Gonorrhea

Overview

Gonorrhea is a bacterial infection transmitted through vaginal, anal or oral sexual contact and from mother to newborn during delivery. The organism preferentially infects mucosal epithelium, so symptoms and complications depend on the site involved and whether infection ascends or spreads beyond the local mucosa. ^{[1] [2]}

N. gonorrhoeae attaches to and invades mucosal cells, producing inflammation and purulent discharge. Cervical infection can ascend into the uterus and fallopian tubes, causing pelvic inflammatory disease, while urethral infection in men can involve the epididymis. Pharyngeal infection is often silent and is harder to eradicate than urogenital disease. ^{[1] [2]}

Gonorrhea frequently coexists with chlamydia and is an important marker of broader STI risk. Because many infections are asymptomatic, screening recommendations are based on age, sexual practices, pregnancy and individual risk rather than symptoms alone. Antimicrobial resistance is a major public-health concern and influences current treatment choices. ^{[1] [2] [3]}

Symptoms and warning signs

Urethral infection may cause burning urination and purulent discharge. Cervical infection can cause increased vaginal discharge, bleeding between periods or after sex, pelvic discomfort or no symptoms. Rectal infection may cause pain, discharge, bleeding or tenesmus; pharyngeal infection is commonly asymptomatic but can cause sore throat. ^{[1] [2]}

Urgent evaluation is needed for severe pelvic or lower-abdominal pain, fever, vomiting, pregnancy with concerning symptoms, testicular pain or swelling, or systemic features such as fever with rash and painful swollen joints. These can signal PID, epididymitis or disseminated gonococcal infection. ^{[1] [2]}

Diagnosis

NAAT is the preferred diagnostic method for most genital, rectal and pharyngeal specimens. Testing should match the sites of sexual exposure; a urine test alone can miss rectal or throat infection. In symptomatic urethritis, microscopy can sometimes provide immediate supportive evidence, but NAAT remains important for confirmation and co-infection testing. ^{[1] [2]}

Culture is especially useful when treatment failure or antimicrobial resistance is suspected because it allows susceptibility testing. People diagnosed with gonorrhea should also be tested for chlamydia, syphilis and HIV, and those without HIV should be assessed for HIV prevention options such as PrEP when appropriate. ^{[1] [2] [3]}

Chlamydia, Mycoplasma genitalium, trichomoniasis, urinary tract infection, bacterial vaginosis and noninfectious urethritis or cervicitis can cause overlapping symptoms. Pelvic pain requires assessment for PID and pregnancy-related diagnoses rather than assuming a lower-tract STI alone. ^{[2] [3]}

Causes, risk factors and clinical context

Risk rises with new or multiple sexual partners, a partner with an STI, inconsistent condom use, prior STIs and sexual networks with higher prevalence. Young sexually active people and some groups defined by sexual practices are screened more frequently under national guidelines. ^{[1] [2]}

Uncomplicated infection is curable with appropriate antibiotics. Reinfection is common when partners are untreated or when new exposure occurs, which is why retesting after treatment and partner management matter. Untreated infection can persist and spread even when symptoms are mild or absent. ^{[1] [2] [3]}

Complications and why the diagnosis matters

In people with a uterus, ascending infection can cause PID, tubal scarring, infertility and ectopic pregnancy. In people with testes, epididymitis can cause pain and rarely affect fertility. Disseminated gonococcal infection can involve joints, tendons, skin and, rarely, the heart or meninges. ^{[1] [2]}

Most uncomplicated gonorrhea resolves with recommended treatment, but treatment does not reverse established tubal scarring or other damage. Recurrent infection increases the risk of reproductive complications, so prevention of reinfection is part of successful care. ^{[1] [2] [3]}

Treatment and management

CDC recommends ceftriaxone as first-line treatment for uncomplicated urogenital, rectal and pharyngeal gonorrhea in the United States, with dose adjusted for body weight. If chlamydia has not been excluded, doxycycline treatment is added for nonpregnant adults according to guideline recommendations. ^{[1] [2]}

Patients should avoid sexual activity for seven days after treatment and until partners have been treated and symptoms have resolved. Partner notification, expedited partner therapy where legally and clinically appropriate, and repeat testing after the recommended interval reduce reinfection. ^{[1] [2] [3]}

Do not rely on leftover oral antibiotics or older gonorrhea regimens. Resistance has eliminated several previously effective options. Suspected treatment failure—especially pharyngeal persistence—requires culture, susceptibility testing and specialist or public-health consultation. ^{[1] [2]}

Follow-up, recovery and prevention

CDC recommends retesting after treatment because reinfection is common. A test of cure is specifically recommended for pharyngeal gonorrhea and in certain alternative-treatment or treatment-failure situations. Persistent symptoms require re-evaluation rather than automatic repeat antibiotics. ^{[1] [2]}

Condoms and barriers reduce risk when used correctly and consistently. Regular site-specific screening, prompt treatment of cases and partners, limiting exposure during treatment and addressing broader STI prevention—including HIV PrEP when appropriate—reduce transmission. ^{[1] [2] [3]}

Special situations and care pathway

Pregnancy changes antibiotic choices and makes prompt treatment important because gonorrhea can affect pregnancy and cause severe neonatal eye infection during delivery. Allergy to cephalosporins and suspected resistant infection should be managed with current specialist guidance rather than improvised alternatives. ^{[1] [2] [3]}

The care pathway is exposure-based testing, same-day recommended treatment when diagnosed, screening for coexisting STIs, partner treatment, temporary sexual abstinence, and scheduled retesting. Suspected treatment failure adds culture and public-health consultation. ^{[1] [2]}

When to seek urgent medical care

Seek urgent care for severe pelvic pain, fever, vomiting, pregnancy with pelvic symptoms, acute testicular pain or swelling, or fever with rash and painful swollen joints. ^{[1] [2]}

Sources

1. CDC — Gonococcal Infections Among Adolescents and Adults — STI Treatment Guidelines
2. CDC — Clinical Treatment of Gonorrhea
3. WHO — Gonorrhoea fact sheet

This article is based on trusted medical sources and is awaiting clinician review. It is not a substitute for personalized medical advice.