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About 10 to 20% of infected women and very few infected men are asymptomatic. About 25% of men have minimal symptoms.

Male urethritis has an incubation period from 2 to 14 days. Onset is usually marked by mild discomfort in the urethra, followed by more severe penile tenderness and pain, dysuria, and a purulent discharge. Urinary frequency and urgency may develop as the infection spreads to the posterior urethra. Examination detects a purulent, yellow-green urethral discharge, and the meatus may be inflamed.

Gonorrhea (Urethritis)

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Epididymitis usually causes unilateral scrotal pain, tenderness, and swelling. Rarely, men develop abscesses of Tyson and Littre glands, periurethral abscesses, or infection of Cowper glands, the prostate, or the seminal vesicles.

Cervicitis usually has an incubation period of > 10 days. Symptoms range from mild to severe and include dysuria and vaginal discharge. During pelvic examination, clinicians may note a mucopurulent or purulent cervical discharge, and the cervical os may be red and bleed easily when touched with the speculum. Urethritis may occur concurrently; pus may be expressed from the urethra when the symphysis pubis is pressed or from Skene ducts or Bartholin glands. Rarely, infections in sexually abused prepubertal girls cause dysuria, purulent vaginal discharge, and vulvar irritation, erythema, and edema.

Gonorrhea (Vaginitis)

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Pelvic inflammatory disease occurs in 10 to 20% of infected women. PID may include salpingitis, pelvic peritonitis, and pelvic abscesses and may cause lower abdominal discomfort (typically bilateral), dyspareunia, and marked tenderness on palpation of the abdomen, adnexa, or cervix.

Fitz-Hugh-Curtis syndrome is gonococcal (or chlamydial) perihepatitis that occurs predominantly in women and causes right upper quadrant abdominal pain, fever, nausea, and vomiting, often mimicking biliary or hepatic disease.

Rectal gonorrhea is usually asymptomatic. It occurs predominantly in men practicing receptive anal intercourse and can occur in women who participate in anal sex. Symptoms include rectal itching, a cloudy rectal discharge, bleeding, and constipation—all of varying severity. Examination with a proctoscope may detect erythema or mucopurulent exudate on the rectal wall.

Gonococcal pharyngitis is usually asymptomatic but may cause sore throat. N. gonorrhoeae must be distinguished from N. meningitidis and other closely related organisms that are often present in the throat without causing symptoms or harm.

Disseminated gonococcal infection (DGI), also called the arthritis-dermatitis syndrome, reflects bacteremia and typically manifests with fever, migratory pain or joint swelling (polyarthritis), and pustular skin lesions. In some patients, pain develops and tendons (eg, at the wrist or ankle) redden or swell. Skin lesions occur typically on the arms or legs, have a red base, and are small, slightly painful, and often pustular. Genital gonorrhea, the usual source of disseminated infection, may be asymptomatic. DGI can mimic other disorders that cause fever, skin lesions, and polyarthritis (eg, the prodrome of hepatitis B infection or meningococcemia); some of these other disorders (eg, reactive arthritis) also cause genital symptoms.

Disseminated Gonococcal Infection (Skin Lesions)

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Image courtesy of Dr. S. E. Thompson and J. Pledger via the Public Health Image Library of the Centers for Disease Control and Prevention.

Gonococcal septic arthritis is a more localized form of DGI that results in a painful arthritis with effusion, usually of 1 or 2 large joints such as the knees, ankles, wrists, or elbows. Some patients present with or have a history of skin lesions of DGI. Onset is often acute, usually with fever, severe joint pain, and limitation of movement. Infected joints are swollen, and the overlying skin may be warm and red.

• Nucleic acid–based testing

• Gram staining and culture

Gonorrhea is diagnosed when gonococci are detected via microscopic examination using a nucleic acid–based test, Gram stain, or culture of genital fluids, blood, or joint fluids (obtained by needle aspiration).

Nucleic acid amplification tests (NAATs) may be done on genital, rectal, or oral swabs and can detect both gonorrhea and chlamydial infection. NAATs further increase the sensitivity adequately to enable testing of urine samples in both sexes.

Gram stain is sensitive and specific for gonorrhea in men with urethral discharge; gram-negative intracellular diplococci typically are seen. Gram stain is much less accurate for infections of the cervix, pharynx, and rectum and is not recommended for diagnosis at these sites.

Meningococcal urethritis has been found as a cause of nongonococcal urethritis at some STI (sexually transmitted infection) centers in the US (1). Neisseria meningitidis cannot be distinguished from N. gonorrhoeae on Gram stain and has similar colony morphology appearance on culture. The diagnosis of presumed gonococcal urethritis on the basis of Gram stain with gram-negative diplococci but negative NAAT for gonorrhea requires confirmation of the Neisseria species by culture.

Culture is sensitive and specific, but because gonococci are fragile and fastidious, samples taken using a swab need to be rapidly plated on an appropriate medium (eg, modified Thayer-Martin) and transported to the laboratory in a carbon dioxide–containing environment. Blood and joint fluid samples should be sent to the laboratory with notification that gonococcal infection is suspected. Because NAATs have replaced culture in most laboratories, finding a laboratory that can provide culture and sensitivity testing may be difficult and require consultation with a public health or infectious disease specialist.

In the US, confirmed cases of gonorrhea, chlamydial infection, and syphilis must be reported to the public health system. Serologic tests for syphilis (STS) and HIV and NAAT to screen for chlamydial infection should also be done.

Asymptomatic patients considered at high risk of sexually transmitted infections (STIs) can be screened by NAAT of urine samples, thus not requiring invasive procedures to collect samples from genital sites. The following are based on CDC's  Sexually Transmitted Infections (STI) Treatment Guidelines, 2021.

Women are screened annually if they are sexually active and < 25 years of age or if they are ≥ 25 years of age, sexually active, and have one or more of the following risk factors:

• Have a history of a prior STI

• Engage in high-risk sexual behavior (eg, have a new sex partner or multiple sex partners; engage in sex work; or use condoms inconsistently when not in a mutually monogamous relationship)

• Have a partner who has an STI or engages in high-risk behavior (eg, a sex partner who has concurrent partners)

• Have a history of incarceration

Pregnant women who are < 25 years or who are ≥ 25 years with one or more of the risk factors are screened during their first prenatal visit and again during their 3rd trimester for women who are < 25 or at high risk.

There is insufficient evidence for screening heterosexual men who are at low risk for infection.

Men who have sex with men are screened at least annually if they have been sexually active within the previous year (for insertive intercourse, urine screen; for receptive intercourse, rectal swab; and for oral intercourse, pharyngeal swab), regardless of condom use. Those at increased risk (eg, with HIV infection, receive preexposure prophylaxis with antiretrovirals, have multiple sex partners, or whose partner has multiple partners) should be screened more frequently, at 3 to 6-month intervals.

Transgender and gender diverse people are screened if they are sexually active on the basis of sexual practices and anatomy (eg, annual screening for all people with a cervix who are < 25 years old; if ≥ 25 years old, people with a cervix should be screened annually if at increased risk; rectal swab based on reported sexual behaviors and exposure).

(See also the US Preventive Services Task Force’s summary of recommendations regarding screening for gonorrhea.)

• For uncomplicated infection, a single dose of ceftriaxone

• Concomitant treatment for chlamydial infection

• Treatment of sex partners

• For disseminated gonococcal infection (DGI) with arthritis, a longer course of parenteral antibiotics

Uncomplicated gonococcal infection of the urethra, cervix, rectum, and pharynx is treated with the following:

• A single dose of ceftriaxone 500 mg IM (1 g IM for patients weighing ≥ 150 kg)

If ceftriaxone is not available, use cefixime 800 mg orally in a single dose. 

If chlamydial infection has not been excluded, treat for chlamydia with doxycycline 100 mg orally twice a day for 7 days. In patients who have a doxycycline allergy, treat for chlamydia with a single dose of azithromycin 1 g orally.

Patients who are allergic to cephalosporins (including ceftriaxone) are treated with

• Gentamicin 240 mg IM in a single dose plus azithromycin 2 g orally in a single dose

DGI with gonococcal arthritis is initially treated with IM or IV antibiotics (eg, ceftriaxone 1 g IM or IV every 24 hours, ceftizoxime 1 g IV every 8 hours, cefotaxime 1 g IV every 8 hours) continued for 24 to 48 hours once symptoms lessen, followed by oral therapy guided by antimicrobial susceptibility testing, for a total treatment course of at least 7 days. If chlamydial infection has not been excluded, add doxycycline 100 mg orally twice a day for 7 days (1).

Gonococcal purulent arthritis usually requires repeated synovial fluid drainage either with repeated arthrocentesis or arthroscopically. Initially, the joint is immobilized in a functional position. Passive range-of-motion exercises should be started as soon as patients can tolerate them. Once pain subsides, more active exercises, with stretching and muscle strengthening, should begin. Over 95% of patients treated for gonococcal arthritis recover complete joint function. Because sterile joint fluid accumulations (effusions) may develop and persist for prolonged periods, an anti-inflammatory drug may be beneficial.

Posttreatment cultures are unnecessary if symptomatic response is adequate. However, for patients with symptoms for > 7 days, specimens should be obtained, cultured, and tested for antimicrobial sensitivity.

Patients should abstain from sexual activity until treatment is completed to avoid infecting sex partners.

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

1. US Preventive Services Task Force: Chlamydia and Gonorrhea: Screening: A review of evidence that screening tests can accurately detect chlamydia and gonorrhea