Gonorrhea: Symptoms and Treatment
Clinical Presentation
Gonorrhea presents differently in men and women, with men typically developing symptomatic urethritis while women are frequently asymptomatic, making screening essential to prevent serious complications like pelvic inflammatory disease and infertility.
Symptoms in Men
- Urethral discharge (mucopurulent or purulent) and dysuria are the hallmark symptoms, prompting most men to seek treatment before serious sequelae develop 1
- Symptoms typically appear within days of infection, with median time to symptom resolution of 2 days after effective treatment 2
- May also present with epididymitis, proctitis, or prostatitis 3
Symptoms in Women
- Majority of infections are asymptomatic, which is why screening is critical 1
- When symptomatic, women may experience mucopurulent vaginal discharge, dysuria, pelvic discomfort, or cervical motion tenderness 1, 4
- Symptom resolution takes longer in women (median 4 days) compared to men (median 2 days) 2
- Untreated infection can progress to pelvic inflammatory disease (PID), leading to tubal scarring, infertility, or ectopic pregnancy 1
Other Manifestations
- Pharyngeal infection is often asymptomatic but common, especially in adolescents 5
- Anorectal infection may cause proctitis symptoms 4
- Disseminated gonococcal infection (DGI) presents with arthritis, tenosynovitis, and dermatitis 6
- Neonatal conjunctivitis and scalp abscesses in newborns exposed during delivery 4
Diagnostic Approach
Nucleic acid amplification tests (NAATs) are the diagnostic standard, with urine testing offering comparable sensitivity to urethral/cervical swabs.
- NAATs on first-void urine have sensitivity and specificity >95% for urogenital infections 4, 5
- Vaginal swabs (provider or self-collected) are increasingly preferred for women 5
- Gram stain of urethral discharge showing intracellular gram-negative diplococci has >99% specificity in symptomatic men but insufficient sensitivity in asymptomatic patients 1
- Culture with antimicrobial susceptibility testing is mandatory for treatment failures and pharyngeal infections 1, 7
- Test all patients for concurrent chlamydia, syphilis, and HIV 1, 4
Treatment Recommendations
The CDC recommends ceftriaxone 250 mg IM PLUS azithromycin 1 g orally as a single-dose dual therapy regimen for all uncomplicated gonorrhea, addressing both the infection and presumptive chlamydial coinfection.
Primary Regimen
- Ceftriaxone 250 mg IM (single dose) PLUS azithromycin 1 g orally (single dose) 7
- This dual therapy addresses rising antibiotic resistance and treats concurrent chlamydia (present in 40-50% of cases) 7
- Effective for cervical, urethral, rectal, and pharyngeal infections 7
- Never use azithromycin 1 g alone for gonorrhea—efficacy is only 93% 7
Alternative Regimens (When Ceftriaxone Unavailable)
- Cefixime 400 mg orally PLUS azithromycin 1 g orally (single doses) 7, 8
- Mandatory test-of-cure at 1 week required with this regimen due to declining cefixime effectiveness 7
Severe Cephalosporin Allergy
- Azithromycin 2 g orally (single dose) with mandatory test-of-cure at 1 week 7
- Lower efficacy (93%) and significant gastrointestinal side effects 7
- Alternative: Gentamicin 240 mg IM PLUS azithromycin 2 g orally (100% cure rate in trials) 7
Critical Pitfalls to Avoid
- Never use fluoroquinolones (ciprofloxacin, ofloxacin)—widespread resistance makes them ineffective despite historical 99.8% cure rates 1, 7
- Spectinomycin has only 52% efficacy for pharyngeal infections and should be avoided for this site 1, 7
- Gentamicin has only 20% efficacy for pharyngeal infections 7
- Pharyngeal gonorrhea is significantly harder to eradicate than urogenital infections—ceftriaxone is the only reliably effective treatment 7
Special Populations
Pregnancy
- Ceftriaxone 250 mg IM PLUS azithromycin 1 g orally 1, 7
- Never use quinolones, tetracyclines, or doxycycline in pregnancy 1, 7
Men Who Have Sex with Men (MSM)
- Only ceftriaxone-based regimens recommended due to higher prevalence of resistant strains 1, 7
- Do not use patient-delivered partner therapy in MSM due to high risk of undiagnosed coexisting STDs or HIV 1, 7
Pediatric Patients
- Erythromycin 50 mg/kg/day divided into 4 doses for 14 days (weight <45 kg) 1
- Azithromycin 1 g orally single dose (weight >45 kg but age <8 years) 1
- Adult regimens for children ≥8 years 1
Partner Management and Follow-Up
All sexual partners from the preceding 60 days must be evaluated and treated with the same dual therapy regimen, even if asymptomatic.
- Partners should receive ceftriaxone 250 mg IM PLUS azithromycin 1 g orally 1, 7
- Expedited partner therapy (patient-delivered medication) may be considered when partners cannot access timely care, using oral cefixime 400 mg PLUS azithromycin 1 g 7
- Patients must abstain from sexual intercourse until both they and partners complete therapy and are asymptomatic 1
- Retest all patients at 3 months due to high reinfection rates (not test-of-cure) 1, 4
- Routine test-of-cure is unnecessary with recommended regimens unless symptoms persist 1
Treatment Failure Management
If symptoms persist after treatment, obtain culture with antimicrobial susceptibility testing immediately and report to public health within 24 hours.
- Culture all relevant sites and perform phenotypic susceptibility testing 1, 7
- Consult infectious disease specialist 7
- Salvage regimens include gentamicin 240 mg IM PLUS azithromycin 2 g orally, or ertapenem 1 g IM for 3 days 7
- Most treatment failures occur with pharyngeal infections, not urogenital sites 7
Screening Recommendations
The USPSTF recommends annual screening for all sexually active women <25 years and older women with risk factors.
- Risk factors include: previous gonorrhea, other STDs, new/multiple partners, inconsistent condom use, commercial sex work, drug use 1
- Screen pregnant women at increased risk 1
- No routine screening recommended for low-risk men and women 1
- Consider pharyngeal screening in adolescents and MSM 5
Coinfection Considerations
Concurrent chlamydia infection occurs in 40-50% of gonorrhea cases and prolongs symptom resolution.