Gonorrhea is an sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae, a Gram-negative intracellular diplococcus. Although gonorrhea is not common in many parts of the UK, sporadic outbreaks occur and the infection is endemic in many inner cities. In 2001 the rate of gonorrhea in female genitourinary medicine clinic attendees in England was 65/100 000. There is wide regional variation with rates being highest in Greater London (over 165/100 000). There has been a recent increase in infection rates, especially amongst women under 20 years of age.

The incubation period of N. gonorrhoeae is 3 to 5 days. The common sites affected are the endocervix, urethra, pharynx and rectum, which may be infected by anal intercourse or contamination with vaginal discharge. Gonococcal conjunctivitis can also occur. Gonorrhea is asymptomatic in up to 50% of women with genital infection and in up to 90% of those with pharyngeal infection. Knowledge of local gonorrhea rates and a high index of suspicion are required to optimize opportunities for testing.

When present, symptoms include abnormal vaginal discharge, dysuria and symptoms of upper genital tract infection such as low abdominal pain, dyspareunia and intermenstrual bleeding. Gonorrhea can also present as a Bartholin’s abscess. There may be no abnormal clinical signs, but there may be mucopurulent endocervical discharge, contact bleeding and signs of pelvic inflammatory disease. Coexistent urethral infection is common but discharge is rarely apparent in women.

The main complication is pelvic inflammatory disease; disseminated infection causing arthritis and skin lesions is rare. Very occasionally pericarditis, endocarditis, hepatitis and meningitis are seen. Vertical transmission can lead to opthalmia neonatorum, which is a notifiable disease.

Gonorrhea: Diagnosis

If gonorrhea is suspected, specimens should be taken from the urethra and rectum in addition to the endocervix. The oropharynx should also be tested if fellatio has occurred.

Microscopy demonstrates the typical appearance of Gram-negative intracellular diplococci within polymorphonucleocytes. Microscopy of an endocervical sample gives a presumptive diagnosis in 20-50% of women but should not be used for pharyngeal specimens. Culture provides definitive diagnosis and antibiotic sensitivities. If gonorrhea is strongly suspected but the test results are negative, some advocate re-testing prior to treatment.

Gonorrhea: Treatment

Treatment for gonorrhea should be guided by local antibiotic resistance patterns, which are monitored by microbiology laboratories or genitourinary medicine clinics. Resistance to penicillins, tetracyclines and quinolones occurs, especially in cases imported from locations overseas such as South East Asia. Penicillins should only be used as a first-line treatment if the incidence of resistance is known to be low. Pharyngeal gonorrhea responds poorly to penicillins (Table Single-dose treatment regimens for gonorrhea). As many women with gonorrhea are also infected with chlamydia, it is common practice to treat with a combination of antibiotics effective against both organisms. After treatment further cultures should be performed to detect treatment failure or reinfection.

Table Single-dose treatment regimens for gonorrhea

a) Women who are not pregnant < or lactating
  Drug (dose)
Uncomplicated genital gonorrhea
Oral Ampicillin (2 g) with probenecid (1 g)

Ciprofloxacin (500 mg)

Ofloxacin (400 mg)

Levofloxacin (250 mg)

Alternative regimen for uncomplicated genital gonorrhea imported from South East Asia
IM Ceftriaxone (250 mg)

Cefotaxime (500 mg)

Spectinomycin (2 g)

Pharyngeal gonorrhea  
Oral Ciprofloxacin (500 mg)

Ofloxacin (400 mg)

IM Ceftriaxone (250 mg)
b) Pregnant and lactating women *
  Drug (dose)
Uncomplicated genital gonorrhea
Oral Ampicillin (2 g) with probenecid (1 g)
IM Ceftriaxone (250 mg)

Cefotaxime (500 mg)

Spectinomycin (2 g)

*Quinolones and tetracyclines are contraindicated in pregnant and lactating women; IM, intramuscular

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