Gonorrhea: Symptoms, Treatment & How to Prevent STI

What Is Gonorrhea and How Common Is It?

Gonorrhea is a sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae that can infect the genitals, rectum, and throat. With approximately 87 million new cases globally each year, it is the second most common bacterial STI after chlamydia. The infection is curable with antibiotics but can cause serious complications if left untreated.

Gonorrhea has been affecting humans for centuries and remains one of the most prevalent sexually transmitted infections worldwide. The bacterium that causes gonorrhea, Neisseria gonorrhoeae (also called gonococcus), specifically targets the mucous membranes of the reproductive tract, including the cervix, uterus, and fallopian tubes in women, and the urethra in both men and women. It can also infect the mucous membranes of the mouth, throat, eyes, and rectum.

According to the World Health Organization (WHO), gonorrhea affects people of all ages who are sexually active, but rates are highest among adolescents and young adults aged 15-29. The infection can be transmitted through vaginal, anal, or oral sexual contact with an infected partner. It cannot be spread through casual contact like hugging, sharing food, or using the same toilet seat.

One of the most concerning aspects of gonorrhea is that many infected individuals experience no symptoms, particularly women. This means the infection can spread unknowingly between partners and cause damage to the reproductive system before being detected. The bacteria can survive in warm, moist areas of the body, which is why it can infect multiple sites simultaneously.

Understanding the basics of gonorrhea is essential for prevention, early detection, and effective treatment. The infection responds well to antibiotic therapy when diagnosed early, but delays in treatment can lead to serious health complications including infertility, ectopic pregnancy, and increased susceptibility to HIV infection.

Why Is Gonorrhea a Public Health Concern?

Gonorrhea presents significant challenges for public health systems worldwide. The emergence of antibiotic-resistant strains of Neisseria gonorrhoeae has been identified by the WHO as one of the most urgent antimicrobial resistance threats. Some strains have developed resistance to nearly all antibiotics used for treatment, making effective treatment increasingly difficult.

The high rate of asymptomatic infections contributes to ongoing transmission within communities. When people don't know they're infected, they continue sexual activity without taking precautions, unknowingly passing the infection to others. This creates a cycle of transmission that can only be broken through widespread screening programs and partner notification.

What Are the Symptoms of Gonorrhea?

Gonorrhea symptoms typically appear 1-14 days after infection and include painful urination, abnormal discharge from the penis or vagina, testicular pain in men, and bleeding between periods in women. However, many people have no symptoms at all—about 50% of women and 10% of men are asymptomatic, which is why testing is essential.

The presentation of gonorrhea symptoms varies significantly between individuals and depends on the site of infection. Understanding these symptoms is crucial for early detection, but it's equally important to recognize that the absence of symptoms does not mean the absence of infection. Many people carry and transmit gonorrhea without ever experiencing any noticeable signs.

When symptoms do occur, they typically develop within one to fourteen days after exposure to the bacteria, though some people may not notice symptoms for weeks. The severity of symptoms can range from mild discomfort to more pronounced signs of infection. In all cases, seeking medical evaluation and testing is important if there's any possibility of exposure.

Symptoms in Men

Men are more likely to experience noticeable symptoms than women, with approximately 90% of infected men developing some signs of infection. The most common symptoms in men include:

• Painful or burning urination (dysuria): Often described as a burning sensation when passing urine, this is frequently the first symptom men notice
• Urethral discharge: A white, yellow, or green discharge from the tip of the penis, which may be particularly noticeable in the morning
• Testicular pain or swelling: One or both testicles may become painful or swollen due to epididymitis (infection of the epididymis)
• Frequent urination: An increased need to urinate, often with small amounts of urine
• Itching or irritation inside the urethra: Discomfort within the penis may be present

Symptoms in Women

Women are more likely to have asymptomatic infections, which is particularly concerning because untreated gonorrhea can lead to serious reproductive complications. When symptoms do occur in women, they may be mild and easily mistaken for other conditions:

• Increased vaginal discharge: May be watery, creamy, or slightly green in color
• Painful urination: Burning or stinging sensation when urinating
• Bleeding between periods: Spotting or irregular bleeding outside the normal menstrual cycle
• Heavier periods: Menstrual periods may be heavier than usual
• Pelvic or abdominal pain: Lower abdominal discomfort, which may indicate spread of infection to reproductive organs
• Pain during intercourse: Discomfort during vaginal penetration

Symptoms Based on Infection Site

Gonorrhea can infect areas beyond the genitals, and symptoms vary depending on where the infection occurs:

How Is Gonorrhea Transmitted?

Gonorrhea spreads through sexual contact including vaginal, anal, and oral sex with an infected person. The bacteria are transmitted through semen, pre-ejaculate, and vaginal fluids. An infected pregnant person can also pass gonorrhea to their baby during childbirth. Gonorrhea cannot spread through casual contact, toilet seats, or swimming pools.

Understanding how gonorrhea spreads is essential for prevention. The bacterium Neisseria gonorrhoeae is highly adapted to human hosts and requires direct contact with infected mucous membranes or bodily fluids to survive and spread. Unlike some other bacteria, it cannot survive for long outside the human body, which limits its transmission routes.

Sexual transmission occurs when infected mucous membranes (in the genitals, rectum, or throat) come into contact with uninfected mucous membranes. The bacteria are present in genital secretions including semen, pre-ejaculatory fluid (pre-cum), and vaginal fluids. Even without ejaculation, the bacteria can be transmitted through genital-to-genital contact.

Oral sex presents a particular challenge because many people don't consider it a risk for STI transmission. However, giving oral sex to someone with genital gonorrhea can result in throat (pharyngeal) infection, and receiving oral sex from someone with throat gonorrhea can lead to genital infection. Pharyngeal gonorrhea is usually asymptomatic, making it a hidden reservoir for transmission.

Anal sex, whether receptive or penetrative, can transmit gonorrhea to and from the rectum. Rectal infections may be asymptomatic or cause symptoms like discharge, bleeding, and discomfort. Using condoms correctly during anal sex significantly reduces but doesn't completely eliminate transmission risk.

Mother-to-Child Transmission

Pregnant individuals with untreated gonorrhea can pass the infection to their baby during vaginal delivery. The bacteria can infect the baby's eyes, leading to a condition called gonococcal ophthalmia neonatorum, which can cause blindness if not treated promptly. This is why prenatal screening for gonorrhea is recommended, and why antibiotic eye drops or ointment are routinely applied to newborns' eyes in many healthcare settings.

What Doesn't Transmit Gonorrhea

It's equally important to understand what activities do NOT spread gonorrhea:

• Hugging, kissing (mouth to mouth), or holding hands
• Sharing food, drinks, or eating utensils
• Using the same toilet seat, towels, or bathing facilities
• Swimming pools, hot tubs, or saunas
• Coughing or sneezing

How Is Gonorrhea Diagnosed and Tested?

Gonorrhea is diagnosed through laboratory testing of urine samples or swabs taken from potentially infected sites (urethra, cervix, throat, or rectum). Nucleic acid amplification tests (NAATs) are the most sensitive and commonly used testing method. Results typically take 1-7 days, and testing can detect infection about one week after exposure.

Testing for gonorrhea is straightforward, confidential, and widely available through healthcare providers, sexual health clinics, and home testing kits. Because many infections are asymptomatic, anyone who is sexually active should consider regular STI testing as part of their healthcare routine, regardless of whether they have symptoms.

The timing of testing matters for accuracy. The recommended window for gonorrhea testing is at least one week after potential exposure. Testing too soon after exposure may result in a false-negative result because the bacteria haven't multiplied to detectable levels yet. If you have symptoms, however, testing should be done regardless of when exposure occurred.

Types of Tests

Several testing methods are available for diagnosing gonorrhea:

• Nucleic Acid Amplification Tests (NAATs): The most sensitive and commonly used tests. They detect the genetic material of the bacteria and can be performed on urine samples or swabs. NAATs are highly accurate and can detect infections at multiple sites.
• Culture tests: Involve growing the bacteria in a laboratory. While not as sensitive as NAATs, cultures are important for determining antibiotic resistance patterns. They require a swab sample and take longer for results.
• Gram stain: A rapid microscopy test that can provide immediate results by examining discharge under a microscope. It's most useful for symptomatic men but less sensitive for women and asymptomatic infections.

Where Samples Are Collected

The location of sample collection depends on the type of sexual activity and potential exposure sites:

• Urine sample: Non-invasive option for detecting urethral and cervical infections
• Urethral swab: For men, may be taken from inside the tip of the penis
• Cervical or vaginal swab: For women, can often be self-collected
• Rectal swab: If you've had receptive anal sex
• Throat swab: If you've had oral sex (giving)

How Is Gonorrhea Treated?

Gonorrhea is treated with antibiotics, typically a single injection of ceftriaxone. Treatment cures the infection but doesn't provide immunity—you can get gonorrhea again. It's crucial to complete treatment, avoid sex until cleared, get a follow-up test of cure, and ensure all recent partners are tested and treated.

The good news about gonorrhea is that it's completely curable with appropriate antibiotic treatment. However, successful treatment requires more than just taking medication—it involves completing the full course of antibiotics, abstaining from sexual activity until treatment is complete and confirmed effective, and ensuring sexual partners receive treatment too.

Treatment recommendations have evolved over time due to the emergence of antibiotic-resistant strains of Neisseria gonorrhoeae. What worked decades ago may no longer be effective today, which is why following current treatment guidelines is essential. Self-treating with leftover antibiotics or antibiotics obtained without a prescription is not recommended and can contribute to resistance.

Current Treatment Guidelines

According to current CDC and WHO guidelines, the recommended treatment for uncomplicated gonorrhea is:

• First-line treatment: A single intramuscular injection of ceftriaxone 500mg (or 1g for persons weighing ≥150 kg)
• Alternative when ceftriaxone is not available: Gentamicin 240mg IM plus azithromycin 2g orally
• For chlamydia co-infection: Add doxycycline 100mg orally twice daily for 7 days if chlamydia is detected or not ruled out

What to Expect During Treatment

Treatment for gonorrhea is usually straightforward and completed in a single clinic visit:

1. Receive the injection: Ceftriaxone is given as an intramuscular injection, usually in the buttock or thigh
2. Abstain from sex: Do not have any sexual contact for 7 days after treatment and until any symptoms have resolved
3. Return for test of cure: Come back 1-2 weeks after treatment for a follow-up test to confirm the infection has cleared
4. Notify partners: Inform all sexual partners from the past 60 days so they can be tested and treated

Why Follow-Up Testing Matters

A test of cure (follow-up testing after treatment) is increasingly important due to antibiotic resistance concerns. This test confirms that the treatment successfully eliminated the bacteria. It should be done 1-2 weeks after completing treatment. If you have ongoing symptoms or your test remains positive, you may need additional treatment with different antibiotics.

Treatment for Sexual Partners

All sexual partners from the past 60 days (or your most recent partner if it's been longer) should be notified, tested, and treated for gonorrhea regardless of whether they have symptoms. This is called expedited partner therapy (EPT) or partner treatment. Some healthcare providers can provide antibiotics for partners who can't easily access healthcare.

What Complications Can Untreated Gonorrhea Cause?

Untreated gonorrhea can lead to serious complications including pelvic inflammatory disease (PID), infertility in both men and women, ectopic pregnancy, chronic pelvic pain, and increased risk of HIV. In rare cases, the bacteria can spread to the blood and joints (disseminated gonococcal infection), which can be life-threatening.

While gonorrhea is easily treatable, leaving it untreated can result in significant and sometimes permanent health consequences. The longer the infection persists, the greater the risk of complications. This is particularly concerning given that many infections are asymptomatic, allowing the bacteria to silently damage reproductive organs over time.

The risk of developing complications increases with each untreated infection. Someone who has had gonorrhea multiple times without treatment faces a higher cumulative risk of fertility problems and other issues. Additionally, having gonorrhea makes the genital tissues more susceptible to other infections, including HIV.

Complications in Women

Women face particularly serious risks from untreated gonorrhea because the infection can spread upward from the cervix to the uterus, fallopian tubes, and ovaries:

• Pelvic Inflammatory Disease (PID): The bacteria can cause inflammation and scarring of the reproductive organs. PID affects about 10-15% of women with untreated gonorrhea and can cause chronic pelvic pain.
• Infertility: Scarring in the fallopian tubes can block the passage of eggs, making pregnancy difficult or impossible. Even a single episode of PID significantly increases infertility risk.
• Ectopic pregnancy: Scarring can cause fertilized eggs to implant in the fallopian tube instead of the uterus—a life-threatening emergency.
• Chronic pelvic pain: Persistent pain that can interfere with daily activities and quality of life.

Complications in Men

While men are less likely to experience complications from gonorrhea, untreated infections can still cause serious problems:

• Epididymitis: Inflammation of the epididymis (the tube carrying sperm from the testicle) causing pain, swelling, and potential fertility problems.
• Prostatitis: Infection can spread to the prostate gland, causing pain and urination problems.
• Urethral stricture: Scarring can narrow the urethra, making urination difficult and potentially requiring surgical correction.
• Infertility: Severe or repeated infections can affect sperm production and transport.

Disseminated Gonococcal Infection (DGI)

In rare cases (1-3% of untreated infections), the bacteria can enter the bloodstream and spread throughout the body, causing a condition called disseminated gonococcal infection. This serious complication can cause fever, skin lesions, joint pain and swelling (septic arthritis), and in severe cases, infection of the heart valves (endocarditis) or brain (meningitis). DGI requires hospitalization and intravenous antibiotics.

How Can You Prevent Gonorrhea?

Prevent gonorrhea by using condoms correctly and consistently during vaginal, anal, and oral sex; getting tested regularly if sexually active; being in a mutually monogamous relationship with a tested partner; and having open conversations about sexual health. Using dental dams during oral sex and avoiding sharing sex toys also reduces risk.

Preventing gonorrhea requires a combination of personal protective measures, regular testing, and open communication with sexual partners. No prevention method is 100% effective except abstaining from sexual activity entirely, but using multiple prevention strategies together significantly reduces your risk of infection.

Understanding your own risk factors is the first step in prevention. Factors that increase gonorrhea risk include having multiple sexual partners, inconsistent condom use, a history of previous STIs, and being in communities with higher STI prevalence. Knowing your risk level can help you make informed decisions about testing frequency and prevention strategies.

Barrier Methods

Barriers create a physical shield that prevents the exchange of bodily fluids during sexual activity:

• External (male) condoms: Most effective when used correctly every time for vaginal, anal, and oral sex. Reduces risk by approximately 80% when used consistently.
• Internal (female) condoms: Can be inserted into the vagina or anus before sex; provide similar protection to external condoms.
• Dental dams: Thin sheets of latex used during oral sex to prevent direct mouth-to-genital or mouth-to-anus contact.

Regular Testing and Communication

Since gonorrhea often has no symptoms, regular testing is essential for sexually active individuals. Open communication with partners about STI status and testing history helps both of you make informed decisions about protection.

• Get tested before starting a new sexual relationship
• Ask partners about their testing history and STI status
• Get tested regularly if you have multiple partners (every 3-6 months)
• Test after any potential exposure, even if you used protection

Newer Prevention Options

Research has shown that taking doxycycline within 72 hours after unprotected sex (called doxycycline post-exposure prophylaxis or doxyPEP) can reduce the risk of gonorrhea, chlamydia, and syphilis. This option may be recommended for people at high risk. Discuss with your healthcare provider whether doxyPEP is appropriate for you.

What About Gonorrhea During Pregnancy?

Gonorrhea during pregnancy increases the risk of miscarriage, preterm birth, and low birth weight. The infection can be passed to the baby during delivery, potentially causing severe eye infections that can lead to blindness. All pregnant individuals should be tested for gonorrhea, and the infection can be safely treated with antibiotics during pregnancy.

Pregnancy adds important considerations to gonorrhea prevention, testing, and treatment. The health of both the pregnant person and the developing baby can be affected by this infection. Fortunately, with proper prenatal care including routine STI screening, gonorrhea can be detected and treated before it causes problems.

Untreated gonorrhea during pregnancy is associated with several adverse outcomes. The infection can trigger premature rupture of membranes, leading to preterm labor and delivery. Babies born prematurely face various health challenges and may require extended hospital stays. Additionally, the chronic inflammation caused by untreated infection can affect fetal development.

Risks to the Baby

The most significant risk to the baby occurs during vaginal delivery, when the newborn can be exposed to infected genital secretions:

• Gonococcal ophthalmia neonatorum: Eye infection that develops within the first few days of life. Without prompt treatment, it can cause permanent blindness.
• Scalp infections: Can occur at monitoring electrode sites during labor
• Disseminated infection: In rare cases, the bacteria can spread throughout the newborn's body

Prevention and Treatment During Pregnancy

Routine prenatal care includes STI screening, typically during the first prenatal visit and again in the third trimester for those at higher risk. Gonorrhea can be safely treated during pregnancy with ceftriaxone, which does not harm the developing baby. Treating the infection before delivery prevents transmission to the newborn.

As an additional precaution, antibiotic eye drops or ointment (erythromycin) are routinely applied to newborns' eyes shortly after birth in many countries to prevent eye infections from gonorrhea and chlamydia.