Untreated gonorrhea doesn't just linger. Left alone, this bacterial infection can climb into the reproductive tract and cause pelvic inflammatory disease, scarring, and infertility, and in some people it seeps into the bloodstream to inflame joints and skin. Gonorrhea is curable, but antibiotics can't undo damage that's already happened.
| Item | Cases per 100,000 |
|---|---|
| 2021 | 214 |
| 2022 | 194.4 |
| 2023 | 179.5 |
The essentials: what untreated gonorrhea does over time
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, which can infect the genitals, rectum, and throat CDC. Left untreated, the infection rarely goes away on its own. It keeps replicating where it landed and can travel to tissues that scar permanently.
In people with a uterus, ascending infection causes pelvic inflammatory disease (PID), inflammation of the uterus, fallopian tubes, and ovaries. PID is the main reason untreated gonorrhea threatens fertility: inflammation can scar the fallopian tubes, which can block them and lead to infertility or ectopic pregnancy (a pregnancy that implants outside the uterus, a medical emergency), plus chronic pelvic pain. In people with a penis, the bacteria can spread to the epididymis (the coiled tube behind each testicle that stores sperm), causing epididymitis, a painful swelling that, untreated, can affect fertility.
Most articles skip disseminated gonococcal infection (DGI). When the bacteria enter the bloodstream, they can settle in joints and skin. The classic picture is gonococcal arthritis, with hot, swollen, painful joints that sometimes migrate from one joint to another, a scattered rash of small pustular or hemorrhagic spots, and inflammation of the tendon sheaths (tenosynovitis). DGI is uncommon but serious. It usually starts from an untreated infection that was silent at the original site, which is why asymptomatic infections shouldn't be ignored.
Untreated gonorrhea also makes it easier to acquire or transmit HIV, and a pregnant person can pass it to a newborn during delivery, where it can cause a serious eye infection. None of this is inevitable; it's the cost of waiting. Treatment cures gonorrhea, though medicine can't reverse damage already done. See is gonorrhea curable? what to know about a cure.
Symptoms — and why so many people have none
Many gonorrhea infections cause no symptoms at all. In women infections are commonly asymptomatic, and the majority of throat infections are silent CDC STI Guidelines. A silent infection still does damage and still spreads, giving you no warning to seek care.
When symptoms do appear, they vary by site:
- Men: burning when urinating; a white, yellow, or green discharge from the penis; less often, swollen or painful testicles.
- Women: when symptoms occur, painful or burning urination, increased vaginal discharge, and bleeding between periods. Most women notice nothing.
- Rectal: discharge, anal itching, soreness, bleeding, or painful bowel movements.
- Throat: usually no symptoms, which makes pharyngeal infection easy to miss and to pass on.
Symptoms of disseminated infection are different and easy to mistake for other illnesses: joint pain and swelling, a low fever, and a sparse rash. If you've had a possible exposure and develop painful, swollen joints with skin spots, mention gonorrhea specifically to whoever sees you.
Testing: how to make sure nothing gets missed
The preferred test is a NAAT (nucleic acid amplification test), which detects the bacterium's genetic material with sensitivity usually above 90% and specificity around 99% CDC. For the genitals, that's a first-catch urine sample (for men and women) or a vaginal swab; for the throat and rectum, it's a quick swab of those sites. Patient-collected swabs are acceptable, so you can often do them yourself.
Screen every site you've exposed. A urine test alone will miss a throat or rectal infection, and those are usually the symptomless ones. If you've had oral or anal sex, ask explicitly for a throat or rectal swab and don't assume it's included. Timing matters too; if it's very soon after a possible exposure, read when to test after exposure so you don't test too early and get false reassurance. When you're ready, you can get tested at a clinic or with an at-home kit.
Treatment: a single injection, not take-home pills
The recommended treatment is ceftriaxone 500 mg as a single intramuscular injection, given in the clinic, for people under 150 kg; for people 150 kg or more, the dose is 1 g. That one shot covers genital, anorectal, and throat infections. If chlamydia hasn't been ruled out, a short course of doxycycline pills is added to cover it.
In 2020 the CDC moved from dual therapy (ceftriaxone plus azithromycin) to ceftriaxone alone, and raised the ceftriaxone dose MMWR, 2020. Azithromycin was dropped because resistance climbed fast, with isolates showing elevated azithromycin levels rising more than sevenfold over several years, and because of stewardship and gut-microbiome concerns. For you, that means oral antibiotics are no longer reliable first-line, so plan to get the injection on-site rather than expecting a prescription to fill at the pharmacy.
A few situations change the plan. People with a true cephalosporin allergy get an alternative two-drug regimen. If ceftriaxone isn't available, oral cefixime can treat genital and rectal infection only; it does not reliably cure the throat, so a test-of-cure is recommended afterward. Throat infections are harder to clear than genital ones. Even fully susceptible pharyngeal infections fail treatment a small but real percentage of the time, so the guidance is to return 7–14 days later for a throat test-of-cure Clin Infect Dis, 2020. For the full breakdown of drugs and doses, see gonorrhea treatment.
The throat matters beyond your own cure. The pharynx is where gonorrhea picks up resistance genes from harmless throat bacteria, and those infections are usually symptomless and can persist for weeks. Ceftriaxone-resistant strains, first reported abroad in 2015, are no longer hypothetical, and the WHO estimates tens of millions of new infections worldwide each year WHO. No verified US clinical ceftriaxone failures have been reported to date, but cephalosporins are described as essentially the last reliable class, so dosing and follow-up are taken seriously. More on this at gonorrhea treatment.
After treatment: abstain from sex for 7 days after the shot so you don't pass it back and forth, and notify partners from the prior 60 days so they can be treated. Where in-person care isn't possible for a heterosexual partner and it's legally permitted, expedited partner therapy (giving the partner oral medication to take) is an option. Plan to retest about 3 months later. Reinfection is common, and a new positive then usually means a new exposure rather than a failed cure.
On cost and access: testing and the injection are often free or low-cost at public health clinics, and the shot is given on the spot. Don't sit on a swollen, painful testicle. Epididymitis needs prompt treatment, not wait-and-see.
| Situation | What's used | Follow-up |
|---|---|---|
| Standard (under 150 kg) | Single ceftriaxone injection | Retest in about 3 months |
| 150 kg or more | Higher single ceftriaxone dose | Retest in about 3 months |
| Chlamydia not excluded | Add a short doxycycline course | Retest in about 3 months |
| Cephalosporin allergy | Alternative two-drug regimen | As advised by clinician |
| Throat infection / cefixime used | Same injection (or cefixime if no ceftriaxone) | Test-of-cure 7–14 days later |
Prevention that actually works
The methods with the best track record are unglamorous but effective: correct condom use every time, regular screening of every site you expose, and treating partners so the infection doesn't ping-pong between you. Abstaining is the only certain method, and mutual monogamy with a tested partner lowers risk.
You may have heard about DoxyPEP, taking doxycycline shortly after sex. It cuts chlamydia and syphilis substantially, but it's much less effective for gonorrhea and results vary across studies, so the CDC does not recommend it for gonorrhea prevention, partly out of concern it could drive resistance MMWR, 2024. Don't rely on it as a gonorrhea shield.
For context, reported gonorrhea has been falling nationally, but rates vary enormously by place CDC AtlasPlus, 2023. Where you live affects your background risk, one more reason to test on a regular schedule rather than only when symptoms appear.
When to see a clinician
- You have burning urination, unusual discharge, or bleeding between periods.
- A partner told you they tested positive. Get treated even if you feel fine.
- You have a swollen, painful testicle. This needs prompt care, not waiting.
- You develop painful, swollen joints with a fever or a sparse rash after a possible exposure. This can be disseminated infection.
- You've had oral or anal sex and want every exposed site checked, not just a urine test.
- You finished treatment but symptoms persist beyond a few days, or you had a throat infection and need a test-of-cure.