Rectal gonorrhea is an infection of the anus and rectum caused by the bacterium Neisseria gonorrhoeae, usually picked up through receptive anal sex. It often causes no symptoms at all; when it does, you may notice anal itching, soreness, discharge, bleeding, or painful bowel movements. A standard urine test misses it. Only a rectal swab finds it.
test all exposed sites
500 mg IM, single shot
| Item | Value |
|---|---|
| Test method | NAAT — test all exposed sites |
| Treatment | ceftriaxone — 500 mg IM, single shot |
| Throat infection | harder to cure |
| Retest | 3 mo |
The essentials
Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can colonize the genitals, the rectum, and the throat CDC, About Gonorrhea. The rectum is one of those sites because the same cells that line the urethra and cervix also line the anal canal, and the bacteria attach and reproduce there just as readily. Anal sex delivers them directly to that tissue.
A urine test can't see a rectal infection. Urine only carries cells shed from the urethra, so it tells you what's happening in the genital tract and nothing about the rectum or throat. If you've had receptive anal sex, the infection lives where the urine never travels, and these cases slip through screening when nobody asks for a rectal swab.
Rectal gonorrhea is curable. The right antibiotic clears it, but treatment can't undo damage that an untreated infection has already caused, so catching it early matters. Reported gonorrhea has been falling lately, roughly 601,000 cases nationally in 2023, down from a 2021 peak CDC AtlasPlus, 2023, though rates swing enormously by location, from the national figure up to far higher numbers in places like Washington, DC.
What are the symptoms of rectal gonorrhea?
Most rectal infections are silent. Like gonorrhea at other sites, it can sit in the body without producing anything you'd notice, so screening is how these infections get found. When symptoms do appear, they're local to the anus and rectum:
- Anal or rectal discharge — mucus or pus you might see on toilet paper or in stool.
- Anal itching that doesn't resolve.
- Soreness or a raw, tender feeling in the anal area.
- Rectal bleeding, often noticed as spotting.
- Pain or straining during bowel movements (proctitis — inflammation of the rectal lining).
These overlap with hemorrhoids, anal fissures, and other causes of proctitis, so the symptoms alone don't confirm gonorrhea; only testing does. Gonorrhea at other sites looks different. In men, the classic genital signs are burning on urination and a white, yellow, or green penile discharge, with swollen, painful testicles being less common; you can read the full picture of gonorrhea symptoms in men if you've also had genital exposure. In women, genital infection is commonly asymptomatic, and the majority of throat infections cause no symptoms at all. Because a person can carry the infection at more than one site, a clear urine result doesn't rule out a rectal one.
How is rectal gonorrhea tested?
The preferred test is a NAAT (nucleic acid amplification test), which detects the bacterium's genetic material with high sensitivity (usually over 90%) and high specificity (around 99%) CDC STI Treatment Guidelines. For the rectum, the specimen is a rectal swab, a quick swipe inside the anal canal. Patient-collected swabs are acceptable, so you can often do it yourself in the exam room, which many people find easier than having a clinician do it.
Screen every anatomic site of sexual exposure. A first-catch urine sample (or a vaginal swab) covers the genitals, but it will never detect a rectal or throat infection; those need their own swabs. This is the single most common testing mistake. If you've had receptive anal sex and only give a urine sample, a rectal infection gets missed entirely. Ask for a rectal swab by name, and add a throat swab too if you've had oral sex.
Timing matters too. Testing too soon after a hookup can return a false negative before the bacteria have multiplied enough to detect, so check guidance on when to test after exposure. For the practical logistics — what a gonorrhea test involves and how to read the result — and the choice between clinic and home, see how to get tested for gonorrhea at home or clinic. When you're ready, you can get tested.
How is rectal gonorrhea treated?
First-line treatment is a single intramuscular injection of ceftriaxone — 500 mg for people under 150 kg, or 1 g for those 150 kg or more — given in the clinic, not as take-home pills MMWR, 2020. That one shot covers urogenital, anorectal, and pharyngeal infection, so it treats a rectal infection directly. If chlamydia hasn't been ruled out — and it often travels with gonorrhea — a short course of oral doxycycline is added on top of the injection.
Oral antibiotics alone are no longer reliable for gonorrhea, so the injection is standard. The guidelines shifted in 2020: the older regimen paired ceftriaxone with azithromycin, but azithromycin resistance climbed fast — isolates with elevated azithromycin levels rose more than sevenfold over a few years — so the CDC dropped it and raised the ceftriaxone dose, leaving a single injection as the lone first-line regimen Clin Infect Dis, 2020. For people with a true cephalosporin allergy, an alternative single-dose regimen of an injection plus oral medication is used. If ceftriaxone simply isn't available, oral cefixime is an option for urogenital and anorectal infection only; it does not reliably cure throat infection, and a test-of-cure is advised afterward.
Two new oral antibiotics were approved in December 2025 — zoliflodacin (Nuzolvence) and gepotidacin (Blujepa), the first new antibiotic classes for gonorrhea in over thirty years FDA, 2025. Both are pills, both are approved for uncomplicated urogenital infection in eligible patients, and gepotidacin is meant as a reserve option when resistance leaves few alternatives FDA Blujepa, 2025. Neither replaces ceftriaxone as first-line yet. Injectable ceftriaxone still anchors treatment because the bacterium has steadily outrun nearly every other class — sulfonamides, penicillin, tetracyclines, fluoroquinolones, and cefixime — and a ceftriaxone-resistant strain has already emerged abroad and spread internationally WHO.
After treatment, abstain from sex for seven days after the shot so you don't pass the infection back and forth, and retest in about three months, because reinfection is common. A rectal infection doesn't need a routine test-of-cure the way a throat infection does. Throat gonorrhea is harder to eradicate, and the pharynx also acts as a resistance breeding ground where the bacterium picks up genes from other throat microbes CDC Drug-Resistant Gonorrhea.
| Site of infection | How it's detected | Does the standard injection cover it? | Test-of-cure needed? |
|---|---|---|---|
| Genital (urethra/cervix) | First-catch urine or vaginal swab | Yes | No, routine retest at ~3 months |
| Rectum | Rectal swab | Yes | No, routine retest at ~3 months |
| Throat | Pharyngeal swab | Yes | Yes — return 7–14 days after treatment |
How do you prevent rectal gonorrhea?
- Use condoms correctly every time, including for anal sex — this is the practical mainstay.
- Get screened at every exposed site on a regular schedule, not just the genitals.
- Make sure partners from the prior 60 days are notified and treated, and abstain from sex for seven days after your own treatment so you don't reinfect each other.
- Mutual monogamy between two tested, uninfected partners lowers risk; abstinence is the only certain method.
DoxyPEP — a dose of doxycycline taken within 72 hours of sex — cuts chlamydia and syphilis substantially but works poorly against gonorrhea, with inconsistent results across trials CDC DoxyPEP, 2024. The CDC does not recommend it specifically to prevent gonorrhea, partly over concern that it could drive tetracycline resistance in the bacterium. Don't lean on DoxyPEP as your gonorrhea plan.
On cost and access: testing and the injection are free or low-cost at many public health clinics, and the shot is given on-site the same visit.
When should you see a clinician?
See a clinician if you have anal discharge, bleeding, persistent itching, or painful bowel movements after receptive anal sex, or if a partner tells you they tested positive, even with no symptoms of your own. Don't sit on a swollen, painful testicle: that can signal epididymitis (inflammation of the tube behind the testicle that can affect fertility), and it needs prompt care, not a wait-and-see approach. If you've had anal sex and are due for screening, get evaluated and ask specifically for a rectal swab.