Gonorrhea is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. It is one of the oldest known STIs, with evidence of its existence dating back thousands of years.
When was gonorrhea first discovered?
The first known descriptions of gonorrhea date back to ancient China, Egypt, and Greece. The earliest surviving descriptions come from China around 200 BCE. Ancient Chinese medical texts referred to gonorrhea as “fire in the loins” and recommended herbal remedies as treatment. The ancient Greeks also described gonorrhea symptoms such as painful urination and yellowish discharge as early as the 2nd century BCE. The causative agent, N. gonorrhoeae, was first identified in 1879 by German physician Albert Neisser, for whom it is named.
How common was gonorrhea historically?
Throughout history, gonorrhea has been a widely spread infection affecting all levels of society. During the Middle Ages in Europe, gonorrhea was so prevalent that it was called “the clap” – a nickname that survives to this day. Soldiers and sailors returning from foreign wars helped spread gonorrhea and other STIs throughout Europe. As colonialism expanded worldwide from the 15th to 20th centuries, gonorrhea was also spread globally.
Prevalence in the 20th century
In the early 20th century, gonorrhea rates were very high. During World War I, the U.S. army lost 7 million person-days and discharged more than 10,000 men due to gonorrhea. Up until the discovery of antibiotics, the only treatments were harsh chemicals like silver nitrate, zinc, and mercury that were often ineffective. After penicillin became widely available by the 1940s, gonorrhea rates fell sharply in developed countries. By the 1970s, gonorrhea rates were at historic lows.
Resurgence in the late 20th century
After being easily treatable with antibiotics for decades, signs of antibiotic resistance began emerging in the late 1970s. Throughout the 1980s and 1990s, antibiotic-resistant strains became more common and harder to treat. Gonorrhea rates began rising again during this time, especially among young people ages 15-24.
How does gonorrhea spread?
Gonorrhea is spread through unprotected oral, anal, or vaginal sex with an infected partner. Less commonly, it can be spread through genital contact like touching or kissing. Gonorrhea can also sometimes spread from an untreated mother to her baby during childbirth.
Gonorrhea can infect the following body parts:
- Urethra (pee hole)
- Cervix
- Uterus
- Fallopian tubes
- Rectum
- Eyes
- Throat
The most common sites of infection are the urethra in men and the cervix in women. An infected mother can also pass the infection to her baby during delivery.
What are the symptoms of gonorrhea?
Many people with gonorrhea are asymptomatic, especially women. When present, symptoms of uncomplicated gonorrhea infection include:
- Men: Burning sensation during urination, green or yellow discharge from the penis, swollen or painful testicles.
- Women: Increased vaginal discharge, burning sensation during urination, vaginal bleeding between periods.
Rectal infections may cause discharge, itching, soreness, bleeding, or painful bowel movements. Pharyngeal (throat) infections are usually asymptomatic.
How is gonorrhea diagnosed?
Gonorrhea can be definitively diagnosed in men with a urethral swab to collect a sample of discharge to be tested in a lab. For women, cervical or vaginal swabs may be taken. These samples can be examined under a microscope looking for evidence of gram-negative diplococci bacteria which is indicative of gonorrhea. The most sensitive way to diagnosis gonorrhea in both men and women is a nucleic acid amplification test (NAAT), which detects the genetic material of N. gonorrhoeae.
Can gonorrhea be cured?
Yes, gonorrhea can be cured with the right antibiotics prescribed by a doctor. The recommended first line treatments are:
- Ceftriaxone (injectable)
- Azithromycin (oral)
- Cefixime (oral)
It is critical to take all medication as directed and avoid unprotected sex until treatment is complete and tests show the infection has cleared. Cases should also be reported to any recent partners so they can get tested.
What complications can gonorrhea cause if left untreated?
Untreated gonorrhea can cause many complications, especially in women. Possible complications include:
- Pelvic inflammatory disease (PID) – an infection of the uterus, fallopian tubes, and other reproductive organs that can cause scarring and infertility.
- Ectopic pregnancy – a dangerous pregnancy located outside the uterus.
- Chronic pelvic pain
- Infertility – damage to reproductive organs can impact fertility in both women and men.
Other complications include:
- Disseminated gonococcal infection (DGI) – the spread of infection into the bloodstream and joints.
- Gonorrheal arthritis – joint inflammation.
- Conjunctivitis and blindness – if gonorrhea spreads to the eyes.
- Neonatal infections – newborns can be infected during birth causing eye infections leading to blindness, joint infections, or scalp abscesses.
Prompt antibiotic treatment can help prevent the majority of complications. But delays can allow the infection to spread causing permanent damage.
How can gonorrhea be prevented?
The most reliable ways to avoid gonorrhea infection include:
- Abstinence from sex
- Being in a long-term mutually monogamous relationship with an uninfected partner
- Using male or female condoms correctly every time you have sex
- Limiting your number of sexual partners
Getting tested regularly, at least once a year, is also key if you are sexually active, especially with new partners. And completing the full course of antibiotics is vital to cure an infection and prevent spreading it back to your partner.
How common is antibiotic-resistant gonorrhea?
Over the past few decades, N. gonorrhoeae has developed resistance to nearly all antibiotics available for treatment:
| Antibiotic | Year Resistance Detected |
|---|---|
| Penicillin | 1976 |
| Tetracycline | 1985 |
| Fluoroquinolones | 2007 |
| Azithromycin | 2013 |
| Cephalosporins | 2016 |
Currently, the only reliable treatments are injectable ceftriaxone combined with oral azithromycin. But even these drugs are showing early signs of declining effectiveness as resistant strains continue emerging and spreading globally.
Countries with extensively drug-resistant (XDR) gonorrhea
As of 2022, XDR gonorrhea has been reported in the following countries:
- UK
- Australia
- France
- Spain
- Japan
- Canada
- Denmark
- Ireland
The first several cases in the U.S. were reported in Hawaii and California in 2022. Continued misuse of antibiotics and lack of access to dual therapy in some regions is accelerating resistance.
What new treatments are in development?
With traditional antibiotics becoming less effective, researchers are urgently working to develop new gonorrhea treatments. Some potential new drugs under investigation include:
- Zoliflodacin – a new type of antibiotic in Phase 3 trials
- Gepotidacin – another novel antibiotic finishing Phase 2 trials
- Various multidrug implants and formulations to provide longer-acting treatment
Non-traditional treatments are also being studied like antibodies, bacteriophage therapy, and antimicrobial peptides. However, new drugs are still years away from widespread availability. Preventing antibiotic resistance through responsible use of existing antibiotics is crucial.
Conclusion
Gonorrhea has afflicted humanity for millennia and remains a common STI today. While often asymptomatic, untreated gonorrhea can cause serious reproductive health complications in both women and men. The bacterium Neisseria gonorrhoeae has proven highly adept at evolving resistance to antibiotics, rendering treatments less effective. Dual therapy with injectable ceftriaxone and oral azithromycin remains the most reliable option, but rising resistance globally threatens to make gonorrhea untreatable again. Ongoing prevention efforts through safe sex practices, testing, partner notification, and responsible antibiotic use are essential to control its spread.