Introduction 

Gonorrhoea is a sexually transmitted infection. It is caused by the bacterium Neisseria gonorrhoeae. It can be transmitted by vaginal, anal or oral sex. It has many slang names, the most well-known of which is “the clap”.

Gonorrhoea infections also increase susceptibility to HIV infections. Other common STIs are syphilis and chlamydia, which can also co-infect with gonorrhoea. Men who have sex with men (MSM) and those who have unprotected sex, especially with multiple sexual partners are at a higher risk of acquiring sexually transmitted infections (STIs) including gonorrhoea.¹

In those assigned male at birth, the main symptoms are whitish or yellow/green discharge from the penis, pain and swelling in the testes, or a burning sensation when passing urine (caused by urethritis, inflammation of the urethra).⁸ In those assigned females at birth, symptoms are not always present. Still, if present it includes a burning sensation while passing urine, discharge from the vagina, and bleeding during sex or between menstrual periods. 

Uncomplicated gonorrhoea is treatable with antibiotics. The regimen varies from country to country but is usually treated with cephalosporins. Cephalosporins are a group of multiple antibiotics, in which ceftriaxone, cefixime and ceftazidime are commonly used. In the UK, it is treated with a combination of azithromycin and ceftriaxone.^3,8 

If left untreated, it can cause cervicitis, pelvic inflammatory disease, ectopic pregnancies and ultimately infertility in people assigned female at birth. A gonorrhoea infection during pregnancy can also have some severe consequences including low birth weight, spontaneous abortion and preterm birth. Gonorrhoea can also be passed on from mother to baby during childbirth. 

The most common symptom of neonatal gonorrhoea is conjunctivitis, which should be treated soon to avoid complications of conjunctival perforation and subsequent blindness. In adults, in rare severe cases, gonorrhoea can also cause infections such as encephalitis, which can be fatal. 

Global prevalence and trends

The annual incidence of gonorrhoea is around 87 million adults per year in 15-49 year olds, worldwide. Gonorrhoea is prevalent in all regions of the world, in countries of all income levels. The highest prevalence of all STIs globally is in Sub-Saharan Africa. Central Asia and Eastern Europe are other regions with a particularly high prevalence of gonorrhoea.

However, it is worth noting in countries where healthcare access and provision may be limited, the statistics are likely to be an underestimate of the true number of cases. The reason for the high prevalence in Sub-Saharan Africa and other low-income settings is largely due to longstanding poverty, limited access to healthcare (e.g. sexual health clinics) and limited general knowledge about sexual health.¹ 

In many countries, gonorrhoea case rates have increased in recent years. In the US, case rates increased by 75.2% from 2009 (98 per 100,000) to 2017 (172 per 100,000).¹ In Australia, cases increased from 66 per 100 000 in 2013 to 118 per 100 000 in 2017 and in Canada from 34 per 100 000 in 2010 to 55 per 100 000 in 2015.^1,5

In almost all countries, case numbers have been increasing more in people assigned male at birth compared to those assigned female at birth. Young adults and adolescents saw the highest rates of infection in almost all countries too. 

The COVID-19 pandemic did influence numbers. There was a spike in incidence (an increase of 16% from previous years) in 2021-2022. The main reason for this was the lifting of lockdown measures and increased activity, rather than any reduced provision of STI testing during the lockdown periods. According to UKHSA, 2022 had seen the highest number of gonorrhoea cases since records began. The highest increase was noted in the 15-24 year old age group, with a 50.3% increase from 2021. 

Another metric used for disease outcomes (particularly those that are not fatal but do affect long-term health) is disability-adjusted life years or DALYs. Between 1990 and 2019, DALYs for gonorrhoea have been going down across all age groups due to the increased availability of healthcare and treatment. 

A couple of notable examples of countries where gonorrhoea incidence has been decreasing are China and Morocco. Both countries have had strong governmental initiatives for the prevention, control, and surveillance of STIs, including gonorrhoea. There is political involvement at all levels, from managing individual patients and their treatment to following national or regional statistics. This shows that given the correct support, case numbers can be reduced. 

High-risk groups

MSM in 2016, in Europe, accounted for 46% of gonorrhoea cases. In the UK, this figure was 51% of cases in 2014. In certain countries, where there is still significant stigma (more so than stigma in high-income countries) around disclosing same-sex sexual partners, it is difficult to obtain data. Condom use in MSM has also declined in recent years, which also increases the incidence.¹

In many high-income countries, ethnicity is not recorded at sexual health clinics. However, from the data that is there, those from minority backgrounds are more likely to be affected by gonorrhoea. Indigenous communities in the US, Canada, and Australia have several times the incidence of STIs compared to their non-indigenous counterparts. Their discrimination from almost all areas of society (including healthcare, employment and education), generational trauma and abuse all contribute to poorer health outcomes. 

Sex workers are at a much higher risk of STIs. Multiple sexual partners, sex without condoms, and stigma around sex work and accessing healthcare make them more vulnerable. Some sexual counters may also involve abuse, coercion or drug use, which can complicate matters and add to discrimination. 

International travel also influences sexual activity. This can be bringing STIs from one country to another, influence sexual behaviours, or even as part of sex work. International travellers are another group where gonorrhoea is more prevalent especially in the Western Pacific and Southeast Asia, such as in Thailand where travelling for sex is very common.^1,6 

Multidrug-resistant (MDR) gonorrhoea

Over the years, the bacteria N. gonorrhoeae has become resistant to an increasing number of antibiotics. While case numbers of gonorrhoea are rising worldwide, the proportion of these cases that are multidrug-resistant is increasing too. Penicillins, macrolides, sulphonamides, and cefixime are some of the groups of antibiotics that gonorrhoea is already showing resistance to. 

MDR gonorrhoea is a significant threat to public health. Cephalosporins are a last-line option, they are a very powerful type of antibiotic and can kill multiple types of bacteria, including those that are resistant to other antibiotics. However, some studies have shown that gonorrhoea is starting to become resistant to ceftriaxone too.⁷ 

The reasons for antimicrobial resistance are many, but in general, it is because of overuse and misuse of antibiotics. Pressure on healthcare systems, pharmaceutical companies lobbying and mass availability of antibiotics also feeds into the problem. Therefore, whilst antimicrobial resistance is a public health crisis already, it is likely to only worsen.^2,4

Informing partners and following medication advice

It is important for anyone with symptoms of an STI, a new sexual partner, or any concern after a sexual encounter to be checked for STIs. In people assigned female at birth, gonorrhoea infections are often asymptomatic, which can give a false sense of security.

It is acknowledged that informing partners may well be easier said than done, and that stigma around STIs remains to be an issue. Still, it is strongly advised from a moral standpoint to inform partners, take medication as advised, and avoid sexual contact during the antibiotic course to control the spread of STIs and prevent possible long-term health complications. 

Summary 

Gonorrhoea is an STI which is a significant public health issue. It is increasing in prevalence throughout the world, with the highest prevalence in Africa. Gonorrhoea prevalence has been on the rise since the early 2000s, and in the 2020s has been higher in many parts of the world than it has ever been before.

Gonorrhoea can affect people of all ages and backgrounds, but young adults and teenagers have the highest incidence worldwide. Men who have sex with men, sex workers and those of ethnic minority backgrounds also have a higher prevalence. 

Another major aspect of gonorrhoea is antibiotic resistance. The bacteria causing gonorrhoea are already resistant to many antibiotics, and the one that is used now is ceftriaxone, a very powerful antibiotic used as a last resort with no alternative currently available. An increasing number of gonorrhoea cases are multidrug-resistant, and this is an impending public health concern. Therefore It is important to be checked for STIs regularly and to take medications as advised.