Gonorrhea: Symptoms, Physical Examination, Diagnosis, Treatment, Autoinoculation and Risk Factors

Gonorrhea is a purulent infection of the surfaces of the mucous membrane caused by Neisseria gonorrhoeae. N. Gonorrhoeae.

It is spread by sexual contact or transmission during childbirth. The Centers for Disease Control (CDCE) recommends that all patients with Gonorrheal infection also be treated for presumed Chlamydia Coinfection.

Signs and symptoms

In women, the main genitourinary symptoms of Gonorrhea include the following:

  • Vaginal discharge: the most frequent presenting symptom of Gonorrhea, the vaginal discharge of Endocervicitis, is generally described as thin, purulent, and slightly odorous; however, many patients have minimal or no symptoms of gonococcal cervicitis.
  • Dysuria.
  • Intermenstrual bleeding.
  • Dyspareunia (painful intercourse)
  • Low and mild abdominal pain.

If the infection progresses to Pelvic Inflammatory Disease (PID), the symptoms may include the following:

  • Low abdominal pain
  • Increased vaginal discharge or mucopurulent urethral discharge.
  • Dysuria: usually without urgency or frequency.
  • Sensitivity to cervical movement.
  • Adnexal acuity (usually bilateral) or adnexal mass.
  • Intermenstrual bleeding.
  • Fever, chills, nausea, and vomiting (less common).

In men, the main genitourinary symptoms of Gonorrhea include the following:

  • Urethritis: the primary manifestation of gonococcal infection in men; initial characteristics include burning during urination and serous secretion; a few days later, the discharge usually becomes more profuse, purulent, and, sometimes, tinged with blood
  • Acute epididymitis: usually unilateral and often occurs together with a urethral discharge
  • Urethral strictures: have become uncommon in the era of antibiotics. Still, they may present a decrease and abnormality of urine flow and secondary complications of prostatitis and cystitis.
  • Rectal infection: may present with pain, pruritus, secretion, or tenesmus.

In newborns, in whom Bilateral Conjunctivitis (Neonatal Ophthalmia) often follows the vaginal delivery of a mother not treated with a gonococcal infection, the symptoms of gonococcal conjunctivitis include the following:

  • Eye pain.
  • Redness
  • Purulent discharge.

Physical exam

Look for the following genitourinary symptoms during the physical examination in women:

  • Vacuum, urethral, or cervical mucopurulent or purulent discharge.
  • Vaginal bleeding, vulvovaginitis in girls.
  • Cervical friability, tendency to bleed after manipulation.
  • Sensitivity to cervical movement during the bimanual pelvic examination.
  • The annexes’ fullness and sensitivity are unilateral or bilateral (e.g., Ovaries, fallopian tubes).
  • Pain/tenderness in the lower abdomen, with or without sensitivity to rebound.
  • Possible low back pain.
  • Upper proper abdominal sensation (with perihepatitis).

Look for the following genitourinary symptoms during the physical examination in men:

  • Mucopurulent or purulent urethral discharge: obtained by milking the urethra along the axis of the penis.
  • Possible epididymitis: unilateral epididymal sensitivity and edema, with or without penile discharge or dysuria.
  • Penal edema: without other manifest inflammatory signs.
  • Urethral stricture: Uncommon; more often seen in the pre-antibiotic era with urethral irrigation using caustic liquids.


Culture is the most common diagnostic test for Gonorrhea, followed by the deoxyribonucleic acid (DNA) probe and then the Polymerase Chain Reaction (PCR) and the Ligand Chain Reaction (RCL) assay.

The DNA probe is an antigen detection test that uses a search to detect gonorrhea DNA in samples.

The specific culture of a swab from the site of infection is a standard criterion for diagnosis in all possible areas of gonococcal disease.

Cultures are beneficial when the clinical diagnosis is unclear, when treatment failure has occurred, when contact tracking is problematic and when legal questions arise.


Three sets of blood cultures should also be obtained.

Treatment Administration

For uncomplicated Urogenital, Anorectal, and Pharyngeal Gonorrhea infection, a medication regimen may use Ceftriaxone plus Azithromycin or Doxycycline.

Antimicrobial drugs used alone or in various combinations in other gonococcal infections include the following:

  • Gonococcal Arthritis: Ceftriaxone.
  • Gonococcal conjunctivitis: Ceftriaxone
  • Gonorrhea: Cefoxitin, Ceftriaxone, Doxycycline, Metronidazole, Cefotetan, Clindamycin, Gentamicin.
  • Gonococcal epididymitis: Ceftriaxone, Doxycycline.
  • Gonococcal meningitis and endocarditis: Ceftriaxone.

Sexually transmitted infection

Gonococcal infection usually follows inoculation of the mucosa during vaginal, anal, or oral sexual contact. It can also be caused by mucosa injection by fingers or other contaminated objects.

Transmission through penile-rectal contact is quite efficient.

The risk of transmission of N. Gonorrhoeae from an infected woman to the urethra of her male partner is approximately 20% per episode of vaginal intercourse and increases to 60-80% after four or more exposures.

On the other hand, the risk of male-to-female transmission is close to 50-70% per contact, with little evidence of increased risk with more sexual exposure.

As central transmitters, people who have unprotected sex with new partners are often defined enough to maintain the infection in a community.

Pediatric and neonatal gonococcal infection

Neonatal gonococcal infection can follow conjunctival infection, obtained through birth canal passage. In addition, the direct infection can occur through the scalp at fetal monitoring electrode sites.

In children, the infection can occur due to sexual abuse by an infected individual or possibly by non-sexual contact in the child’s home or institutional settings.


Autoinoculation can occur when a person touches an infected site (genital organ) and contacts the skin or mucosa.

Risk factor’s

Risk factors for Gonorrhea include the following:

  • Sexual exposure to an infected partner without barrier protection (e.g., lack of condom use or condom failure).
  • Multiple sexual partners.
  • Male homosexuality
  • Low socioeconomic status
  • History of ETS simultaneous or past.
  • Exchange of sex for drugs or money.
  • Use of crack cocaine.
  • Early age of onset of sexual activity.
  • Pelvic inflammatory disease (PID).


With adequate early therapy, complete healing and return to normal function are the rule. Most gonococcal infections respond rapidly to Cephalosporin therapy.

Delayed, delayed, or inappropriate therapy can lead to significant morbidity or death.

Complications in men Urethral strictures secondary to gonococcal infection in men are less common than previously thought.

Some stenoses in the pre-antibiotic era probably resulted from treatment by urethral irrigation using caustic compounds instead of Gonorrhea itself.

Other complications, such as Peneana Lymphangitis, Periurethral Abscess, Acute Prostatitis, Seminal Vesiculitis, and infection of the Tyson and Cowper glands, are now rare.

Complications in women

The spleen’s scars and infertility are the main complications of gonococcal infection in women.

The incidence of involuntary infertility is estimated at 15% after an attack of Pelvic Inflammatory Disease (PID) and approximately 50% -80% after three episodes.

Despite the clinical and microbiological cure of the infection, one study showed 13% infertility rates in women with (PID) due to illness by N. gonorrhoeae.

Failure to diagnose (PID) can cause acute morbidity, including tube / ovarian abscess, endometritis, Fitz-Hugh-Curtis syndrome (Perihepatitis), and other chronic sequelae.

Perihepatitis secondary to Gonorrhea presents as pain in the right upper quadrant and nausea.

The incidence of ectopic pregnancy increases 7 to 10 times in women with the previous salpingitis, with the consequent increase in maternal and fetal mortality rates.

Gonococcal infections in women can also manifest as gonococcal urethritis or disease of the Periurethral glands (Skene) or Bartholin.

Patient education

Discuss safe sexual practices with everyone in whom Gonorrhea is suspected.

Proper education to prevent Gonorrhea can be more effective than simplistic instructions to avoid sex, especially for adolescents.

Adolescents who participate in abstinence campaigns only have rates of Sexually Transmitted Diseases (STDs) unchanged and acquire disproportionately anal and oral infections instead of vaginal infections (the perception is that if an activity is not vaginal sex, it is not sex)

Emphasize that oral or anal sex can also transmit the disease.

Patients should know the disease’s transmission method and the adverse impact of recurrent infections on future fertility.

They should be advised about the risks of complications after gonococcal infection and the risk of other STDs.

They should always be instructed to recommend sexual partners for prompt evaluation and treatment.

In addition, these people should be aware that they should avoid contact until the medication is finished and until their partners are thoroughly evaluated and treated.

After that, they should avoid unprotected contact.

The discussion about responsible sexual behavior should not be limited or suspended due to personal religious or moral opinions because the patient can not share them.

Adolescents are notorious for sexual experimentation; the evidence suggests that offering only a limited discussion to the adolescent population is a disservice.

This advice is especially relevant in states where sex education is almost non-existent in the school system due to the teaching of abstinence alone, which is misleading and inaccurate.

Risks of unprotected sex

Patients should also be counseled about the additional risks of unprotected sex, including acquiring more serious or lifelong infections, such as herpes, hepatitis B, HIV, and, of course, the chances of pregnancy.

It is also necessary to address the emotional aspect of sexual relations, especially in adolescents. Adolescents are vulnerable because they are sexually mature, but they are not emotionally mature yet.