Medically Reviewed by Gale Burstein, MD, MPH
Erie County Department of Health
Associate Professor of Clinical Pediatrics
Women and Children's Hospital of Buffalo
Medically Reviewed by Allison Eliscu, MD, FAAP
Assistant Professor of Clinical Pediatrics
Division Chief of Adolescent Medicine
Stony Brook Children’s Hospital
Stony Brook, NY
- Overview & Diagnosis
- Treatment & Prevention
- Facts to Know & Questions to Ask
- Key Q&A
- Lifestyle Tips
- Organizations and Support
What Is It?
Gonorrhea is a curable sexually transmitted disease (STD), second only to chlamydia as the most frequently reported STD in the United States. Gonorrhea is caused by Neisseria gonorrhoeae, also called the gonococcus.
Untreated gonorrhea can cause infertility, especially in females. If you are under the age of 25 and sexually active, you should get tested annually for this disease. 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 STD has gradually declined substantially since a national control program was instituted in 1975. However, gonorrhea rates have not decreased in this decade, and rates in the United States remain higher than in any other industrialized country.
In 2011, 321,849 cases of gonorrhea were reported to Centers for Disease Control and Prevention (CDC); however, over 700,000 cases are believed to occur annually. Rates of infection are higher among young people, females, men who have sex with men and African Americans, particularly those in urban areas.
Gonorrhea is spread during sexual intercourse, whether it is vaginal, oral or anal. Even without anal sex, females 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 STDs, infection is transmitted more readily from males to females than from females to males.
Gonorrhea can also be transmitted between male partners through sexual contact; indeed, the rates of gonorrhea are higher in men who have sex with men than in females or heterosexual males. All men who have sex with men should be screened for STDs, including gonorrhea, at least annually. Those at higher risk should be screened more frequently.
For females, 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.
For males, the most common site of infection is the urethra, and rectal infection is common in men who have anal sex with men or females. Both males and females may get gonorrhea infections of the throat from oral sex. Although uncommon, in both males and females, untreated gonorrhea can lead to serious systemic infections, including disseminated gonococcal infection in the joints, skin, heart or blood.
Pregnant females 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.
Females who have gonorrhea often have no symptoms or only mild symptoms, such as increased vaginal discharge, until the infection has spread into the upper genital tract, and they experience pain from PID. When it leads to symptoms in males, gonorrhea usually causes 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 females. Males may be infected in the urethra without symptoms, but this is less common than asymptomatic infection in females.
Many people infected with gonorrhea are also infected with chlamydia at the same time. Both these bacterial STDs are often present without symptoms and are transmitted in the same way. Therefore, treatment for gonorrhea is almost always accompanied by routine treatment for chlamydia infection at the same time.
When symptoms occur in infected females, 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. Females 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 and tubo-ovarian abscess. It is difficult to diagnose. Its signs and symptoms vary widely, and many females have only subtle symptoms. Other females 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 surgically inserted near or through the belly button to examine the pelvic area.
Because gonorrhea is often present in females without recognizable symptoms, it is recommended that sexually active females, 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 females at risk for infection.
Risk factors for gonorrhea include:
- being younger than 25 years old
- having a previous gonorrhea or other sexually transmitted diseases
- having new or multiple sexual partners
- using condoms inconsistently
- doing sex work
- drug use
It's a common misconception that the use of an intrauterine device (IUD) increases the risk of developing PID. The risk of developing PID is minimally increased during the first 20 days after insertion of the device, but after that time, the risk returns to baseline. This risk can be reduced by testing women for STDs before IUD insertion and treating appropriately. IUDs are an extremely safe and effective means of preventing pregnancy, with less than 1 percent unintended pregnancies per year.
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 females 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 sexually transmitted diseases (STDs).
Gonorrhea is diagnosed by identifying the gonococcus at common sites of infection (the cervix in females and the urethra in males), 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 the gonococcus at sites of infection:
- NAATs (nucleic acid amplification tests): To detect gonococcal DNA or RNA, using swab specimens from the cervix, vagina, rectum or throat. When pelvic exams or vaginal swabs are not practical, urine can be tested instead. Urine is the preferred specimen for testing males.
- Gram stain: Looking for the gonococcus under a microscope, used primarily in males with gonorrhea of the penis (this test does not work well in females or for infections of the rectum or throat and is not available in every office). However, this test has the advantage of speed, giving results within a few minutes.
- Culture: Growing the bacteria in the laboratory, typically requiring three to four days to get test results.
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. NAATs have revolutionized gonorrhea and chlamydia control, because they permit screening of large numbers of males and females, 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. NAATs are much more sensitive than any other genial gonorrhea test, even for testing the throat and rectum.
If you test positive for gonorrhea, the infection can be cured with antibiotics. Because resistance to N. gonorrhoeae is emerging in the United States, as well in other parts of the world, the main recommended treatment for gonorrhea is two antibiotics taken at the same time: ceftriaxone (Rocephin), which requires a single injection, plus either azithromycin (Zithromax), orally in a single dose, or doxycycline tablets (Vibramycin, Doryx, and generic brands) twice daily by mouth for seven days.
If your health care provider doesn't offer intramuscular injections, you will not be able to be treated with ceftriaxone. Instead, the treatment likely will be cefixime (Suprax), which is taken in a single dose by mouth, plus either azithromycin orally in a single dose or doxycycline tablets twice daily by mouth for seven days. If cefixime is used as an alternative treatment, the Centers for Disease Control and Prevention recommends you return in one week for a repeat test to make sure the infection has been cured.
The group of antibiotics called fluoroquinolones were used frequently for gonorrhea until a few years ago but are no longer recommended because gonococcus strains resistant to these drugs have spread worldwide and now are common in the United States. The best-known fluoroquinolone is ciprofloxacin (Cipro).
If you are pregnant and are also infected with gonorrhea, you can be treated without harming the fetus, but some drugs are less effective or less safe than in nonpregnant females. Therefore, it is critical that you tell your health care professional that you are pregnant. Most importantly, pregnant females should not take doxycycline.
According to CDC, an estimated 13,200 pregnant females are infected with gonorrhea each year, and those who are infected put their infants at high risk of developing health problems, including eye inflammation (conjunctivitis). Infants with gonorrhea may be born prematurely. They also may experience reactive arthritis (a common cause of arthritis in childhood that usually follows a viral infection such as strep, meningitis or gonorrhea) and gonococcal scalp abscesses.
Detecting infection in newborns, which is often without symptoms, requires sensitive and specific methods, including NAATs, 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.
Some gonococcal organisms have become resistant to some antibiotics, and therefore a repeat culture and an alternate antibiotic may be needed if symptoms persist in spite of a full course of treatment. 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 too often partners 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 to four months after treatment or whenever you can after a month following treatment.
In general, treatment is recommended for any partners with whom you've had sexual contact up to 60 days before having symptoms or a diagnosis of gonorrhea or if the last time you had sex before your diagnosis was more than 60 days, your last partner should be treated for exposure of infection.
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
- 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 females may need surgery to remove scar tissue and blockages caused by long-term infection.
Scientists recently have determined the sequence of the Neisseria gonorrhoeae bacterial genome. The sequence represents an encyclopedia of information about the bacterium that causes gonorrhea. This accomplishment will give scientists important information as they try to develop a safe and effective vaccine and attempt to better understand how the bacterium becomes antibiotic-resistant.
In addition, the National Institute of Allergy and Infectious Diseases (NIAID) is supporting a comprehensive program of research on gonorrhea. Researchers are looking into how gonococci bypass the human immune system to infect cells. They hope to develop improvements in the diagnosis and treatment of the infection. Specifically, researchers are examining the human response to gonococci infection, how the gonococci bacteria attaches to host cells, how it gets inside cells and how the gonococcal surface structures can change.
Because of the increase in antibiotic-resistant strains of the infection, scientists also hope to prevent antibiotic resistance from spreading and to develop new antibiotics for the treatment of gonorrhea.
The NIAID research is also examining potential topical microbicides, preparations that females can insert into the vagina to prevent gonorrhea infection.
Protecting yourself from gonorrhea requires the same care and attention needed to prevent other sexually transmitted diseases (STDs). 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 STD, 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 STDs.
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 sexually transmitted disease agents, including HIV.
- Lesbians 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. Do not use saliva or oil-based lubricants such as petroleum jelly or vegetable shortening. Over-the-counter vaginal contraceptives that contain the spermicide nonoxynol-9 include a warning label from the U.S. Food and Drug Administration (FDA) stating that vaginal contraceptives containing nonoxynol-9 do not protect against infection from HIV (human immunodeficiency virus, the AIDS virus) or other STDs. 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 STDs from infected partners. If you decide to use a spermicide along 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 15- to 19-year-old and 20- to 24-year-old females and 20- to 24-year-old males.
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. Many cases of gonorrhea produce no symptoms; this is especially true in females. Diagnosis most often results from partner notification as a result of infection in males, which usually produces symptoms.
4. According to recent statistics provided by the U.S. Centers for Disease Control and Prevention, rates of the disease decreased nearly 74 percent annually from 1975 to 1997, Rates of the infection began to plateau for several years and then decreased further in 2009. The rate slightly increased again in 2010 and 2011, with 321,849 cases reported in the United States in 2011. Currently, over 700,000 estimated new infections with N. gonorrhoeae occur each year in the United States.
5. Research has shown that females infected with gonorrhea are more at risk for acquiring HIV than females not exposed.
6. Females with untreated gonorrhea are at increased risk for PID. Some females with PID become infertile and others may experience chronic pelvic pain or life-threatening ectopic pregnancy.
7. Gonorrhea and chlamydia cause at least two-thirds of the cases of PID.
8. It is important that you are prescribed the right type of antibiotics for gonorrhea. Because of increased antibiotic resistance, the CDC no longer recommends fluoroquinolones for the treatment of gonorrhea, nor do they recommend oral-only treatment, such as cefixime (Suprax), as a first line of treatment. The most common antibiotic used for gonorrhea treatment is the injectable cephalosporin ceftriaxone (Rocephin), plus either azithromycin or doxycycline.
9. Between 2010 and 2011, gonorrhea rates increased among all regions of the country. In 2011, gonorrhea rates were highest in the South, followed by the Midwest, Northeast and West.
10. Young children who have gonorrhea almost always have been exposed through sexual abuse.
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.
How is gonorrhea diagnosed? Which tests or exams will I have to have?
If I'm infected, what should I tell my partner?
How long should I abstain from sex after treatment begins?
How do I know if the infection has damaged my reproductive tract?
If gonorrhea often doesn't cause any symptoms, how do I know if I have been infected and, if so, for how long?
Is it possible I am infected with chlamydia as well?
If I am pregnant and infected, what are my chances of passing the infection to my baby?
Do I need to be retested after treatment to be sure I am cured?
What are the symptoms of pelvic inflammatory disease?
1. What is gonorrhea?
Gonorrhea infection is caused by a bacterium called Neisseria gonorrhoeae. The bacterium can be transmitted during vaginal, oral or anal sexual contact with an infected person. If left untreated, it can lead to infertility and serious pregnancy-related complications, such as premature delivery and tubal pregnancy.
2. If a gonorrhea infection usually doesn't cause symptoms, why is it necessary to get treated?
Even though infection often occurs without symptoms, it can still cause serious consequences for females and their infants. Also, the only way to stop the spread of the disease is by treating everyone infected, whether they have symptoms or not.
3. How will gonorrhea infection affect my chances of getting pregnant?
It depends on several factors, such as how long you have been infected and whether the infection has migrated into your upper genital tract. Pelvic inflammatory disease, which can be caused by untreated gonorrhea infection, increases the chances of infertility in females who have the condition.
4. Does having gonorrhea put me at greater risk for other sexually transmitted diseases (STDs)?
Yes. Gonorrhea infection increases your risk of HIV by producing more of the type of white blood cells to which HIV attaches itself. The risk factors for gonorrhea also put you at risk for other STDs, especially chlamydia, which is often found in the same populations that are infected with gonorrhea.
5. What are the side effects from gonorrhea treatment?
Gonorrhea can be cured with antibiotics without causing significant side effects. However, you must receive an injection and/or take all of the prescribed pills to be cured.
6. How is pelvic inflammatory disease treated?
Most cases of PID are treated adequately with a combination of oral antibiotics and a single intramuscular injection. More serious cases may require intravenous antibiotics, hospitalization and maybe even surgery.
7. Can a pregnant female pass on gonorrhea to her infant?
Yes. The infection can be transmitted during birth and can cause eye, ear and lung infection in a newborn. Fortunately, a pregnant female can take medication that will cure gonorrhea without harming her or her child.
8. How often should I be tested for gonorrhea?
If you are sexually active and under the age of 25, you should be screened at least once a year. If you suspect you have been exposed, see your health care professional immediately.
10. What are the greatest risk factors for gonorrhea infection?
Having unprotected sex creates the biggest risk of infection. Also, starting sex early and having multiple partners increases your risk of infection.
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 females 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 abdominal pain and ectopic, or tubal, pregnancy. Others may experience chronic pelvic pain or life-threatening ectopic pregnancy. To prevent PID, make sure your partners are screened for STDs, 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 STDs. 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 STDs 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 sexually transmitted diseases. Most STDs 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 sexually transmitted disease is a latex condom. However, it doesn't provide 100 percent protection against STDs––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 you 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. Pinch the tip of the condom to leave room for semen collection. 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 STDs
No single test screens for all STDs. Some require a vaginal 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 STDs 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. Or call the CDC at 1-800-CDC-INFO (1-800-232-4636) or log on to http://hivtest.cdc.gov/STDTesting.aspx to find free or low-cost clinics in your area.
5. Know whether you have an STD
While some STDs 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 STD just by looking. Don't rely on a partner's self reporting and assume that will prevent you from acquiring an STD. 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 STD. 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 STDs
Sexually transmitted diseases are particularly common among adolescents. And it's an issue kids are concerned about. Parents can play a large role in their adolescents' behavior, both in terms of the behavior you model yourself and in terms of the communication between you and your teens. 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 STDs 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
American Social Health Association (ASHA)
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Email: [email protected]
ASHA's STI Resource Center Hotline
Address: American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709
Address: 834 Chestnut Street, Suite 400
Philadelphia, PA 19107
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: [email protected]
National Family Planning and Reproductive Health Association (NFPRHA)
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Email: [email protected]
Planned Parenthood Federation of America
Address: 434 West 33rd Street
New York, NY 10001
Hotline: 1-800-230-PLAN (1-800-230-7526)
Sexuality Information and Education Council of the United States (SIECUS)
Address: 90 John Street, Suite 704
New York, NY 10038
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
Medline Plus: Gonorrhea
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: [email protected]
CDC and Prevention
Address: CDC National Prevention Information Network (NPIN)
P.O. Box 6003
Rockville, MD 20894
Email: [email protected]