Gonorrhea

Disease Description (Causes and Symptoms)

• Cause: Caused by sexual transmission of Neisseria gonorrhoeae (gonococcus). It can also be transmitted through vaginal penetration, anal sex, and oral sex. Rarely, it can spread through the bloodstream and cause systemic symptoms (fever, rash, and arthritis). In pregnant women, it can cause conjunctivitis in newborns during delivery.
• Pathophysiology (brief): Gonococcus infiltrates and multiplies in mucous membranes (urethra, cervix, rectum, pharynx, and conjunctiva), causing mucositis and localized purulent discharge and inflammatory responses. In some cases, complications occur due to ascending infection or hematogenous spread.
• Main symptoms
  • Men: Urethral discharge (pus), dysuria (burning sensation), urinary frequency, and redness of the urethral opening — however, approximately 10–15% are asymptomatic.
  • Women: Atypical vaginal discharge, dysuria, urinary frequency, abnormal bleeding, and pelvic pain — asymptomatic cases are more common in women.
  • Anal infection: Rectal pain, discharge, and discomfort during bowel movements.
  • Pharyngeal infection: Sore throat or pharyngeal symptoms (many cases are also asymptomatic).
  • In cases of systemic dissemination: Fever, characteristic skin rash, arthralgia/arthritis (septic arthritis).
• Incubation period: Usually 2–7 days (rarely, the onset may be delayed longer).

Treatment

• Basic principles: The first-line treatment for localized uncomplicated gonorrhea is an injection of ceftriaxone/ceftriaxone-class drugs (the recent guidelines recommending an alternative to ceftriaxone instead of ceftriaxone may be confusing regarding the term ceftriaxone, so refer to the latest recommendations below). General recommendations based on the latest guidelines (e.g., CDC recommendations, updated since 2020) include:
  • Ceftriaxone 500 mg IM as a single dose (1 g IM for body weight ≥150 kg). — Applies to uncomplicated urethral, cervical, rectal, and pharyngeal infections.
  • If concomitant chlamydia infection has not been excluded: Doxycycline 100 mg PO twice daily for 7 days. (Doxycycline is contraindicated during pregnancy — for pregnant patients, consider azithromycin 1 g PO as a single dose for treatment of concomitant chlamydia infection.)
  • If ceftriaxone cannot be used (such as severe beta-lactam hypersensitivity): Consultation with a specialist or an infectious disease/epidemiology specialist is required (treatment based on culture and susceptibility results, with administration of an alternative medication).
• Pregnancy: A single dose of ceftriaxone IM is standard. If concomitant chlamydia infection is suspected, azithromycin is recommended instead of doxycycline (considering safety during pregnancy).
• In cases of complications or severe infection: If pelvic inflammatory disease, epididymitis, systemic (hematogenous) infection, or other conditions develop, hospitalization, intravenous antibiotics, and consultation with an infectious disease specialist are required.
• Follow-up and additional measures
  • Testing and treatment are recommended for sexual partners (those within the past 60 days or the period specified by a healthcare professional), even if they are asymptomatic.
  • Avoid sexual contact for 7 days after treatment (or until both the patient and all partners have completed treatment).
  • For pharyngeal infection, testing within 2 weeks after treatment (test of cure) is recommended (because of the possibility of antibiotic resistance and insufficient treatment efficacy).
  • If symptoms persist or recur after treatment, repeat testing and culture and susceptibility testing should be performed.
• Antibiotic resistance: Because gonococcus is showing increasing antibiotic resistance (especially to alloquinolones and others), treatment that reflects local guidelines and susceptibility data is important.
• Public health: This is a notifiable infectious disease (depending on the classification in each country).

Outpatient Visit Checklist (Including Items to Bring and Sample Questions)

• Items to bring / prepare in advance
  • A list of currently taken medications (including prescription drugs, OTC medicines, and supplements).
  • Allergy history (especially to antibiotics such as penicillins and cephalosporins).
  • Recent sexual history (number of recent sexual partners, whether partners have symptoms, types of sexual activity: vaginal, anal, or oral), and the date of the last sexual contact.
  • When symptoms began and how they have changed (discharge color and amount, presence of pain, fever, rash, etc.).
  • Possibility of pregnancy (whether pregnant or the results of a recent pregnancy test).
  • Previous test results (gonorrhea and chlamydia tests, culture results, etc.) and history of previous treatment.
• Items to tell the attending physician first during the outpatient visit
  • Specify the types of sexual activity (including oral/anal sex) in detail (essential for determining the testing sites).
  • Whether antibiotics have been taken recently (this affects interpretation of the treatment response).
• Test preparation
  • A urine specimen (NAAT) or a swab/culture and NAAT test collected from the infected site (urethra/cervix/rectum/pharynx).
  • Culture and antibiotic susceptibility testing if necessary (when recurrence or resistance is suspected).

General Sample Questions to Ask the Doctor

• "What side effects can I expect from this medication (the recommended antibiotic)? What alternative medication is available if I have an allergic reaction?"
• "How long should I avoid sexual intercourse after treatment? What should be done regarding my partner?"
• "If symptoms remain after treatment, when should I be retested? When can a test confirm that I am cured?"
• "I am pregnant. What treatment and precautions are recommended?"
• "What actions do you recommend to prevent reinfection? Is using condoms alone sufficient?"

Sample Disease-Specific Questions

• "I had oral (or anal) sex. Which sites should be tested first? Do I need a pharyngeal (or rectal) test?"
• "When do you perform a test of cure for pharyngeal infection after treatment? (For example, is testing after 2 weeks recommended?)"