)

Men who have sex with men (MSM)

References:[1][5]

Clinical features

Gonorrhea can present with a wide variety of symptoms and courses. An asymptomatic
course is common, particularly in women, and increases the risk of further spreading and
complications!

Incubation time: 2–7 days

Urethritis: purulent urethral discharge (yellow-green, possibly blood-tinged) , dysuria and
urinary frequency

In males: potentially epididymitis: one-sided scrotal pain and swelling

In females

Cervicitis

Purulent, yellow, malodorous cervical discharge

Cervical pain and bleeding on manipulation (e.g., pelvic exam)

Pelvic in ammatory disease (PID)

Fever, abdominal/pelvic pain, dyspareunia

Abnormal, intermenstrual bleeding

Fitz-Hugh-Curtis syndrome (perihepatitis with RUQ pain)

Bartholinitis: pain, edema, and discharge of the labia

Vaginitis is usually not present

Extragenital manifestations

Pharyngitis (sore throat, pharyngeal exudate, cervical lymphadenitis)

Proctitis
Purulent discharge, possible anorectal bleeding and pain

Rectal mucosa in ammation

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Rectal abscess (less common)

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Disseminated gonococcal infection (DGI; ∼ 2% of cases)

Usually occurs in patients < 40 years old

More common in women (4:1)

Two possible clinical presentations

Clinical triad (arthritis-dermatitis syndrome)

Polyarthralgias: migratory, asymmetric arthritis that may become purulent

Tenosynovitis: simultaneous in ammation of several tendons (e.g., ngers, toes, wrist,

ankle)

Dermatitis: vesicular, pustular, or maculopapular lesions, possibly with a necrotic or

hemorrhagic center
Most commonly distributed on the trunk, extremities (sometimes involving the
palms and soles)

Typically < 10 lesions that have a transient course (subside in 3–4 days)

Additional manifestations: fever and chills (especially in the acute phase)

Purulent gonococcal arthritis

Abrupt in ammation in up to 4 joints (commonly knees, ankles, and wrists)

No skin manifestations, rarely tenosynovitis

Only 25% of patients present with genitourinary manifestations

Not to be confused with reactive arthritis

References:[1][5][6][7][8][9]

Diagnostics
Specimens for testing include

First-catch urine

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Swab specimens of secretions: urine, urethra, endocervix, pharynx

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For DGI: collect blood and synovial uid (gained via arthrocentesis)

Test of choice: rapidly detect N. gonorrhoea via nucleic acid ampli cation testing (NAAT)

Alternatives

Gonococcal gram stain

Gonococcal culture
Useful in determining antibiotic resistance

Results are not rapidly available (about 48 hours)

Sensitivity is lower than NAAT

Additionally for arthritis: synovial uid analysis

May be clear (nonpurulent) or cloudy (purulent)

↑ Leukocyte count (up to 50,000 cells/mm3): especially segmented neutrophils

Gram stain sometimes positive (< 25% of cases)

Screening for gonorrhea (CDC recommendations)

Annual NAAT screening of gonorrhea (typically also chlamydia) for:

Sexually active women < 25 years

Women > 25 years with risk factors (e.g., new or multiple sex partners, sex partner with
an STI)

Evaluate for other STIs if positive (e.g., Chlamydia, syphilis, HIV)

References:[1][6][8][10][11]

Treatment
Uncomplicated gonorrhea

Combination therapy is recommended due to high resistance rates to cephalosporins and

to cover a possible coinfection with Chlamydia trachomatis.

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First-line treatment: single-dose ceftriaxone IM + single-dose azithromycin PO

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Alternatively: single-dose ce xime PO + single-dose azithromycin PO
Complicated gonorrhea: : single-dose ceftriaxone IM + doxycycline PO for 10–14 days

DGI: ceftriaxone IM or IV; + single-dose azithromycin PO

If purulent joint(s) → drain

Evaluate and treat the patient's sexual partners from the past 60 days

Sexual partners must be treated simultaneously to avoid reinfections!

References:[1][12]

Complications
Hymenal and tubal synechiae, tubal motility disorders → infertility

Gonococcal conjunctivitis (particularly in neonates, see neisserial conjunctivitis)

Of DGI: sepsis with endocarditis, meningitis, osteomyelitis, or pneumonia

References:[8][9]

We list the most important complications. The selection is not exhaustive.

References
1. Wong B. Gonorrhea. In: Haran Chandrasekar P, Gonorrhea. New York, NY: WebMD.
http://emedicine.medscape.com/article/218059 . Updated: October 7, 2016. Accessed:
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March 26, 2017.

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2. Gonorrhea - CDC Fact Sheet (Detailed Version). https://www.cdc.gov/std/gonorrhea/stdfact-
gonorrhea-detailed.htm . Updated: October 25, 2016. Accessed: April 10, 2017.

3. Ghanem KG. Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in

adults and adolescents . In: Post TW, ed. UpToDate. Waltham, MA: UpToDate.
http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-neisseria-
gonorrhoeae-infection-in-adults-and-adolescents#H790870951 .Last updated: May 27,
2016. Accessed: April 10, 2017.

4. Miller KE. Diagnosis and treatment of Neisseria gonorrhoeae infections. Am Fam Physician.
2006; 73 (10): p.1779-1784.

5. Robbins R. Gonococcal Arthritis. Gonococcal Arthritis. New York, NY: WebMD.

http://emedicine.medscape.com/article/333612-overview . Updated: August 12, 2016.
Accessed: April 10, 2017.

6. Goldenberg DL, Sexton DJ. Disseminated gonococcal infection. In: Post TW, ed. UpToDate.
Waltham, MA: UpToDate. http://www.uptodate.com/contents/disseminated-gonococcal-
infection .Last updated: September 12, 2016. Accessed: April 10, 2017.
7. Summary. https://www.cdc.gov/std/laboratory/2014labrec/default.htm . Updated: March
14, 2014. Accessed: April 10, 2017.

8. Mayor MT, Roett MA, Uduhiri KA. Diagnosis and Management of Gonococcal Infections. Am
Fam Physician. 2012; 86 (10): p.931-938.
9. 2015 Sexually Transmitted Diseases Treatment Guidelines: Gonococcal Infections.
https://www.cdc.gov/std/tg2015/gonorrhea.htm . Updated: July 27, 2016. Accessed:
March 25, 2017.

10. Chlamydia and Gonorrhea — Two Most Commonly Reported Infectious Diseases in the
United States. https://www.cdc.gov/features/dsstddata/ . Updated: April 22, 2011.
Accessed: April 10, 2017.

11. Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States,
2008.

12. Current Epidemiology of Selected STDs.

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