Learn All About Gonorrhea: Its Causes, Symptoms, Treatment, and Prevention

Each day there are more than one million sexually transmitted infections (STIs or STBBIs) acquired worldwide, the majority of which are asymptomatic. Of these, 374 million are 1 of 4 curable STIs: chlamydia, gonorrhea, syphilis, and trichomoniasis.

STIs can have a direct impact on sexual health. This can include stigmatization, infertility, cancers, pregnancy, and other reproductive issues.

What is The Clap Otherwise Known as Gonorrhea and How Is It Transmitted?

Gonorrhea is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhea. Commonly known as “the clap,” it is spread through oral, genital, or anal sex with someone who is infected. It can also spread from mother-to-child during birth.

In addition to the infection localizing in the genital area, it is possible to get gonorrhea in the mouth. People often ask, “Can you get gonorrhea from kissing?” A recent report in 2019 from Australian researchers tested this theory of whether gonorrhea can be transmitted mouth-to-mouth. The research did show that kissing may be associated with oral or “throat” gonorrhea.

Statistics

Gonorrhea rates are climbing worldwide, and reasons are not fully clear as to why. After a low in 2019, it is thought that closures of health services unrelated to COVID-19 have impacted testing access and availability and may have contributed to lower reported numbers, but not necessarily prevalence rates.

Canada

In the past decade, rates have almost tripled (181.7%)
In 2019, there were 35,443 cases reported, for a rate of 94.3 cases per 100,000
Between 2010 and 2019, rates were consistently higher among males
In 2019, 65.5% of cases were among males and increased faster in males, widening the gap between males and females
More than half of cases (51.9%) were among people less than 30 years old

United States

In 2020, there were 667,769 cases of reported gonorrhea – making it the second most common notifiable disease in the US for the year
Rates of gonorrhea have increased by 111% since the historic low of 2009
During 2019-2020 alone, the rate increased by 5.7%
As in Canada, rates are higher among men than women, and it is thought that men who have sex with me (MSM) account for approximately a third of cases
However, the 2019-2020 reporting period showed a greater increase in women (15%) compared with men (6.6%), but this may be due to the differences in diagnosing and reporting of cases among MSM in 2020

United Kingdom

In 2021, there were 51,074 gonorrhea cases reported
This is a 1.7% increase compared to 2020
Gonorrhea was one of the most commonly diagnosed STIs, with 16.4% of the distribution of STIs in the country
Among MSM, diagnoses increased by 9.0% (from 24,784 to 27,123)
Among people aged 15-24, gonorrhea rates decreased by 7.4%, but it is not yet clear if these decreases relate to a fall in infection rates in the community

Europe

In 2019, the number of reported cases of gonorrhea increased by 55% across the EU/EEA
Numbers for gonorrhea (and chlamydia, syphilis, and LGV) reached an all-time high in 2019
Reported cases of gonorrhea are three times more common among men than women
Young women, however, are a vulnerable group, with a median diagnosis age of 22 compared to 26 years for a heterosexual man and 31 for MSM
In 2019, there were a record number of infections, with 117,881 reported cases from 27 countries in the EU/EEA
The UK reported the highest number of cases at 66% total
For cases with reported modes of transmission, 48% were in MSM, 24% in heterosexual women and 22% in heterosexual men

Global

Each year, there are more than one million cases per day of STIs
Each year, there are an estimated 374 million cases of one of four curable diseases, including gonorrhea
In 2020, the WHO estimated that there were 82 million new gonorrhea infections
Most cases in 2020 were in the WHO African and Western Pacific Regions
Most people affected were between 15-49 years old
There is a global incident rate of 19 cases per 1000 women and 23 per 1000 men

What are the Symptoms?

Symptoms are different depending on gender. People with gonorrhea, especially females, may be asymptomatic (that is, they present with no symptoms.) If someone is symptomatic, they usually occur within two to seven days after contracting the infection.

For women, early symptoms of gonorrhea are often mild and non-specific; that is, they are often mistaken for a bladder or vaginal infection. Females who experience mild or no symptoms are still at risk of serious complications, such as pelvic inflammatory disease (PID). PID risks include abdominal pain, fever, internal abscesses, long-lasting pelvic pain, and scarring of the fallopian tubes, which can lead to infertility and can increase the chance of ectopic/tubal pregnancies.

If the infection is passed onto the baby in the birth canal during delivery, it can cause blindness, joint infection, or a life-threatening blood infection.

For those that do experience symptoms, these can include:

a burning sensation when urinating
vaginal discharge
pain in the lower abdomen
pain during sex
vaginal bleeding between periods or after sex

For men, symptoms may include:

a burning sensation when urinating
yellowish/white discharge from the penis
burning or itching at the opening of the penis
painful or swollen testicles

Men can develop epididymitis, a painful inflammation in the tubes attached to the testicles. If untreated, it can lead to infertility on rare occasions.

For all genders, gonorrhea can infect the rectum. Symptoms can include:

discharge
anal itching
soreness
bleeding
painful bowel movements

For all genders, if the infection is left untreated, it is at risk of spreading through the bloodstream and infecting other parts of the body, including joints. This condition can be life-threatening.

If gonorrhea is contracted orally, the person infected this way may experience a sore throat; however, they usually have no other symptoms with contracting gonorrhea in the mouth.

Risk Factors

It is important if sexually active to reduce risks, including using protection and having open discussions about health with all sexual partners. There are risk factors for contracting gonorrhea and other STIs, including:

Having condomless vaginal, oral, or anal sex
Being younger (15-29 years old)
Having multiple sexual partners

Additionally, in couples where one person has an HIV infection and one doesn’t (serodiscordant or mixed HIV status), the risk of contracting and transmitting HIV is increased if one partner already has another STI.

How do you Test for Gonorrhea?

Even when asymptomatic, it is important to remember that the infection can still be passed to others. It is important that if someone is sexually active, that regular STI testing, including for gonorrhea, is conducted.

Gonorrhea tests are conducted to:

To confirm if a gonorrhea infection is causing symptoms such as pain during urination, anal itching, and bleeding, vaginal bleeding after intercourse, or with abnormal penis or vaginal discharge
Screening for those at higher risk of infection
Retest to confirm gonorrhea treatment worked
Check for infections in newborns if they were exposed during delivery

Testing for gonorrhea can be done using a simple swab or urine test. There are different tests used to confirm the presence of infection. They include:

Rapid Gonorrhea Tests (Screening tests): these tests are similar to what is seen with COVID-19 rapid tests. They use a swab and test for the presence of the gonorrhea antigen. Test results can usually be read within 10-20 minutes. All positive results should be confirmed through a healthcare provider
Nucleic Acid Amplification Tests (NAAT): these are the most sensitive tests and may be done without waiting 48 hours after exposure. These can also be used to detect rectal and pharyngeal infections.
Gonorrhea Culture: These provide antimicrobial susceptibilities and should be used when antibiotic resistance is suspected, which is important for case management. These are recommended (with NAAT) if there is suspected treatment failure, the patient is symptomatic, with PID, with pregnancy, and when sexual abuse is suspected.
Gram Stain: A Gram stain test is done on a fluid sample from the penis or, less commonly, the cervix. It is less reliable than culture or NAAT testing but offers faster results. Samples done on cervixes are not very accurate and are mostly used on fluid samples from the penis.

Testing Preparation

If the test is a direct sample test, this means a sample of body fluid is taken from the area where gonorrhea is suspected, such as the cervix, vagina, rectum, throat, or eyes. A doctor or healthcare professional may collect the sample, or it may be self-collected.

If it is a urine test, do not urinate for 2 hours prior to the sample collection. Do not wipe the genital area before urination; collect the first part of the urine stream just as urination begins.

Testing usually only takes a few minutes. There may be minor discomfort for a fluid sample, and a cervical sample may feel similar to a Pap test or pelvic examination. Collecting a urine sample does not usually cause any discomfort or pain.

If an infection is suspected, it is important to refrain from sex until a negative test result is received. If an infection is suspected, testing for other STIs is also important.

Test Results

Normal: No signs of gonorrhea bacteria are found. If a culture is done, no gonorrhea bacteria growth was found in the culture. More testing for other sexually transmitted infections may be needed to find the cause of any symptoms.
Abnormal: Signs of gonorrhea bacteria are found. If a culture is done, gonorrhea bacteria grow in the culture.

Screening Recommendations

Screening for gonorrhea is recommended for anyone with STI risk factors. Screening is effective for detecting and treating asymptomatic infections and preventing complications, transmission, and reinfection. Depending on the type of sexual activity, samples may need to be taken from more than one anatomical site.

Testing is specifically recommended for the following groups:

Sexually active adolescents and young adults under 25 years old
Pregnant people during the first prenatal visit
- If an infection is diagnosed, TOC (transition of care) is recommended
  - Rescreen in the third trimester for those at high risk of infection or reinfection
  - Screen at delivery
- Newborn children who are exposed to gonorrhea

Additional STBBIs screening may be recommended depending on age, gender/sex, medical, and sexual history.

Those who are being evaluated for gonorrhea are recommended to also test for chlamydia, syphilis, and HIV.

Does Gonorrhea Go Away and What Treatments Are Available?

Gonorrhea medication (treatment) is available, but many strains circulating globally have become resistant to previously recommended treatments. In Canada, along with an increase in prevalence rates, there is an increase in antimicrobial resistance. If diagnosed with gonorrhea, it is important to follow the healthcare professional’s treatment and follow-up recommendations.

To avoid onward transmission, it is important to avoid unprotected sexual activities with sexual partner(s) until all treatment is complete and a negative test result is returned.

Prevention

Practicing safe sex is an important tool to help prevent the contraction and transmission of all STIs, including gonorrhea. Some ways to practice safer sex include:

Consistently and correctly use condoms and oral/dental dams during sex
Get tested for STIs if you are sexually active, and encourage all sexual partner(s) to do the same
Make informed decisions and talk to partner(s) about STI status
If diagnosed, it is important to inform the local health department and any sexual partners at risk of infection, as they will need to be tested and treated if positive.

To avoid onward transmission, it is important to avoid unprotected sexual activities with sexual partner(s) until all treatment is complete and a negative test result is returned.

Resources

The Government of Canada’s Booklet on Sexually Transmitted Infections

References