All About Gout - Symptoms, Diagnosis, Treatment

Gout is a form of inflammatory arthritis that can cause extreme pain in the joints, most often in the big toe. Learn about the symptoms, risks, and causes of gout, as well as how to prevent and treat the condition.

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Gout Overview

Gout is one of the most common forms of inflammatory arthritis and can cause extreme pain, joint swelling, warmth, and redness. About half of gout cases affect the big toe joint (metatarsophalangeal joint), while the remaining cases typically affect other joints in the foot as well as the knee, elbow, wrist, and fingertips.¹

While there are several known triggers for an episode of gout, symptoms can also occur suddenly and without warning, often flaring up in the middle of the night. A gout episode can last for a few days or even weeks with the worst pain usually occurring in the first day or two.

Gout is characterized by acute, painful swelling in the joints from uric acid buildup. Common areas include the foot and big toe.

Centuries ago, gout was nicknamed the "king’s disease" or "rich man's disease" because eating meat and drinking alcohol were known to bring on a gout flare-up. Despite its reputation, gout can affect anyone: the estimated number of Americans who have gout ranges from 3 to 6 million.^2-4 Another common term for gout is "gouty arthritis."

Experts do not completely understand why some people get gout and others do not, but the risk factors, diagnosis and treatment for gout are well established.

What is Gout?

Gout results from a build-up of uric acid crystals (monosodium urate crystals) in a joint. These needle-like, microscopic crystals collect in the soft tissue of the joint, causing pain that can be excruciating, as well as swelling, redness, and warmth.

Consuming purines leads to a buildup of uric acid.¹ This is normally filtered through the kidneys². but in too much uric acid may build in up in the joints leading to gout³.

The build-up of uric acid crystals begins with purines, a chemical compound found in many foods. When the body metabolizes purines it produces a substance called uric acid, which is delivered to the bloodstream. The uric acid is then filtered out by the kidneys and excreted via urine (70%) or stool (30%).⁵

Too much uric acid in the bloodstream is called hyperuricemia. In some people, the excess uric acid forms crystals that collect in the joints, resulting in gout.

Read more about Hyperuricemia - High Uric Acid Levels and Gout

An inability to adequately process and excrete uric acid accounts for an estimated 80 to 90% of gout cases.⁶

Left untreated, a gout episode will usually resolve itself within a few days or weeks. Repeated instances of gout are called chronic gout, which can permanently damage a joint over time, resulting in decreased range of motion and other problems. For this reason, it is important to diagnose, treat and prevent gout as early as possible.

Gout Symptoms

Many forms of arthritis occur gradually, and in the early stages a person may experience only occasional mild pain. In contrast, gout strikes quickly, severely, and without warning. In fact, gout pain can be so severe that some people assume a more serious medical problem is at play, which can delay an accurate diagnosis.

Typical gout symptoms are:

Pain. The most notable symptom of gout is extreme pain at the affected joint. Gout sufferers have compared the pain to being constantly stabbed with tiny, hot knives.

Typically, it is uncomfortable if not impossible for a person to put weight on an affected foot or knee.

Rapid onset. Acute gout can develop suddenly and without warning, taking only a few hours to become severely painful.⁷ (Though not usually the case, it is possible for gout symptoms to appear more gradually)

Symptoms interrupt sleep. It is not uncommon to hear a gout sufferer recount how a gout flare-up struck in the middle of the night, waking the person from a sound sleep. The affected joint, often a big toe, causes so much pain that the person cannot tolerate even a bed sheet resting on it.

The reason gout episodes often strike at night is that body temperature drops slightly during sleep, and this drop in temperature catalyzes the formation of uric acid crystals in the joint. This factor also helps explain why gout often affects joints in the feet and fingers - these extremities tend to maintain a lower temperature than the rest of the body.

Additionally, when a body is sleeping and joints are at rest, some of the water in the joints' synovial fluid is reabsorbed into the body. The uric acid, however, remains in the joint. The high concentration of uric acid in the joint may spur the formation of uric acid crystals.⁸

Gout Causes and Risk Factors

Although experts do not fully understand why some people get gout and others do not, many causes and risk factors of gout are well established.

Diet. The risk of gout is increased by the frequent consumption of foods high in purines, including meats, seafood, certain vegetables and beans, and foods containing fructose.

Alcohol use. Drinking alcohol decreases the body's ability to flush out uric acid. Additionally, beer is made with brewer's yeast, which is high in purines.

Gender. Men are more likely to have gout. Women are less likely to get gout, however, their risk of developing gout increases after menopause.

Age. Many people have their first episode of gout between the ages of 30 and 50, and the risk of gout continues to increase with age. It is estimated that nearly 12% of men aged 70 to 79 have had gout while less than 3% of men under the age of 50 have had it.^9-10

Excess weight. People who are overweight have a greater risk of developing gout.

Race. African American men are nearly twice as likely to report having had gout as Caucasian men, according to a study cited by the Centers for Disease Control and Prevention.¹¹

Family history. Genetics plays a role, making some people’s bodies more prone to accumulating uric acid and developing the uric acid crystals that lead to gout. More research needs to be done to understand why some people have several risk factors and never get gout while other people have few or no risk factors and do get gout.

Certain medications. Taking certain medications can increase the risk of gout. Some of these medications include:

• Diuretics, sometimes called "water pills"
• Aspirin
• Cyclosporine, an immunosuppressant sometimes prescribed to people who have rheumatoid arthritis or psoriasis, or who have had an organ transplant
• Levodopa, often used to treat Parkinson's disease

Chronic renal failure. A person who has chronic renal failure no longer has fully functioning kidneys. When the kidneys’ ability to flush out uric acid is compromised, gout may develop.

Lead exposure. People who are exposed to lead in the environment have a higher incidence of gout. Though much less common today, gout caused by lead exposure was common years ago when people unwittingly drank from leaded crystal glassware.

A trigger event, such as injury, surgery, or medical therapy. Specific events can trigger a change in body chemistry and bring on a gout flare up. Such events include, but are not limited to, infection, trauma, surgery, psoriasis, and the initiation of chemotherapy. Stopping or starting allopurinol, which is used to treat gout, can also bring on gout symptoms.

Interestingly, many people who experience an episode of gout may not ever have symptoms again, or at least not for several years. People who do experience gout symptoms repeatedly may notice that episodes get longer and more severe. Gout and its precursor, hyperuricemia, should be addressed to prevent joint damage in the long term.

Gout Diagnosis

A doctor will want to rule out other possible conditions that can cause symptoms similar to gout, such as septic arthritis and pseudogout. A patient exam and interview along with a lab test(s) can confirm or disprove a gout diagnosis:

Physical exam. A doctor will examine the patient's affected joint, noting swelling, pain points, and range of motion. The doctor will also look for the presence of white or yellowish bumps under the skin. These are collections of uric acid crystals (monosodium urate crystals) called tophi. Tophi are a strong indicator that a person suffers from chronic gout.

Patient interview. A doctor will ask a patient about family history and to describe the onset and pattern of his or her symptoms.

See 5 Unusual Gout Symptoms

Joint fluid analysis. The most dependable way to diagnose gout is by examining the joint fluid under a microscope and looking for uric acid crystals. To obtain a joint fluid sample, a doctor will use a needle and syringe to draw a fluid from the affected joint. If uric acid crystals are found in the fluid sample, then gout is confirmed.

See How Arthritis Causes Joint Pain

A small percentage of people have gout but do not have uric acid crystals in the joint fluid during analysis. For these people, additional tests must be done to rule out other possibilities, such as septic arthritis (infectious arthritis).

See Septic Bursitis

Blood or urine test. A doctor may test a blood or urine sample for uric acid levels. Abnormally high uric acid levels, called hyperuricemia, indicate gout may be present. However, it is possible for the levels of uric acid in the blood to return to normal once a gout attack strikes, so absence of hyperuricemia does not completely rule out a diagnosis of gout.

See Hyperuricemia - High Uric Acid Levels and Gout

Synovial biopsy. During a biopsy a doctor will arthroscopically remove a part of the membrane that encapsulates the affected joint, called the synovial membrane. The synovial membrane can be tested and examined for uric acid crystals and signs of gout.

X-rays. An X-ray of the joint may show the deposition of uric acid crystals. However, X-rays can be normal even when gout is present.

Most gout cases are diagnosed with a joint fluid analysis. An accurate diagnosis is important to long-term treatment and health.

Gout Treatment

During an acute gout episode, a person's first priority will be to alleviate the immediate pain and other symptoms. Once that is done, steps should be taken to prevent future gout attacks.

Without treatment and prevention, gout can become chronic, leading to repeated episodes of intense gout pain and possibly permanent damage to the affected joint(s).

The immediate goals for treating a gout flare-up are to reduce intense pain, swelling, warmth, and redness. With proper treatment, gout pain and other symptoms can be under control within 24 hours and completely gone within a matter of days.

Ice. A soft cool compress applied to the affected joint can help relieve discomfort.

Avoid pressure. Avoid contact with anything. Anything that touches the affected joint may cause a sharp increase in pain.

Rest. It is usually painful to use the affected joint, and resting it will help alleviate pain, swelling, and other symptoms.

Elevation. Elevate the affected limb to help reduce swelling. If the foot is affected, sit down with the foot resting on a footstool or lie down with the foot propped up on a pillow.

Over-the-counter medication. Over-the-counter anti-inflammatory medications, such as ibuprofen and naproxen, can relieve pain, particularly if pills are taken as soon as the patient perceives the gout attack coming on.¹² A doctor should be consulted regarding the adequate dosage. Aspirin should be avoided, since it can impair the kidneys' ability to filter out uric acid, making gout symptoms worse.

Prescription pain relievers. When over-the-counter pain relievers are not sufficient, prescription painkillers such as codeine, hydrocodone, and oxycodone may be prescribed for short-term relief of acute pain.

Colchicine. A prescription drug called colchicine is very effective at stopping an acute gout attack. Evidence shows that gout pain, swelling, and inflammation decrease when colchicine is taken within the first 12 to 24 hours of an attack, along with a second, smaller dose an hour or two later.

Colchicine should be taken only as directed. Many people taking colchicine experience gastrointestinal side effects, such as vomiting or diarrhea.

Corticosteroids injections. A doctor may inject the inflamed joint with steroids to relieve the pain. This treatment is particularly useful for people with sensitivities to certain medications. Repeated corticosteroid injections, however, can have side effects.

See Cortisone Injection Risks and Side Effects

Surgery. Gout cannot be treated with surgery. However, if untreated gout leads to the development and buildup of tophi, surgery to remove the tophi may be warranted.

Find out more about surgery as an arthritis treatment option in our Surgery Health Center

Gout is usually so painful that a person cannot ignore it and will take steps to treat it. Once the symptoms of a gout attack are under control, a person can take steps to lower the uric acid levels in the blood and prevent another attack.

Gout Prevention

People prone to gout want to avoid a painful gout attack in the first place. There are several lifestyle and dietary changes that can reduce the risk of gout. When these changes are not enough to prevent gout episodes, a doctor may recommend daily prescription medications.

Avoid or limit alcohol. Alcohol impedes the body's ability to excrete uric acid. However, not all alcoholic drinks are the same. Beer and some red wines are especially high in purine content and should be avoided or very limited. White wine, on the other hand, is not as highly associated with gout and an occasional glass or two does not pose a problem for some people prone to gout.

Drink plenty of water. Increasing water intake will help keep the kidneys healthy and help them flush out uric acid from the body. Experts recommend at least eight 8-ounce glasses of water per day.

Lose weight or maintain a healthy weight. Obtaining and maintaining a healthy weight through diet and exercise helps reduce the risk of gout. However, people trying to lose weight should do so gradually, because dramatic weight loss can trigger a gout episode.

Eat a healthy, low-purine diet. Those who are prone to gout can prevent uric acid buildup in the bloodstream by avoiding foods high in purines. Foods with high purine content include seafood, meats, certain vegetables, lentils, and dried beans. Most vegetables, low-fat dairy, eggs, plant-based proteins, and complex carbohydrates, such as fruits, are low in purines and may even decrease uric acid production.

See Hyperuricemia - High Uric Acid Levels and Gout

Prescription medication. If gout attacks are becoming more frequent or severe, if gout has caused joint damage, or if tophi or kidney stones are present, a doctor may recommend regularly taking prescription medications to reduce the amount of uric acid produced by the body. These medications, most commonly allopurinol and probenecid, effectively prevent gout attacks but do not treat a gout attack once it has started. Starting and stopping allopurinol use is known to trigger gout attacks; changes in dosage should not be made without consulting a doctor.¹³

Certain foods, such as meats and shellfish (e.g. oysters and shrimp), have a higher purine content than others. Since consuming purines leads to the production of uric acid that can lead to gout, people who are prone to gout should maintain a low purine diet.

See What Are Purines?

See Hyperuricemia - High Uric Acid Levels and Gout

Gout Diet

A low purine diet adheres to these guidelines:

Limit meat and seafood consumption. Experts recommend that people with gout limit purine intake by eating no more than 4 to 6 ounces of meat, poultry or seafood per day. Plant-based proteins (e.g. nuts and legumes) should be incorporated into meal planning and high-protein diets should be avoided.

Consume low-fat dairy products. People who consume low-fat dairy products such as skim milk and yogurt can decrease their levels of uric acid and thereby decrease their risk of gout attacks.¹⁴ Experts recommend 16 to 24 ounces of daily low-fat dairy consumption.¹⁵ High-fat dairy products do not have the same protective effect.

Eat plenty of plant-based proteins, vegetables, and complex carbohydrates. Replacing some meat and seafood with legume consumption (fresh, canned or frozen, not dried) will decrease purine intake. Gout sufferers also will benefit from avoiding foods made with sugar and corn syrup. Instead, complex carbohydrates, such as fruit and whole-grain products, are better. Many people believe eating cherries or drinking cherry juice will help fend off gout, and there is some scientific evidence to support this.^16-17

Avoid foods high in purines. Foods that are high in purines should be avoided altogether. These foods include:

• Seafood, particularly scallops and other shellfish, anchovies, sardines, herring, and mackerel
• Meats, especially organ meats or "sweetmeats," such as liver, brains, and beef kidneys, as well game meats, such as venison, which are typically fattier than farm-raised meats
• Gravy
• Foods and drinks made with high fructose corn syrup, such as sodas¹⁸

Some otherwise healthy foods are also high in purines and should be eaten in moderation:

• Certain vegetables, including asparagus, spinach and mushrooms
• Dried beans and peas

Eating a low purine diet and taking other preventative steps, such as drinking plenty of water, avoiding alcohol, and maintaining a healthy weight, can go a long way towards preventing gout, as well as other types of arthritis and heart disease.