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If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
What is gonorrhea?
Gonorrhea is one of the most common sexually transmitted infections (STIs). It can affect the genitals, mouth, throat, eyes, and rectum. Albert Neisser discovered the group of bacteria that give rise to gonorrhea in 1879, specifically the bacteria Neisseria gonorrhoeae. However, even before that, the disease had been well known. In fact, references to gonorrhea appear in the Old Testament of the Bible (Haney, 1976). The word comes from the Greek gonos, meaning “sperm,” and rhoia, meaning “flow.” Slang terms for gonorrhea include “the clap” or “the drip.”
Prevalence of gonorrhea
According to the CDC, approximately 820,000 new cases of gonorrhea occur in the United States each year, and over sixty percent are in young people aged 15-24 years old (CDC, 2019). Both men and women can contract gonorrhea, but it tends to affect men more. Also, in the US, gonorrhea is more common in African Americans.
Risk factors for getting gonorrhea include (Abraha, 2018):
- Age <25 years
- Gender- men have higher rates of infection than women
- African Americans have higher rates of infection
- Men who have sex with men have higher rates of infection than men who have sex with women only
- New sex partner
- Sex partner with concurrent partners
- Sexual partner with an STI
- Inconsistent condom use in a mutually non-monogamous relationship
- Previous or coexisting STI
- Exchanging sex for drugs or money
Signs and symptoms of gonorrhea
People who are infected with gonorrhea may never develop symptoms, but those who do usually experience symptoms within two to 14 days after exposure. However, even if a person does not have symptoms, he or she is still contagious. As with many infections, the symptoms depend on the site of infection. Also, gonorrhea affects men and women differently.
Many men never develop any symptoms. When they do, they may first notice pain or burning with urination. These symptoms are due to an infection of the urethra, the tube that carries urine from the bladder through the penis where it exits the body. An infection of the urethra is also called urethritis. As the condition progresses, other symptoms can arise, including:
- Increased frequency or urgency of urination
- White, yellow, or green purulent (pus-like) discharge from the penis
- Edema (swelling) or erythema (redness) at the opening of the penis
- Pain in the testicles
- Swelling of the scrotum
Sometimes gonorrhea can affect the rectum causing rectal pain, itching, discharge, or constipation (Skerlev, 2014). If other areas are infected, such as the throat or the eyes, you may experience a sore throat or severe conjunctivitis (eye infection) that can lead to blindness if untreated.
Most women (approximately 70%) do not experience any symptoms from a gonorrheal infection. When they do, the most common symptoms are due to cervicitis (infection of the cervix) and include:
- Vaginal discharge
- Vaginal bleeding
- Vaginal itching
- Pain with urination
These symptoms are not specific to gonorrhea, however, and can also be found in other conditions, such as yeast infections, vaginitis, etc. As a result, many women are infected with gonorrhea and never realize it. Women can also get gonorrheal infections in the rectum, throat, or eyes with similar symptoms as those seen in men.
STI vs. STD: what’s the difference?
How is gonorrhea transmitted?
Gonorrhea spreads via sexual activity in adults. If you have a single interaction with an infected partner, you have a 30-70% chance of getting gonorrhea from them (Sherrard, 2014). Any type of sexual contact can lead to gonorrheal infection, including vaginal, anal, or oral sex. It is often asymptomatic, so you may not be aware that your partner is infected. N. gonorrhea, the bacteria that causes gonorrhea, does not survive long outside of the body. One implication of that—you can’t get gonorrhea from touching toilet seats.
Pregnant women with gonorrhea are at higher risk for premature rupture of membranes, preterm birth, and spontaneous abortions (Morgan, 2016). They can also pass the gonorrheal infection on to their child. If a pregnant mother is infected at the time of delivery, there is a 30% risk that the baby picks up the infection as it passes through the birth canal. This type of transmission is called vertical transmission.
Gonorrheal infection of a newborn usually presents within the first week of life and can cause an eye infection, called ophthalmia neonatorum, which can lead to blindness if untreated. In the US, all newborns are given an antibiotic ointment in their eyes within 24 hours of birth to prevent ophthalmia neonatorum. In some cases, newborns can get a gonorrhea infection in their bloodstream, leading to sepsis — a potentially life-threatening condition caused by the body’s response to infection. After the first few weeks of life, any gonorrheal infection in a child should raise suspicions for child abuse.
Complications of gonorrhea
Gonorrhea complications arise from infections that are left untreated. In men, this can lead to abscesses in the penis or scarring of the urethra. Depending on the extent, the scarring can cause infertility.
Women have a higher risk of complications from untreated gonorrheal infections (Sherrard, 2014). One of the most common complications is the development of pelvic inflammatory disease (PID). This occurs when the untreated infection travels up into the uterus, fallopian tubes, and ovaries; symptoms of PID include:
- Lower abdominal or pelvic pain
- Vaginal discharge or bleeding
- Pain with sexual intercourse
- Pain with urination
- Fevers and/or chills
- Nausea and/or vomiting
PID can lead to endometritis (inflammation of the wall of the uterus), abscesses in the ovaries or fallopian tube (tubo-ovarian abscess), pelvic scarring, and fallopian tube obstruction, which can result in infertility or ectopic pregnancies (fertilized egg implanting outside of the uterus).
There is a risk of disseminated infection (meaning spread in the blood throughout the body) in both men and women though fortunately, this is rare. It occurs in only 0.4-3% of patients with gonorrhea, often 2-3 weeks after infection and without previous symptoms (Morgan, 2016). Symptoms can include high fever, joint pain and inflammation, and painless skin lesions.
Genital herpes: signs, symptoms, treatment, and more
Gonorrhea and HIV risk
HIV is an STI, just like gonorrhea. If you engage in high-risk sexual activities, such as sex without a condom, you could become infected with one or more STIs. However, the relationship between HIV and gonorrhea goes beyond their both being STIs.
Infection with gonorrhea at the same time as exposure to HIV changes your risk of getting HIV. Studies have shown that having gonorrhea makes HIV more infectious (more viral shedding) and also makes HIV transmission easier. In other words, if you have gonorrhea and you are exposed to HIV, you are more likely to get HIV from that encounter than if you did not have gonorrhea at the same time (Fleming, 1999). If your body is already fighting a gonorrheal infection, it can be easier for the HIV infection to take hold (CDC, 2019).
Testing for gonorrhea
Anyone engaging in sexual activity can get a gonorrhea infection. Screening tests are necessary as people often don’t have symptoms and are likely to pass gonorrhea on to their sexual partners without knowing.
The CDC recommends the following screening guidelines (CDC, 2015-a):
- Annual screening for all sexually active women younger than 25 years of age and in older women at increased risk
- Screening for women three months after gonorrhea diagnosis and treatment
- Pregnant women at their initial visit if younger than 25 years of age or older women with additional risk factors
- Annual screening for sexually active men who have sex with men (MSM) at all exposure sites (urethra, rectum, pharynx)
- Screening every 3–6 months in high-risk MSM patients
- Annual screening for sexually active HIV patients
Also, anyone with genital symptoms such as discharge, burning during urination, sores, or rash should stop having sex and see a healthcare provider for testing and evaluation. People who are diagnosed with gonorrhea should also be tested for other STIs, including chlamydia, syphilis, and HIV (CDC, 2014).
Testing for gonorrhea looks for the presence of the N. gonorrhea bacteria in your body. Typically, your healthcare provider will take a urine sample or swab from a potentially affected location. These areas can include the cervix, urethral opening, mouth, eye, or rectum.
Once the samples have been obtained, they are tested for N. gonorrhea. A “smear” of the sample can be placed on a microscope slide and treated with special stains to see the bacteria in the specimen. Under the microscope, the bacteria look like roundish pink cells in pairs (gram-negative diplococci).
Alternatively, the sample can be placed on a culture plate; however, this method needs time for the bacterial colonies to grow. It is more common to use a technique called nucleic acid amplification test (NAAT) (Unemo, 2014). This test looks for the genetic material (DNA) of the N. gonorrhea bacteria; if it is present, then you have the infection.
Chlamydia transmission: how common is chlamydia and how is it spread?
Gonorrhea treatment and emerging resistance
Fortunately, gonorrhea is treatable with antibiotics. However, the combination of widespread antibiotic use and the ability of N. gonorrhea to develop antibiotic resistance has led to the emergence of antibiotic-resistant or “superbug” strains of gonorrhea. Past trends show that antibiotic-resistant gonorrhea (ARG) emerges every 10-20 years (Morgan, 2016). As resistance to currently used drugs arises, alternative treatment options will need to be found. The FDA is currently conducting clinical trials looking at new antibiotics to help combat ARG (NIH, 2018).
Currently, the CDC recommends dual treatment with two different antibiotics: ceftriaxone and azithromycin (CDC, 2015-b). Each of these antibiotics has a different mechanism of action against N. gonorrhea, increasing the chances that the treatment will be effective and hopefully preventing antibiotic resistance. These two antibiotics are typically given as a one-time dose at the same time, curing the infection for most people.
After treatment, you should abstain from sexual activity for at least seven days. Most cases of recurrent symptoms are from repeat infection and not from incomplete treatment (Morgan, 2016). People treated for gonorrhea should be retested three months later (CDC, 2015-b).
In addition to getting prompt treatment for your gonorrhea, it is crucial that any of your recent sexual partners also be treated. Your health care provider can help you navigate this potentially uncomfortable conversation. It is vital for your sexual partner’s long-term health that they are aware of their potential risk for infection and get evaluated.
How to prevent gonorrhea
There are no vaccines or drugs that will prevent gonorrhea. Since gonorrhea is an STI, you can avoid it by employing safe sex practices such using condoms. Infection with gonorrhea does not protect you against future infections. Each occurrence of high-risk sexual behavior carries with it the chance of getting gonorrhea.
STIs can lead to long-term health problems if not recognized and treated promptly. Maintaining a safe sexual lifestyle can go a long way to keeping you and your partner healthy. Practice safe sex by using condoms and knowing your STI status by getting tested when appropriate. Gonorrhea is only one of several STIs that can be present and contagious without any apparent symptoms. Talk to your healthcare provider if you have any questions or concerns.
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Dr. Tzvi Doron is Board Certified in Family Medicine by the American Board of Family Medicine and is Ro's Chief Clinical Officer.