History
The incubation period for gonorrhea is usually 2-7 days after exposure to an infected partner. In all patients who present with a possible STD, the history should include the following:
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Past history of STDs (including HIV infection and viral hepatitis)
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Treatment history for known STDs
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Known symptoms of STDs in current or past sexual partners
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Type of contraception used
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Any history of sexual assault
In women, the history should also include the date of the last menstrual period and the details of parity, including any history of ectopic pregnancies.
Female genitourinary tract
The most common site of gonococcal infection in women is the endocervix (80%-90%), followed by the urethra (80%), rectum (40%), and pharynx (10%-20%). If symptoms develop, they often manifest within 10 days of infection.
Major symptoms include vaginal discharge, dysuria, intermenstrual bleeding, dyspareunia (painful intercourse), and mild lower abdominal pain.
When gonococcal cervicitis is either asymptomatic or unrecognized, the patient may progress to PID, often in proximity to a menstrual period. PID may be asymptomatic or silent and occurs in 10-20% of infected women. Symptoms of PID include the following:
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Lower abdominal pain (most consistent symptom of PID)
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Increased vaginal discharge or mucopurulent urethral discharge
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Dysuria (usually without urgency or frequency)
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Cervical motion tenderness
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Adnexal tenderness (usually bilateral) or adnexal mass
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Intermenstrual bleeding
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Fever, chills, nausea, and vomiting (less common)
Acute perihepatitis (Fitz-Hugh-Curtis syndrome) occurs primarily through direct extension of N gonorrhoeae or Chlamydia trachomatis from the fallopian tube to the liver capsule and overlying peritoneum. Acute perihepatitis is more commonly associated with C trachomatis. Patients with this syndrome may report right upper quadrant pain, nausea, vomiting, and fever, and friction rub may be heard along the right anterior costal margin. Cases tend to occur in individuals with PID and therefore should be among the differential diagnoses of right upper quadrant pain in young sexually active women.
Vaginal discharge from endocervicitis is the most common presenting symptom of gonorrhea and is usually described as thin, purulent, and mildly odorous. Many patients have minimal or no symptoms from gonococcal cervicitis. Dysuria or a scant urethral discharge may be due to urethritis accompanying cervicitis.
Gonorrheal infection of the Bartholin glands (glands near the labia) is asymptomatic in one third of cases but may manifest as perilabial pain, edema, tenderness, and discharge.
Pelvic or lower abdominal pain suggests ascending infection of the endometrium, fallopian tubes, ovaries, and peritoneum. Pain may be midline, unilateral, or bilateral. Fever, nausea, and vomiting may be present. Pelvic examination usually demonstrates bilateral adnexal tenderness, possible tenderness over the uterine fundus, and possible cervical motion tenderness. Abdominal examination elicits lower quadrant tenderness. PID related to gonococcal infection may follow the onset of menses by a few days. The possibility of ectopic pregnancy should always be considered in patients with pelvic or lower abdominal pain.
Rectal infection is often asymptomatic, but rectal pain, pruritus, tenesmus, and rectal discharge may be present if the rectal mucosa is infected. Bloody diarrhea may also occur. Rectal infection may occur from anal intercourse or, in women, by local spread of the organism.
Male genitourinary tract
In men, urethritis is the major manifestation of gonococcal infection. Initial characteristics include burning upon urination and a serous discharge. A few days later, the discharge usually becomes more profuse, purulent, and, at times, blood-tinged.
Acute epididymitis may also be caused by N gonorrhoeae or C trachomatis, especially in men younger than 35 years. This is usually unilateral and often occurs in conjunction with a urethral exudate. The classic presentation of epididymitis is of unilateral pain and swelling localized posteriorly within the scrotum.
Urethral strictures due to gonococcal infection are now uncommon in the antibiotic era, but they can present with a decreased and abnormal urine stream, as well as with the secondary complications of prostatitis and cystitis.
Another manifestation of gonorrhea, rectal infection, may present with pain, pruritus, discharge, or tenesmus.
Sex-independent manifestations
Men and women may exhibit gonococcal infection of the pharynx, rectum, and eye.
Gonococcal pharyngitis is most commonly acquired during orogenital contact, with fellatio predisposing to infection more so than cunnilingus. Pharyngitis is often asymptomatic; however, it may present as exudative pharyngitis with cervical lymphadenopathy. Most cases of pharyngeal infection resolve spontaneously and are believed to be less transmissible than rectal or genital gonorrhea.
Although rectal cultures are positive for gonorrhea in up to 40% of women with cervical gonorrhea (a similar percentage noted in infected homosexual men), symptoms of proctitis are unusual. When symptoms do occur, males are more likely to exhibit symptoms, since trauma during anal intercourse or inoculum size may play a role.
Eye involvement in adults occurs by autoinoculation of gonococci into the conjunctival sac from a primary site of infection, such as the genitals, and is usually unilateral. The most common form of presentation is a purulent conjunctivitis, which may rapidly progress to panophthalmitis and loss of the eye unless promptly treated. Gonococcal conjunctivitis is often reported to be painful and may exhibit photophobia and purulent drainage.
Neonates
In neonates, bilateral conjunctivitis (ophthalmia neonatorum) often follows vaginal delivery from an untreated, infected mother. However, transmission to the newborn can also occur in utero or in the postpartum period.
Symptoms of gonococcal conjunctivitis include eye pain, redness, and a purulent discharge. Neonates may also acquire pharyngeal, respiratory, or rectal infection or disseminated gonococcal infection (DGI).
The organism can cause permanent injury to the eye very quickly. Prompt recognition and treatment are essential to avoid blindness. Blindness due to neonatal gonococcal infection is a serious problem in developing countries but is now uncommon in the United States and in other countries where neonatal conjunctival prophylaxis with antimicrobial therapy is routine. Nevertheless, infants of mothers with untreated infections, poor prenatal care, and unmonitored births continue to be at risk.
Direct infection with N gonorrhoeae in neonates may also occur through the scalp at the sites of fetal monitoring electrodes.
Disseminated gonococcal infection
The symptoms of DGI vary greatly from patient to patient. By the time the symptoms of DGI appear, many patients no longer have any localized symptoms of mucosal infection.
The classic presentation of DGI is an arthritis-dermatitis (tenosynovitis) syndrome. Joint or tendon pain is the most common presenting complaint in the early stage of infection. About 25% of patients with DGI complain of pain in a single joint, but many other patients describe migratory polyarthralgia, especially of the knees, elbows, and more distal joints. Patients may also have tenosynovitis; the early tenosynovitis most commonly affects the flexor tendon sheaths of the wrist or the Achilles tendon ("lovers' heels").
Skin rash is a presenting complaint in approximately 25% of patients, but a careful examination will reveal a rash in most patients with DGI. The rash is usually found below the neck and may also involve the palms and soles.
The dermatitis consists of lesions varying from maculopapular to pustular, often with a hemorrhagic component. Lesions usually number 5-40, are peripherally located, and may be painful before they are visible. Lesions are transient, lasting less than 4 days. Fever is common but rarely exceeds 39°C.
The second stage of DGI is characterized by septic arthritis, by which time the skin lesions have disappeared and blood culture results are nearly always negative. The knee is the most common site of purulent gonococcal arthritis.
Rare complications of DGI include gonococcal meningitis, pericarditis, and endocarditis. Headache, neck pain and stiffness, fever, and decreased sensorium may indicate gonococcal meningitis. This disease may be clinically indistinguishable from meningococcal meningitis on presentation, although the course of gonococcal meningitis is usually less rapid.
Gonococcal endocarditis is more common in men than in women. Patients with collagen vascular disease (especially those with systemic lupus erythematosus) may also be more prone to this complication. The aortic valve is affected most commonly. A subacute onset of fever, chills, sweats, and malaise may indicate the presence of gonococcal endocarditis. Patients with endocarditis may develop atypical chest pain, cough, and dyspnea and may also develop the arthralgias and rash typical of DGI. Gonococcal endocarditis can cause severe valvular damage and death if not recognized and treated rapidly.
Physical Examination
N gonorrhoeae infection may be recognized by the typical signs and symptoms of the disease, but it is important to remember that, by the time disseminated or upper reproductive tract disease is present, the primary site of mucosal infection may be normal in appearance, and the patient may have no localized signs or symptoms.
With oropharyngeal infection, pharyngitis (usually mild) may be occur. With rectal infection, mucopurulent or purulent discharge may be present.
The physical examination should also always include scrutiny for signs of herpes simplex, syphilis, chancroid, lymphogranuloma venereum, and genital warts.
Neonates
In neonates, look for purulent discharge from the eyes or other infected sites. The discharge from the eyes is usually bilateral in ophthalmia neonatorum, while in older patients, the condition most often is unilateral when secondary to self-inoculation.
Also examine neonates for temperature instability (fever, hypothermia), which can result from disseminated sepsis
Female genitourinary tract
Look for the following in females:
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Mucopurulent or purulent vaginal, urethral, or cervical discharge
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Vaginal bleeding; vulvovaginitis in children
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Cervical friability - Tendency to bleed upon manipulation
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Cervical motion tenderness during bimanual pelvic examination
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Fullness and/or tenderness of the adnexa, unilateral or bilateral (eg, ovaries, fallopian tubes)
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Lower abdominal pain/tenderness, with or without rebound tenderness
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Possible low back pain - More common in progression to pelvic inflammatory disease (PID)
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Upper right abdominal tenderness (with perihepatitis)
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Fever
Male genitourinary tract
Look for the following in males:
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Mucopurulent or purulent urethral discharge - Obtained by milking the urethra along the shaft of the penis
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Possible epididymitis - Unilateral epididymal tenderness and edema, with or without penile discharge or dysuria
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Penile edema without other overt inflammatory signs
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Urethral stricture - Uncommon; more often seen in the preantibiotic era with urethral irrigation using caustic liquids
Rectal symptoms
Rectal symptoms of gonorrhea include the following:
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Mucopurulent or purulent discharge with or without rectal bleeding
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Mucopurulent exudate and inflammatory in the rectal mucosa
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Rectal abscess (less common)
Ocular and periocular symptoms
Ocular and periocular manifestations of gonorrhea include the following:
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Anterior chamber - Cellular reaction, hypopyon, endophthalmitis
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Conjunctiva - Chemosis, acute purulent exudate, hemorrhages
This patient presented with gonococcal urethritis, which became systemically disseminated, leading to gonococcal conjunctivitis of the right eye. Courtesy of the CDC/Joe Miller, VD.
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Cornea - Punctate epithelial keratitis; marginal, sterile stromal infiltrates; epithelial defects; infectious stromal infiltrates; stromal ulcerations; descemetocele; perforation; opacification
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Lids - Erythema, edema
Disseminated gonococcal infection
DGI may present with any of the following findings:
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Fever - Usually a temperature of less than 39°C
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Skin - Maculopapular, pustular, necrotic, or vesicular rash, typically occurring on the torso, limbs, palms, and soles may be present; the rash usually spares the face, scalp, and mouth; hemorrhagic lesions, erythema nodosum, urticaria, and erythema multiforme occur less frequently; the skin lesions are usually in different stages of development at the time of clinical presentation
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Joints - Most patients may have polyarthralgia with joint tenderness, decreased range of motion, and erythema; less often, purulent arthritis may affect a single joint with severe pain, tenderness, edema, erythema, and decreased range of motion
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Tenosynovitis - Presents as erythema and local tenderness along a tendon sheath, with pain on active or passive range of motion; tenosynovitis most often occurs in the hands but may be found in the tendons of the lower extremities as well
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Central nervous system - Patients with gonococcal meningitis may present with meningismus or decreased mental status
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Cardiac - Patients with gonococcal endocarditis may have a new murmur, tachycardia, and fever; embolic lesions may be present.; the aortic valve tends to be the main valve affected
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Muscle - DGI can cause abscess formation within the soft tissues, presenting as localized tenderness, edema, and pain with motion
Certain patient populations, such as patients infected with HIV, can experience involvement of unusual joints, such as the sternoclavicular joint and the hips, and the arthritis may have a more aggressive course, with potential destruction of the joint.
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This patient presented with gonococcal urethritis, which became systemically disseminated, leading to gonococcal conjunctivitis of the right eye. Courtesy of the CDC/Joe Miller, VD.
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Gonorrhea rates, United States, 1941-2016. Courtesy of the Centers for Disease Control and Prevention (CDC).
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Gonorrhea rates by race/ethnicity, United States, 2012-2016. Courtesy of the Centers for Disease Control and Prevention (CDC).
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Rates of gonococcal infection per 100,000 by state and outlying regions (2016). Courtesy of the Centers for Disease Control and Prevention (CDC).
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Disseminated gonococcemia, acral pustules.
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Cytologic smear of cutaneous acral pustule showing gram-negative, intracellular diplococci.
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Rates of reported gonorrhea cases by age group and sex, United States, 2016. Courtesy of the Centers for Disease Control and Prevention (CDC).
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- Overview
- Presentation
- DDx
- Workup
- Approach Considerations
- Smears With Gram Stain
- Isolation Via Culture
- Imaging Studies
- Nucleic Acid Amplification Tests
- Nucleic Acid Probe Signal Amplification
- Antibody-Antigen Testing
- Procedures
- Histologic Findings
- Testing for Gonorrhea in Males
- Testing for Gonorrhea in Females
- Testing for Gonorrhea at Extragenital Sites
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- Treatment
- Guidelines
- Medication
- Questions & Answers
- Media Gallery
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