Am Fam Physician. 2006;73(10):1779-1784
A more recent article on chlamydial and gonococcal infections is available.
Patient information: See related handout on gonorrhea, written by the author of this article.
Author disclosure: Nothing to disclose.
The most common site of Neisseria gonorrhoeae infection is the urogenital tract. Men with this infection may experience dysuria with penile discharge, and women may have mild vaginal mucopurulent discharge, severe pelvic pain, or no symptoms. Other N. gonorrhoeae infections include anorectal, conjunctival, pharyngeal, and ovarian/uterine. Infections that occur in the neonatal period may cause ophthalmia neonatorum. If left untreated, N. gonorrhoeae infections can disseminate to other areas of the body, which commonly causes synovium and skin infections. Disseminated gonococcal infection presents as a few skin lesions that are limited to the extremities. These legions start as papules and progress into bullae, petechiae, and necrotic lesions. The most commonly infected joints include wrists, ankles, and the joints of the hands and feet. Urogenital N. gonorrhoeae infections can be diagnosed using culture or nonculture (e.g., the nucleic acid amplification test) techniques. When multiple sites are potentially infected, culture is the only approved diagnostic test. Treatments for uncomplicated urogenital, anorectal, or pharyngeal gonococcal infections include cephalosporins and fluoroquinolones. Fluoroquinolones should not be used in patients who live in or may have contracted gonorrhea in Asia, the Pacific islands, or California, or in men who have sex with men. Gonorrhea infection should prompt physicians to test for other sexually transmitted diseases, including human immunodeficiency virus.
Neisseria gonorrhoeae infections may present as a broad range of symptoms and can affect urogenital, anorectal, pharyngeal, and conjunctival areas. Severe cases can lead to disseminated gonococcal infections, endocarditis, and meningitis; and in women, to pelvic inflammatory disease (PID).
Two methods for detecting N. gonorrhoeae are culture and nonculture tests. Culture techniques are considered the tests of choice; but nonculture techniques, which are less labor-intensive and are similar in accuracy to cultures, have replaced culture techniques in some instances. The newest nonculture technique is the nucleic acid amplification test. This test has good sensitivity (92 to 96 percent) and specificity (94 to 99 percent) compared with cultures.1
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Uncomplicated gonococcal infections of the cervix, urethra, or rectum should be treated with a single 125-mg dose of ceftriaxone (Rocephin) administered intramuscularly. | C | 2 |
| Oral regimens to treat pelvic inflammatory disease should continue for 14 days. | C | 2 |
| Women younger than 25 years who are sexually active should be screened annually for gonococcal infections. | B | 2,12 |
| Fluoroquinolones should not be used to treat gonorrhea in men who have sex with men. | C | 8 |
Urogenital Infections
The most common site of N. gonorrhoeae infection is the urogenital tract. In women it can infect the endocervix and, if an ascending infection develops, it can cause PID. Men may develop urethritis and, occasionally, epididymitis.
FEMALE INFECTIONS
In women, common symptoms include odorless vaginal discharge; vaginal bleeding, particularly after intercourse; and dyspareunia. Many women have no symptoms, however.2 Physical findings in women include cervicitis with mucopurulent drainage from the os. The cervix tends to bleed easily when rubbed with a cotton-tipped swab. Gonorrhea infections do not cause vaginitis, but other concomitant infections may produce vaginal findings.
Ten to 20 percent of women with gonorrhea develop ascending infection that causes acute salpingitis with or without endometritis, also known as PID.2 Presentations may range from no symptoms to severe abdominal pain with a high fever. PID can negatively affect fertility, causing infertility in 15 percent of patients2; 50 percent of patients who have three or more episodes of PID develop infertility.2
The Centers for Disease Control and Prevention (CDC) recommends that physicians maintain a low threshold for diagnosing PID because of significant negative sequelae associated with this infection.2 The CDC currently recommends empiric treatment of PID in women with uterine and adnexal tenderness or cervical motion tenderness if they are at risk of sexually transmitted diseases (STDs) and no other causes can be identified.2 Table 12 includes the CDC's criteria for diagnosing PID.
| Minimal criteria |
| Cervical motion tenderness |
| Uterine or adnexal tenderness |
| Additional criteria* |
| Abnormal cervical or vaginal mucopurulent discharge |
| Elevated C-reactive protein level |
| Elevated erythrocyte sedimentation rate |
| History of gonorrhea or chlamydia infection |
| Oral temperature greater than 101°F (38.3°C) |
| White blood cells present on saline preparation of vaginal secretions |
| Specific criteria |
| Evidence of endometritis on endometrial biopsy |
| Laparoscopic abnormalities consistent with PID |
| Transvaginal ultrasonography or magnetic resonance imaging shows thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex. |
In women with urogenital disease, the nucleic acid amplification test can detect gonorrhea by endocervical or urine sample. Urine samples have a lower sensitivity and, therefore, a higher chance of false negatives than do endocervical samples.1
MALE INFECTIONS
Unlike women, men with urogenital infections are usually symptomatic. The normal incubation period is two to six days after exposure. Symptoms include purulent penile discharge and dysuria. The discharge may present at the meatus, which may be erythematous. Discharge may be expressed by milking the penis.
N. gonorrhoeae may also cause epididymitis, which can present as unilateral testicular pain without discharge or dysuria. The patient may or may not have a fever. On examination, the epididymis is swollen and tender to palpation.
Anorectal Infections
Gonorrhea infections in the rectal area are most common in women and in men who have sex with men (MSM). Perianal contamination from a cervical infection or a direct infection from anal intercourse can cause anorectal infections in women. In MSM, the infection is caused by direct exposure through anal intercourse. Most rectal gonococcal infections are subclinical. If present, symptoms can include anal pruritus and mucopurulent discharge, usually with a bowel movement. Rectal pain, tenesmus, and bleeding are more common in MSM. Severe gonococcal rectal infections may be difficult to differentiate from inflammatory bowel disease.
Although data suggest that nucleic acid amplification tests can detect rectal gonorrhea infections,3 the CDC recommends the culture technique for a diagnosis.2 However, one study4 showed a high prevalence (7 percent) of asymptomatic rectal gonorrhea in MSM; therefore, it may be beneficial to screen these patients using nucleic acid amplification tests.
Pharyngeal Infections
Pharyngeal infections caused by N. gonorrhoeae usually occur after orogenital exposure; symptoms are mild or absent. On physical examination, the pharynx may be erythematous or have exudates. Anterior cervical lymphadenopathy also may be present. Most cases of pharyngeal infection will spontaneously resolve with no treatment and usually do not cause adverse sequelae. Treatment should be initiated, however, to reduce the potential for spreading the infection.2 The CDC currently recommends cultures to test patients who have suspected pharyngeal gonorrhea.2
Infections in Children
There are two distinct categories of gonococcal infections in children. During the neonatal period and the first year of life, gonorrhea infections can cause neonatal conjunctivitis (ophthalmia neonatorum); pharyngitis; rectal infections; and, in rare cases, pneumonia. These infections most commonly develop within two to five days after birth, because the neonate is exposed to infected cervical exudates during delivery. Almost all new gonococcal infections in children older than one year are caused by sexual abuse.
OPHTHALMIA NEONATORUM
N. gonorrhoeae is not the most common cause of ophthalmia neonatorum. However, identifying and treating gonorrhea-related ophthalmia neonatorum is important because, if left untreated, it can cause perforation of the globe of the eye and blindness. Infants at risk of gonococcal conjunctivitis are those who did not receive prophylaxis for ophthalmia neonatorum, those whose mothers had no prenatal care, and those whose mothers have a history of STDs or substance abuse. Common findings include inflammation of the conjunctiva and mucopurulent discharge from the eye.
Testing neonates who have ophthalmia neonatorum for N. gonorrhoeae should begin with a Gram stain of the conjunctival exudates. If intracellular gram-negative diplococci are present, N. gonorrhoeae infection is presumed and treatment should be initiated. Gonococcal cultures should confirm the diagnosis.2
SEXUAL ABUSE
Preadolescent children most commonly contract gonococcal infections through sexual abuse.2 The common presentation is a girl with vaginitis symptoms. Pharyngeal and rectal infections also may be present, but they are usually asymptomatic.
A culture method should be used to test children for N. gonorrhoeae.2 Nonculture techniques should not be used alone because the U.S. Food and Drug Administration has not approved them for use in children. Specimens from the vagina, pharynx, urethra, or rectum should be used to isolate N. gonorrhoeae.
Disseminated Infection
Disseminated infection is rare but can occur 1 to 3 percent of adults who have gonorrhea Septic emboli can cause polyarticular tenosynovitis and dermatitis in these patients.2 Symptoms of disseminated infection can range from slight joint pain, a few skin lesions, and no fever to overt polyarthritis and a high fever. Patients with disseminated gonorrhea usually have no urogenital symptoms.
The skin lesions typically are few and are limited to the extremities; they start as papules and progress into hemorrhagic pustules. Bullae, petechiae, or necrotic lesions also may be present. The skin lesions usually are resolved if the gonorrhea continues to disseminate. Skin lesions and blood cultures usually are negative for N. gonorrhoeae.
The joints most commonly affected by disseminated gonorrhea are the wrists, ankles, and the joints of the hands and feet. The axial skeleton rarely is involved. Initial aspiration of the joint may be negative for infection. If untreated, however, the patient will develop septic arthritis, which will most likely involve elbows, wrists, knees, or ankles. The joints will be swollen and warm, and a joint aspiration will detect more than 40,000 leukocytes per mm3 (40 × 109 per L) and contain gram-negative intracellular diplococci. Fluid cultures usually do not grow the organism.2
Disseminated gonorrhea also may present as bacterial endocarditis, meningitis, and myocarditis, although the incidences of these presentations have declined with the advent of antibiotic therapy.
Treatment
The CDC's treatment guidelines for uncomplicated gonococcal infections are included in Table 2.2 Despite findings that fluoroquinolones have similar cure rates as ceftriaxone (Rocephin), 5 N. gonorrhoeae has become increasingly resistant to fluoroquinolones in some geographic areas. Therefore, the CDC advises against using f luoroquinolones to treat gonorrhea infection in patients who live or may have acquired infection in Asia, the Pacific islands (including Hawaii), and California.2 The CDC recently noted a substantial increase in fluoroquinolone-resistant N. gonorrhoeae in MSM, and it no longer recommends fluoroquinolones as first-line treatment in these patients.6 England, Wales, and Canada also have reported fluoroquinolone-resistant N. gonorrhoeae.7,8
| Cefixime (Suprax), 400 mg orally† |
| Ceftriaxone (Rocephin), 125 mg intramuscularly |
| Ciprofloxacin (Cipro), 500 mg orally |
| Levofloxacin (Levaquin), 250 mg orally |
| Ofloxacin (Floxin), 400 mg orally |
PID can be treated on an outpatient basis if the patient does not meet hospitalization criteria (Table 3).2 Outpatient treatment may include either of two equally effective oral regimens.2 If parenteral antibiotic therapy is indicated, the preferred therapy is cefotetan (Cefotan), 2 g intravenously every 12 hours, or cefoxitin (Mefoxin), 2 g intravenously every six hours, plus doxycycline (Vibramycin), 100 mg orally or intravenously every 12 hours. Doxycycline is best administered orally because intravenous doxycycline can be painful and can adversely affect veins.2 Table 4 includes CDC treatment guidelines for PID.2
| Patient does not respond to oral antimicrobial therapy. |
| Patient is pregnant. |
| Patient has severe illness, nausea and vomiting, or high fever. |
| Surgical emergencies (e.g., appendicitis) cannot be excluded. |
| Patient has a tubo-ovarian abscess. |
| Patient is unable to follow or tolerate an outpatient oral drug regimen. |
| Parenteral regimen | |
| Cefotetan (Cefotan), 2 g IV every 12 hours | |
| Cefoxitin (Mefoxin), 2 g IV every six hours | |
| plus | |
| Doxycycline (Vibramycin), 100 mg orally or IV every 12 hours | |
| Oral regimen A | |
| Ofloxacin (Floxin), 400 mg orally twice per day | |
| Levofloxacin (Levaquin), 500 mg once per day | |
| with or without | |
| Metronidazole (Flagyl), 500 mg orally twice per day | |
| Oral regimen B | |
| Ceftriaxone (Rocephin), single 250-mg dose IM | |
| Cefoxitin, single 2-g dose IM administered concurrently with probenecid (Benemid), single 1-g dose orally | |
| plus | |
| Doxycycline, 100 mg orally twice per day | |
| with or without | |
| Metronidazole, 500 mg twice per day | |
Pharyngeal gonococcal infections are more difficult to treat than urogenital or anorectal infections because few antibiotic regimens can reliably cure this infection. The CDC recommends ceftriaxone in a single 125-mg dose intramuscularly or ciprofloxacin (Cipro) in a single 500-mg dose orally, because these regimens have been shown to effectively treat pharyngeal gonorrhea.2 If resistance to fluoroquinolone is a concern, ceftriaxone is the treatment of choice.
Children with ophthalmia neonatorum or suspected gonococcal infection should be treated with ceftriaxone in a single 25- or 50-mg per kg dose intravenously or intra-muscularly.2 Total dosage should not exceed 125 mg. Fluoroquinolones should be avoided in children who weigh less than 99 lb (45 kg), because they are at risk of articular cartilage damage.2
Patients with suspected disseminated gonococcal infection should be hospitalized initially.2 The evaluation should include examining for clinical signs of endocarditis and meningitis. The CDC recommends ceftriaxone, 1 g intravenously or intramuscularly every 24 hours, for patients with disseminated infections.2 Parenteral antibiotics should be continued for 24 to 48 hours after clinical improvement begins and then oral regimens should begin.2
Fluoroquinolones and tetracyclines are contraindicated for pregnant women.2 If the patient cannot tolerate cephalosporins, the alternative therapy is spectinomycin (Trobicin), 2 g intramuscularly every 12 hours. Both of these regimens have similar cure rates.9 Table 5 includes CDC treatment guidelines for disseminated gonococcal infections.2
| Recommended parenteral regimen |
| Ceftriaxone (Rocephin), 1 g IV or IM every 24 hours |
| Alternative parenteral regimens |
| Cefotaxime (Claforan), 1 g IV every eight hours |
| Ciprofloxacin (Cipro), 400 mg IV every 12 hours |
| Levofloxacin (Levaquin), 250 mg IV once per day |
| Ofloxacin (Floxin), 400 mg IV every 12 hours |
| Spectinomycin (Trobicin), 2 g IM every 12 hours |
| Oral regimen* |
| Cefixime (Suprax), 400 mg twice per day |
| Ciprofloxacin, 500 mg twice per day |
| Levofloxacin, 500 mg once per day |
| Ofloxacin, 400 mg twice per day |
Concomitant STDs
Ten to 30 percent of patients with gonorrhea will have a concomitant chlamydia infection; therefore, many experts advocate empirically treating chlamydia when treating patients with gonorrhea.10 The CDC recommends azithromycin (Zithromax) in a single 1-g dose orally, or doxycycline, 100 mg twice a day for seven days, for patients with uncomplicated infections of the cervix, urethra, and rectum and possible concomitant chlamydia infections.2
Physicians should strongly consider testing patients who have confirmed gonococcal infections for other STDs, including human immunodeficiency virus, using CDC guidelines for STD testing and treatment, which are available online athttp://www.cdc.gov/std/treatment/.2 Unfortunately, compliance with these guidelines is low. In one study11 of an emergency department, compliance ranged from 14 to 79 percent with respect to history taking, physical examination, diagnostic testing, treatment, and counseling about safe sex. Less than one third of patients included in this study received CDC-recommended antibiotics.
Screening
According to the CDC, all sexually active women younger than 25 years should be screened annually for gonorrhea. Women 25 years of age or older should be screened annually if they have a new sexual partner or a history of multiple partners.2 The U.S. Preventive Services Task Force (USPSTF) recommends that all sexually active women, including those who are pregnant, receive routine screening if they are at increased risk of infection.12 Risk factors include age younger than 25 years, history of an STD, new or multiple sexual partners, inconsistent condom use, and history of prostitution or drug use.12 The CDC and the USPSTF do not recommend routine screening for men because they usually are symptomatic.2,12