Gonorrhea: Symptoms, Risks, Complications, and Why Treatment Has Changed

Gonorrhea is the second most commonly reported bacterial STD in the US, with over 600,000 cases annually — and the real number is substantially higher because many infections are never diagnosed. It infects the genitals, rectum, and throat, is predominantly asymptomatic in women, is increasingly resistant to antibiotics, and causes serious complications if untreated. Understanding what gonorrhea actually does, how it spreads, and what treatment now requires is more clinically relevant than ever.

Quick answer: Gonorrhea is a bacterial STD caused by Neisseria gonorrhoeae. It infects genitals, rectum, and throat. Most women and many men have no symptoms. The only currently effective treatment is an injectable ceftriaxone — oral antibiotics no longer work reliably. A test of cure 1–2 weeks after treatment is recommended. Same-day testing is available in Houston, Chicago, Miami, San Diego, and Columbus.

Symptoms: The Asymptomatic Majority

Approximately 50% of women and 10–25% of men with gonorrhea have no symptoms. This is the primary reason gonorrhea is so prevalent: infected people feel fine, don't seek testing, and unknowingly transmit the infection.

When symptoms do occur in women: unusual vaginal discharge, burning on urination, bleeding between periods or after sex, or pelvic pain. In men: purulent (yellow-green) urethral discharge and burning or pain during urination, typically appearing 1–5 days after exposure. Rectal gonorrhea (from receptive anal sex) causes rectal discharge, itching, or pain — or nothing at all. Pharyngeal gonorrhea (from performing oral sex on an infected partner) is almost universally asymptomatic and presents exactly like strep throat when it does cause symptoms.

How Gonorrhea Spreads

Gonorrhea spreads through vaginal, anal, and oral sexual contact. Each anatomical site can be infected independently: urogenital, rectal, and pharyngeal gonorrhea can all coexist or occur in isolation. A standard urine test for gonorrhea only detects urogenital infection — it will miss rectal and pharyngeal infections entirely. If you've had oral or anal sex, tell your provider so they can order the appropriate swabs.

Per-act transmission rates without treatment: from an infected female partner to a male during vaginal sex, approximately 20–30%. From an infected male to a female, approximately 50–70%. Rectal transmission is highly efficient. Pharyngeal gonorrhea can transmit from throat to genitals during oral sex.

Complications of Untreated Gonorrhea

In women, untreated gonorrhea ascends to cause pelvic inflammatory disease (PID), which scars the fallopian tubes and causes infertility and ectopic pregnancy risk. The CDC estimates gonorrhea causes tens of thousands of cases of preventable infertility annually in the US. In men, epididymitis causes testicular pain, swelling, and potential fertility impact. Disseminated gonococcal infection (DGI) occurs when the bacteria spread to the bloodstream, causing fever, joint pain, and skin lesions — this is a medical emergency requiring IV treatment. Gonorrhea at any site increases HIV transmission and acquisition risk.

Testing

NAAT (nucleic acid amplification test / PCR) is the standard, with sensitivity over 98%. Test sites must match exposure sites: urine or urethral/cervical swab for genital exposure; rectal swab for anal sex; throat swab for oral sex. Each site requires a separate specimen — you cannot infer pharyngeal or rectal status from a urine test. Window period: 1–2 weeks after exposure for reliable NAAT results.

Treatment: The Resistance Crisis

Gonorrhea has developed resistance to every antibiotic class previously used to treat it. Current standard treatment is ceftriaxone 500mg intramuscular injection (1g for patients over 150kg). Oral antibiotics are no longer recommended — oral cephalosporins were removed from guidelines in 2012, azithromycin in 2020 due to resistance. Test of cure — repeat NAAT 1–2 weeks after treatment — is now recommended for all gonorrhea cases, not just pharyngeal, given the resistance situation. A positive test of cure requires urgent reporting and alternative management.

Partner Notification

All sexual partners from the previous 60 days should be notified, tested, and treated regardless of symptoms. Simultaneous treatment prevents the ping-pong reinfection pattern that is one of the most common reasons gonorrhea recurs. Expedited partner therapy (EPT) — prescribing treatment for a patient's partner without them being seen — is legal and recommended in most US states for gonorrhea.

When to Seek Urgent Care

• Fever with joint pain and skin pustules after gonorrhea diagnosis or possible exposure: possible disseminated gonococcal infection — ER evaluation required.

• Pelvic pain with fever in women: possible PID — same-day evaluation and treatment.

• Testicular pain or swelling: possible epididymitis — same-day evaluation.

• Symptoms not improving within 3–4 days of treatment: possible treatment failure — return for assessment.

Frequently Asked Questions

Can gonorrhea go away without treatment?

No. Gonorrhea does not self-resolve. Untreated infection persists, continues to cause damage, and remains transmissible. Some symptoms may fluctuate, but the infection does not clear without antibiotics.

Can I have gonorrhea in my throat without knowing?

Yes — in the vast majority of cases. Pharyngeal gonorrhea is almost universally asymptomatic or indistinguishable from a common sore throat. It is only detectable with a specific throat swab NAAT, which is not part of a standard STD panel unless you ask for it or disclose that you've had oral sex.

Why do I need an injection — can't I just take a pill?

Oral antibiotics no longer reliably treat gonorrhea. The CDC removed oral cephalosporins and azithromycin from gonorrhea guidelines due to resistance. Ceftriaxone by injection achieves blood levels that overcome resistance more reliably than oral options. If a provider prescribes oral antibiotics for gonorrhea, ask specifically why injectable ceftriaxone is not available.

What if I'm allergic to penicillin — does that affect gonorrhea treatment?

Ceftriaxone is a cephalosporin, not a penicillin, but there is a small cross-reactivity rate. True severe penicillin allergy (anaphylaxis) warrants allergy testing or management with an allergist before ceftriaxone is used. For mild penicillin sensitivity, the cross-reactivity risk is very low and ceftriaxone can usually be given. The alternative regimen (gentamicin + azithromycin) has lower efficacy data.

Related: Antibiotic-Resistant Gonorrhea · Pharyngeal Gonorrhea: Symptoms and Testing · Understanding Chlamydia · STDs and Infertility · Get tested today →