Gonorrhea

Overview

Gonorrhea is a curable sexually transmitted infection (STI), second only to chlamydia as the most frequently reported STI in the United States. Gonorrhea is caused by Neisseria gonorrhoeae, also called gonococcus.

Untreated gonorrhea can cause infertility, especially in women. If you are under the age of 25 and sexually active, you should get tested annually for this infection. Women with new or multiple sexual partners or those with a sexual partner who has an STI should be tested annually as well, regardless of their age. If you are pregnant, you should be tested early in your pregnancy for the disease.

Gonorrhea rose to epidemic proportions in the United States in the 1960s and 1970s. Fortunately, this widespread STI has gradually declined substantially since a national control program was instituted in 1975. However, gonorrhea rates have increased in this decade, and rates in the United States remain higher than in any other industrialized country. In 2016, 468,514 cases of gonorrhea were reported to Centers for Disease Control and Prevention; however, about 700,000 cases are believed to occur annually. Rates of infection are higher among adolescents and young adults, men who have sex with men, heterosexual males, and African Americans, particularly those in urban areas and southern United States.

Gonorrhea is spread during sexual intercourse, whether it is vaginal, oral or anal. Even without anal sex, women can sometimes become infected in the rectum as a result of contamination of the anal area with vaginal fluids. Although less common, gonorrhea can be transmitted by oral sex. As with most STIs, infection is transmitted more readily from men to women than from women to men. Gonorrhea can also be transmitted between male partners through sexual contact; indeed, the rates of gonorrhea are at least 10 times higher in men who have sex with men than in women or heterosexual men. All men who have sex with men should be screened for STIs, including gonorrhea, at least annually.

For women, the most common site of initial infection is the cervix (cervicitis) and the urethra (urethritis). Without treatment, the bacteria can spread to the uterus and fallopian tubes. The resulting infection is called pelvic inflammatory disease (PID). PID can result in scarring of the fallopian tubes, causing blockage that can result in infertility or ectopic (tubal) pregnancy, sometimes a life-threatening condition, and chronic pelvic pain. In men, the most common site of infection is the urethra. Both men and women may contract a gonorrhea infection in the throat from oral sex and rectal infection from anal sex. Although uncommon, in both men and women, untreated gonorrhea can lead to serious systemic infections, including disseminated gonococcal infection in the joints, skin, heart or blood.

Pregnant women infected with gonorrhea also are at higher risk of premature delivery. And when the infection is passed on to the infant, gonorrhea can cause serious eye infections. Transmission to a newborn results from exposure to the mother's infected cervix during birth.

In many cases, women and men infected with gonorrhea may also be infected with chlamydia at the same time. Both of these bacterial STIs are often present without symptoms and are transmitted in the same way. Therefore, gonorrhea and chlamydia testing is usually done at the same time using a single specimen for both tests.

Diagnosis

When symptoms occur in infected women, they often are mild. Increased vaginal discharge is the most common symptom. Painful urination and spotting between periods, sometimes triggered by sex, are other common symptoms. Women may also experience pain low in the abdomen or discomfort during sex. If these symptoms are ignored and the infection goes untreated, the bacteria often spread from the cervix into the uterus, fallopian tubes and ovaries, causing pelvic inflammatory disease (PID). PID is characterized by inflammation and scarring, primarily of the fallopian tubes, that leads to infertility or tubal pregnancies.

PID is comprised of various inflammatory disorders of the upper genital tract, including endometritis (when tissue that normally lines the uterus grows outside of the uterus) and tubo-ovarian abscess. PID may be difficult to diagnose because its signs and symptoms vary widely, and many women have only subtle symptoms. Other women experience severe pelvic pain, especially during intercourse.

Diagnosis is most frequently based on clinical presentations, such as lower abdominal pain and physical findings like tenderness on palpation of the pelvic organs during a pelvic exam. These findings can be supplemented with laboratory detection of chlamydia and/or gonorrhea from genital specimens. In some cases, diagnosis requires an ultrasound, and, less often, laparoscopy, during which a scope is inserted near or through the belly button to examine the pelvic area.

Because gonorrhea is often present in women without recognizable symptoms, it is recommended that sexually active women, regardless of symptoms, should be tested routinely for gonorrhea if they are at increased risk for infection. Asymptomatic testing is called screening and is recommended in women at risk for infection. Risk factors for gonorrhea include being sexually active; younger than 25 years old; previously having gonorrhea or other sexually transmitted infection (STI); having new or multiple sexual partners; using condoms inconsistently; exchanging sex for money or drugs; and drug use. African Americans and men who have sex with men have a higher prevalence of infection than the general population in many communities and settings.

Routine testing for gonorrhea also is recommended for pregnant women because infection can cause harm to both the mother and infant. However, don't assume your provider will automatically test you. To be on the safe side, you should ask specifically to be tested for gonorrhea, chlamydia and other STIs.

Men also may have no symptoms from a gonorrhea infection, though more commonly infected males will develop a discharge of mucus or pus from the penis, sometimes with painful urination. Epididymitis, an infection of a testicle, is an uncommon but painful complication; it is the male counterpart of PID in women.

Gonorrhea is diagnosed by identifying gonococcus at common sites of infection (the cervix in women and the urethra in men), and sometimes the rectum and throat, depending on sexual practices that may expose these sites. There is no blood test for gonorrhea. There are three main methods to identify gonococcus at sites of infection:

• NAATs (nucleic acid amplification tests): This is used to detect gonococcal DNA or RNA with swab specimens from the cervix, vagina, rectum or throat. Vaginal swabs can be collected by the woman herself. When pelvic exams or vaginal swabs are not practical, urine can be tested instead. Urine is the preferred specimen for testing males. This is the most sensitive test to diagnose gonorrhea.
• Gram's stain: Looking for gonococcus under a microscope is used primarily in men with symptomatic gonococcal urethritis (this test is not as accurate in males without symptoms and does not work well in women or for infections of the rectum or throat). However, this test has the advantage of speed and providing results within a few minutes.
• Culture: This involves growing the bacteria in the laboratory using a swab specimen from the cervix, rectum, throat or urethra. It typically requires three to four days to get test results and is less accurate than NAATs.
• Home test: For women, there is now a home test kit available to screen for gonorrhea. The kit includes vaginal swabs for self-testing, which are then sent to a lab. Women who choose this method can opt to be notified via email or text when their results are ready and then can obtain those results by calling a toll-free hotline or going online.

The NAATs detect the DNA or RNA material of the gonorrhea and/or the chlamydia organisms. The test results usually are available within one to three days. The NAATs have revolutionized gonorrhea and chlamydia control, because they permit screening of large numbers of men and women, using urine or self-collected vaginal swabs, without requiring a pelvic examination or clinic visit. DNA or RNA testing by NAAT now is the primary means of diagnosing gonorrhea and chlamydia in most of the industrialized world.

Treatment

If you test positive for gonorrhea, the infection can be cured with antibiotics. The Centers for Disease Control and Prevention (CDC) recommends people infected with gonorrhea get treated with two antibiotics concurrently because that is more effective than taking one antibiotic and decreases the risk for antibiotic resistance.

The recommended treatment regimen for gonorrhea in the United States is dual therapy using a single 250 mg injection of ceftriaxone (Rocephin) and a single dose of azithromycin (Zithromax), 1 gram orally.

Until recently, the fluoroquinolone group of antibiotics (including ciprofloxacin or Cipro) was the most effective treatment for gonorrhea. However, a large percentage of gonococcus strains in the United States have become resistant to fluoroquinolones so treatment with this antibiotic group is no longer recommended. The CDC carefully monitors antibiotic resistance rates for gonorrhea. Alternate antibiotics may occasionally be used to treat gonorrhea but usually only when an allergy or other problem prevents treatment with ceftriaxone.

If you are pregnant and are infected with gonorrhea, you can be treated without harming the fetus, but some drugs are less effective or less safe than in nonpregnant women. Therefore, it is critical that you tell your health care professional that you are pregnant.

It is important for pregnant women with gonorrhea to be treated because they can spread the infection to their newborn infant. Infants with gonorrhea may be born prematurely. They also may experience eye inflammation (conjunctivitis) or widespread blood infection (sepsis).

Detecting infection in newborns, which is often without symptoms, requires sensitive and specific methods, including tissue culture and gram stains. The most common symptom is conjunctivitis that develops two to five days after birth. Gonorrhea can involve not only the eyes, but less frequently, the infant's genital tract and rectum as well. Recommended treatment for neonatal gonorrhea is ceftriaxone, either as an intravenous or intramuscular injection. Eyedrops are used routinely in hospitals soon after birth to prevent gonococcal conjunctivitis.

If symptoms persist in spite of a full course of appropriate treatment, the gonococcal organism may have become resistant to some antibiotics and may require a repeat culture and an alternate antibiotic. Health departments can work with community providers to test for resistant organisms and develop an appropriate antibiotic treatment plan.

Treatment is recommended for all sexual partners who may have been exposed to gonorrhea; that includes all partners with sexual contact within 60 days prior to symptoms or a diagnosis of gonorrhea or your most recent sexual partner if more than 60 days since last sexual activity.

Some clinics and doctors' offices offer what is called expedited partner therapy (EPT). Patients are given a prescription or the medications that treat gonorrhea to give to their partner(s) without the clinician assessing the partner. There are legal and ethical debates about this approach, and it does have some limitations (including loss of screening and counseling opportunities and the rare potential for adverse reactions to antibiotics), but in some cases, it may be the most effective way to stop the spread of gonorrhea, because many infected partners have no symptoms and are reluctant to seek treatment. EPT is legal in many U.S. states and cities. Click here for more information on its legal status.

Reinfection can occur if partners do not get diagnosed and treated. Therefore, it is important that you abstain from sexual contact until your partner has been tested and completed treatment (seven days after a single-dose regimen or after completion of a seven-day regimen). Since partners frequently are not treated in a timely fashion and resume sex too soon, reinfection is very common. Therefore, it is important that you return to your provider to have a test for reinfection three months after treatment or whenever you can after a month following treatment.

Treating PID

Pelvic inflammatory disease (PID) treatment begins with an antibiotic regimen that primarily provides coverage against gonorrhea and chlamydia. Treatment should begin as soon as a diagnosis is made, because immediate therapy has been shown to reduce the risk of long-term damage from PID. Oral therapy and a muscular injection are most commonly used. In certain cases, medication may be administered via injection into the veins. Hospitalization is recommended in the following circumstances:

• surgical emergencies such as appendicitis cannot be excluded
• pregnancy
• allergy to orally available antibiotics
• severe illness, nausea, vomiting or high fever
• presence of tubo-ovarian abscess
• no response to oral therapy

While medication can stop PID, some women may need surgery to remove scar tissue and blockages caused by long-term infection.

Prevention

Protecting yourself from gonorrhea requires the same care and attention needed to prevent other sexually transmitted infections (STIs). If you have already been infected, you should be vigilant in getting treated and in preventing reinfection, which can increase your risk of infertility. Abstinence is one sure way to avoid infection, as the spread of gonorrhea is almost always limited to sexual contact. It is safe to have sex in a mutually monogamous relationship in which neither partner has an STI, but it can be difficult to know with certainty that your partner is monogamous.

If you have sex, make sure you use a condom correctly at all times. Also know that your risk for gonorrhea infection increases with the more sexual partners you have. If you have any risk factors for gonorrhea, you should ask your health care professional to test you at least once a year. Some of the risk factors are young age, being sexually active, having multiple sex partners and having had prior STIs.

Here are other tips for avoiding gonorrhea:

• Ask about the sexual history of current and future sex partners.
• Reduce your number of sex partners. A mutually monogamous relationship between two uninfected people is safe.
• Always use a condom from start to finish during any type of sex (vaginal, anal and oral). Use latex condoms rather than natural membrane condoms. If used properly, latex condoms offer greater protection against STIs, including HIV.
• Women who have sex with women can use latex gloves and condoms for genital and anal stimulation with the fingers or with sex toys (dildos, vibrators, etc.). A dental dam (flat, latex barrier), non-microwavable plastic wrap or a condom cut lengthwise and placed over the vagina is advisable for oral-genital sex.
• Use only water-based lubricants with condoms. Do not use saliva or oil-based lubricants such as petroleum jelly or vegetable shortening because they may make the condom thinner and more likely to tear. The U.S. Food and Drug Administration requires a warning on the labels of over-the-counter vaginal contraceptives that contain the spermicide nonoxynol-9 stating that those contraceptives do not protect against infection from HIV (human immunodeficiency virus, the AIDS virus) or other STIs. The FDA's warning also advises consumers that use of vaginal contraceptives containing nonoxynol-9 can increase vaginal irritation, which may increase the possibility of transmitting the AIDS virus and other STIs from infected partners. If you decide to use a spermicide with a condom, it is preferable to use spermicide in the vagina according to manufacturer's instructions.

Facts to Know

1. In the United States, the highest rates of gonorrhea infection are usually found in 20- to 24-year-old women and men.

2. Studies have shown that gonorrhea screening and treatment can significantly reduce the risk of lower genital tract infection, as well as pelvic inflammatory disease (PID).

3. A majority of women infected with gonorrhea have no symptoms, compared to only 10 percent of men. Diagnosis most often results from screening asymptomatic young women routinely and from partner notification as a result of sexual contact with symptomatic, infected men.

4. According to recent statistics provided by the U.S. Centers for Disease Control and Prevention (CDC), gonorrhea rates decreased nearly 74 percent from 1975 to 1997. Rates of the infection then began to plateau for several years. However, in 2005, rates started to increase slightly again. In 2016, there were 468,514 new gonorrhea cases reported to the CDC. Gonorrhea is grossly underreported. CDC estimates that closer to 700,000 new gonorrhea infections occur each year in the United States.

5. Research has shown that women infected with gonorrhea are more at risk for acquiring HIV than uninfected women.

6. Untreated gonorrhea infection increases a woman's risk of developing PID. About 20 percent of women with PID become infertile and others may experience chronic pelvic pain or life-threatening ectopic pregnancy.

7. Gonorrhea and chlamydia cause nearly 50 percent of PID cases.

8. It is important that you receive appropriate antibiotics to treat gonorrhea. Because of increased antibiotic resistance, antibiotics that are effective to treat most gonorrhea infections are limited. The most common antibiotics used for gonorrhea treatment are an injection of ceftriaxone (Rocephin) and a single oral dose of azithromycin (Zithromax).

9. Gonorrhea infection is on the rise. Rates rose 18.5 percent between 2015 and 2016. Rates were at a historic low in 2009 and had risen and 48.6 percent by 2016.

10. Rates of gonorrhea infection are slightly higher in men than in women.

Questions to Ask

Review the following Questions to Ask about gonorrhea so you're prepared to discuss this important health issue with your health care professional.

1. How is gonorrhea diagnosed? Which tests or exams will I have to have?
2. If I'm infected, what should I tell my partner?
3. How long should I abstain from sex after treatment begins?
4. How do I know if the infection has damaged my reproductive tract?
5. If gonorrhea often doesn't cause any symptoms, how do I know if I have been infected and, if so, for how long?
6. Is it possible I am infected with chlamydia as well?
7. If I am pregnant and infected, what are my chances of passing the infection to my baby?
8. Do I need to be retested after treatment to be sure I am cured?
9. What are the symptoms of pelvic inflammatory disease?

Key Q&A

Lifestyle Tips

1. Prevent pelvic inflammatory disease

Pelvic inflammatory disease, or PID, is an infection involving the uterus, fallopian tubes or ovaries that results from untreated gonorrhea and chlamydia cervical infections. Although many women have mild or nonexistent symptoms, you may notice pain in your lower abdomen, vaginal discharge or bleeding, painful intercourse, nausea and vomiting and fever. Untreated PID can lead to tubal infertility, chronic pelvic pain and ectopic (tubal) pregnancy. Twenty percent of women with PID caused by chlamydia or gonorrhea may become infertile. To prevent PID, make sure your partners are screened for STIs, particularly chlamydia and gonorrhea, at least once a year, limit the number of sex partners you have and use condoms every time you have sex. Be aware: The U.S. Food and Drug Administration (FDA) has mandated warnings for the labels of over-the-counter vaginal contraceptives that contain the spermicide nonoxynol-9. The warning states that vaginal contraceptives containing nonoxynol-9 do not protect against infection from HIV (human immunodeficiency virus, the AIDS virus) or other STIs. The FDA's warning also advises consumers that the use of vaginal contraceptives containing nonoxynol-9 can increase vaginal irritation, which may increase the possibility of transmitting the AIDS virus and other STIs from infected partners.

2. Take precautions for oral sex
Although unprotected oral sex is presumably safer than unprotected anal sex or vaginal intercourse, it is no guarantee of protection against STIs. Most STIs can be spread via oral sex. To protect yourself, make sure your partner uses a condom if you're performing oral sex; if he's performing oral sex on you, or if you're having oral sex with a woman, use a dental dam, a flat piece of latex used during dental procedures. You can get them in some medical supply stores. They provide a barrier between the mouth and the vagina or anus during oral sex. Household plastic wrap or a split and flattened, unlubricated condom can also be used if you don't have a dental dam. Also, don't brush or floss your teeth right before having oral sex. Either may tear the lining of your mouth, increasing your exposure to viruses.

3. Practice the best protection
The best protection against any type of STI is a latex condom. However, it doesn't provide 100 percent protection against STIs—only abstinence does. If you use a condom, make sure you use it properly. Human error causes more condom failures than manufacturing errors. Use a new condom with each sexual act (including oral sex). Carefully handle it so you don't damage it with your fingernails, teeth or other sharp objects. Put the condom on after the penis is erect and before any genital contact. Use only water-based lubricants with latex condoms. Ensure adequate lubrication during intercourse. Hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect to prevent slippage.

4. Get tested for STIs
No single test screens for all STIs. Some require a genital exam; others require blood or urine tests. And just because you have a negative test doesn't mean you don't have the disease. Gonorrhea, for example, may travel far up into your reproductive tract, so your doctor is unable to obtain a culture. Or your body may not have developed enough antibodies to a virus like HIV to turn up in a blood test. Still, it's important to ask your health care provider to regularly test you for STIs if you're sexually active in a nonmonogamous relationship (or have the slightest concern about your partner's fidelity). You can get tested at your health department, community clinic, private doctor or Planned Parenthood. Planned Parenthood is starting to offer tele-health STI testing services. Click here to search for a site offering STI testing or call the CDC's National STD and AIDS hotlines at 1-800-227-8922 or 1-800-CDC-INFO (1-800-232-4636) for free or low-cost clinics in your area.

5. Know whether you have an STI
While some STIs may present with symptoms such as sores or ulcers or discharge, most, unfortunately, have no symptoms. You can't always tell if you or a partner has a STI just by looking. Don't rely on a partner's self reporting and assume that will prevent you from acquiring an STI. Many infected people do not know they have a problem. They may think symptoms are caused by something else, such as yeast infections, friction from sexual relations or allergies. So educate yourself about your own body and, in turn, learn about your individual risk for contracting an STI. One way to do this is to schedule an examination with a health care provider who can sit down with you and help you learn the principles for staying safe and sexually healthy. Don't allow fear, embarrassment or ignorance to jeopardize your future.

6. Talk to your children about STIs
Sexually transmitted infections are particularly common among adolescents. And it's an issue kids are concerned about. Parents can play a large role in their adolescent's behavior, both in terms of the behavior you model yourself and in terms of the communication between you and your teen. Make sure your daughter has regular visits with a competent gynecologist and that your son sees a medical professional who specializes in adolescent health at least once a year, if, for nothing else, than some plain talk about STIs and pregnancy. And talk to your kids. Study after study proves that when parents talk to their kids about sexual issues, their kids listen. Don't worry that talking about sex is the same as condoning it; hundreds of studies dispute that theory. In fact, studies show that when parents talk about sex, children are more likely to talk about it themselves, to delay their first sexual experiences and to protect themselves against pregnancy and disease when they do have sex.

Organizations and Support

For information and support on coping with Gonorrhea, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: https://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Social Health Association (ASHA)
Website: https://www.ashasexualhealth.org/
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400
Email: info@ashastd.org

CDC National Prevention Information Network
Website: https://www.cdcnpin.org
Address: P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 404-679-3860
Email: info@cdcnpin.org

Guttmacher Institute
Website: https://www.guttmacher.org
Address: 1301 Connecticut Avenue NW, Suite 700
Washington, DC 20036
Hotline: 1-877-823-0262
Phone: 202-296-4012
Email: info@guttmacher.org

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Website: https://www.cdc.gov/nchhstp
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

National Family Planning and Reproductive Health Association (NFPRHA)
Website: https://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

Planned Parenthood Federation of America
Website: https://www.plannedparenthood.org
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Phone: 212-541-7800

Sexuality Information and Education Council of the United States (SIECUS)
Website: https://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

Books

Sexual Health Questions You Have...Answers You Need
by Michael V. Reitano, Charles Ebel

Sex: What You Don't Know Can Kill You
by Joe S. McIlhaney, Marion McIlhaney

Spanish-language resources

Medline Plus: Gonorrhea
Website: https://www.nlm.nih.gov/medlineplus/spanish/gonorrhea.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

CDC and Prevention
Website: https://www.cdc.gov/std/spanish/gonorrea/stdfact-gonorrhea-s.htm
Address: CDC National Prevention Information Network (NPIN)
P.O. Box 6003
Rockville, MD 20894
Hotline: 1-800-458-5231
Email: info@cdcnpin.org