STD Toolkit

Gonorrhea

Symptoms:

Urethral Symtoms:
  • Thick, purulent penile discharge (usually white, greenish or yellow).
  • Dysuria, frequency.
  • Redness or swelling of the urethral meatus.
  • Tenderness or swelling of the testicles with or without complaints of pain.
  • Tingling in the tip of the penis or itching along the length of the urethra.

    *Asymptomatic in 5-20% of cases

 Cervical Symptoms:
  • Green or yellow-green discharge.
  • Irritation of the vulva.
  • Low back pain.
  • Lower abdominal pain.
  • Pain or swelling of the labia.

    *50-80% may be asymptomatic for the first few weeks.

Rectal Symptoms:

  • May have irritation, burning or itching around the anus.
  • Pain with bowel movement.
  • Mucous discharge, blood or pus in feces.

    *May have few noticeable symptoms.

Pharyngeal Symptoms:
  • May complain of sore throat.
  • Yellow or greenish exudates from the pharynx.
  • May have low-grade fever.

Definitive Diagnosis:

Positive lab results (see Testing)

Recommended at least annually for:

  • Women under age 25
  • Women over 25 with risk factors (new partner, multiple partners, unprotected sex, history of STD, commercial sex, coerced sex)
  • Sexually active men who have sex with men

Also recommended for:

  • Pregnant women of any age
  • People in correctional facilities

See US Preventative Services Task Force for more information.

  • Nucleic Acid Amplification Testing (NAAT) - Specimens can be first-catch urines, urethral swabs for males, and vaginal or endocervical swabs for females. May also be used for oropharyngeal or rectal swabs if the lab has established specifications for running them (not FDA approved for this use).
Recommended, with reservations:
  • Culture - recommended for test of cure and other circumstances where antimicrobial susceptibility testing and genetic analysis may be necessary. Specimens can be from pharynx, rectum, urethral swabs for males or endocervical swabs for females. If a female doesn't have a cervix, vaginal swabs are acceptable.
  • Gram Stain (male urethral specimen only) - diagnostic in symptomatic males, but a negative result cannot rule out infection in asymptomatic males.
Not Recommended:
  • Nucleic Acid Hybridization - Specimens can be endocervical swabs for females or urethral swabs for males.

Test of Cure

Test-of-cure is not needed for persons who receive the recommended or alternative regimens for a diagnosis of uncomplicated urogenital or rectal gonorrhea. However, any person diagnosed with pharyngeal gonorrhea who is treated with an alternative regimen should return 14 days after treatment for a test-of-cure culture or NAAT. If symptoms persist after treatment, patient should return for a culture to test for gonorrhea and any gonococci isolated should be tested for antimicrobial susceptibility. 

Retest

Repeat N.Gonorrhoeae testing of recently infected women or men should be a priority for providers. Retesting should occur approximately three months after treatment, regardless of whether they believe that their sex partners were treated. If retesting at three months is not possible, clinicians should retest whenever persons next present for medical care in the 12 months following initial treatment.

First Line Treatment

Ceftriaxone (Rocephin) 500 mg IM in a single dose for persons weighing < 150kg (300lb)

  • For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
  • If chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.

 

Alternative Treatments

Alternative:

Gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally as a single dose

OR

Cefixime 800 mg orally as a single dose. If treating with cefixime, and chlamydial infection has not been excluded, providers should treat for chlamydia with doxycycline 100 mg orally twice daily for 7 days. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.

Uncomplicated gonococcal infections of the pharynx

Ceftriaxone 500 mg IM as a single dose for persons weighing <150 kg (300 lb).

  • For persons weighing ≥150 kg (300 lb), 1 g of IM ceftriaxone should be administered.
  • If chlamydia coinfection is identified when pharyngeal gonorrhea testing is performed, providers should treat for chlamydia with doxycycline 100 mg orally twice a day for 7 days. During pregnancy, azithromycin 1 g as a single dose is recommended to treat chlamydia.

 

Pelvic Inflammatory Disease (PID)

Gonorrhea or chlamydia may progress into PID, though PID may have other causes as well. PID may consist of endometritis, salpingitis, tubo-ovarian abscess, and/or pelvic peritonitis. Patients with PID may be asymptomatic, have mild or non-specific symptoms, or have moderate to severe symptoms. Patients may present with pelvic/lower abdominal pain, vaginal discharge, dyspareunia, or abnormal bleeding. Any female presenting with suspected PID should be evaluated immediately or sent to the hospital or her OB/GYN.

If no other cause for illness is found, and the patient has cervical motion tenderness, uterine tenderness, or adnexal tenderness, she should be treated empirically for PID.

See Treatments for recommended outpatient treatment for mild to moderately severe cases.

Please see the CDC's Sexually Transmitted Diseases Treatment Guidelines, 2015 for more information on the diagnosis and treatment of Pelvic Inflammatory Disease.

Discharge from gonorrhea
Thick, white or snotty yellow-green discharge from gonorrhea
Gonococcal cervicitis
Gonococcal cervicitis