What are the symptoms and treatments of chlamydia and gonorrhea?

Symptoms of Chlamydia and Gonorrhea

Critical Clinical Point: Most Infections Are Asymptomatic

The majority of chlamydia and gonorrhea infections are asymptomatic—chlamydia causes symptoms in only a minority of infected women, and approximately 70% of chlamydia and trichomoniasis infections and 53-100% of extragenital gonorrhea and chlamydia are asymptomatic or minimally symptomatic. 1, 2 This is why screening, not symptom-based diagnosis, is the cornerstone of prevention and control 1, 3.

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Symptoms in Women

Chlamydia

• Vaginal discharge (when symptomatic) 1, 4
• Dysuria (painful urination) 1, 4
• Lower abdominal pain (suggests ascending infection to upper reproductive tract) 1, 4
• Abnormal vaginal bleeding (intermenstrual or postcoital bleeding) 4
• Dyspareunia (painful intercourse) 4
• Mucopurulent cervicitis (yellow endocervical discharge visible on examination) 1

Gonorrhea

• Mucopurulent or purulent cervical discharge 1
• Dysuria 1
• Abnormal vaginal bleeding 1
• Lower abdominal pain (if pelvic inflammatory disease develops) 1

Important Caveat

Most women with chlamydia or gonorrhea do not have mucopurulent cervicitis—this finding is not a sensitive predictor of infection 1. Many women with tubal-factor infertility from these infections never had recognized symptoms of salpingitis 1.

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Symptoms in Men

Chlamydia

• Urethritis (most common manifestation) 4
• Urethral discharge (often clear or white, less purulent than gonorrhea) 4
• Dysuria 4
• Mucopurulent or purulent discharge (when urethritis is present) 1

Gonorrhea

• Purulent urethral discharge (typically more profuse and purulent than chlamydia) 1
• Dysuria 1
• Urethritis with >5 WBCs per oil immersion field on Gram stain 1

Nongonococcal Urethritis (NGU) Diagnostic Criteria

Urethritis can be documented by: 1

• Mucopurulent or purulent discharge
• Gram stain showing ≥5 WBCs per oil immersion field
• Positive leukocyte esterase test on first-void urine
• Microscopic examination showing ≥10 WBCs per high power field in first-void urine

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Extragenital Manifestations

Rectal Infections (Both Infections)

• Generally asymptomatic 4
• Rectal discharge (when symptomatic) 4
• Pain during defecation 4
• Symptoms of proctocolitis 4
• More common in persons engaging in receptive anal intercourse 4

Pharyngeal Infections

• Chlamydia: Can occur but not established as a cause of pharyngitis 4
• Gonorrhea: Often asymptomatic 1

Ocular Manifestations

• Conjunctivitis in adults through exposure to infectious genital secretions or autoinoculation 4
• Neonatal conjunctivitis: Chlamydia is the most common cause (15-25% of exposed infants) 4
• Neonatal pneumonia: 3-16% of infants exposed to chlamydia during delivery 4

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Serious Complications (Often Without Preceding Symptoms)

In Women

• Pelvic inflammatory disease (PID): Estimated 8-30% of untreated chlamydia cases develop salpingitis 1
• Endometritis and salpingitis 1, 4
• Tubal-factor infertility: 17% of women treated for PID become infertile 1
• Ectopic pregnancy: 10% of women with PID who conceive 1
• Chronic pelvic pain: 17% of women after PID 1
• Perihepatitis (Fitz-Hugh-Curtis syndrome) 4
• Postpartum or post-abortion endometritis: 10-34% of untreated pregnant women 1

In Men

• Epididymitis 5, 2
• Epididymo-orchitis 6

Both Sexes

• Reactive arthritis (formerly Reiter's syndrome): Develops 1-4 weeks after genital infection, characterized by inflammation of joints, eyes, and urogenital tract 4
• Increased risk of HIV acquisition and transmission 5, 2

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Key Clinical Pitfalls to Avoid

1. Do not rely on symptoms for diagnosis: The absence of symptoms does not indicate absence of infection or potential complications 1, 7. Untreated infections persist for months, during which complications develop and transmission occurs 1, 7.

2. Screen based on risk factors, not symptoms: All sexually active women <25 years and those ≥25 years with risk factors should be screened annually 1, 3, 5.

3. Test for both infections simultaneously: Because coinfection occurs and specific diagnosis facilitates partner treatment 1.

4. Consider extragenital sites: Obtain pharyngeal and rectal specimens in men who have sex with men and in persons with relevant sexual practices 3.

5. Recognize subclinical upper tract infection: Some women with apparently uncomplicated cervical infection already have subclinical endometritis or salpingitis 1.

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Treatment Overview (Brief)

Chlamydia

• Preferred: Doxycycline 100 mg orally twice daily for 7 days 1, 6, 3, 8
• Alternative: Azithromycin 1 g orally as single dose 1, 9

Gonorrhea

• Recommended: Ceftriaxone 500 mg IM single dose (for patients <150 kg) 3, 8
• Concomitant chlamydia treatment recommended due to frequent coinfection 1

Partner Management

• Evaluate and treat all sex partners within 60 days of symptom onset or diagnosis 1, 7
• Treat the most recent partner even if last contact was >60 days ago 7
• Patients should abstain from intercourse until 7 days after single-dose therapy or completion of 7-day regimen 7

Follow-up Testing

• Retest at 3 months after treatment due to high reinfection rates, especially in women 1, 7, 3
• Test of cure not routinely needed except in pregnancy 7, 3