Generally, gout progresses through four stages. During the first stage, a patient has elevated levels of uric acid in the blood (hyperuricemia) but no other signs or symptoms. At this stage, called asymptomatic hyperuricemia, patients seldom require treatment. In addition, not all people with hyperuricemia go on to develop gout.

The second stage of gout is called acute gouty arthritis. It occurs when the patient suddenly experiences a hot, red, swollen joint, caused by the formation of uric acid crystals between the joints. In most cases, the big toe (a condition once known as podagra) or the knee is affected.

The attack often occurs at night and in a single joint, with the pain becoming more severe. When a single joint is involved, the condition is called monoarticular gout. The pain may grow so intense that even a bed sheet on the joint can cause pain. Chills and a mild fever along with a general feeling of malaise may also accompany the severe pain and inflammation.

Monoarticular gout occurs more often in middle-aged patients and usually involves one joint in the lower limbs, especially the big toe (hallux).

Even without treatment, the first episode often disappears spontaneously within three to 10 days, but prompt treatment can abort the attack in a few hours. Although the pain and swelling disappear, gouty arthritis almost always returns in the same joint or in another one.

A patient is usually symptom-free for a period of time. During this third stage, called interval or intercritical gout, a patient does not have any symptoms and has normal function of the joints. The next attack usually occurs within two years, followed by additional attacks thereafter.

If left untreated, the interval between attacks may shorten and they may become increasingly severe and prolonged. Over time, the attacks can begin to involve multiple joints at once – called polyarticular gout – and may be accompanied by a joint infection (e.g., septic arthritis). Polyarticular gout occurs more often in elderly patients and usually involves the joints in the upper extremities, especially the fingers.

In addition, episodes of acute gouty arthritis can be triggered by circumstances that affect blood levels of uric acid, such as certain chronic illnesses (e.g., diabetes, high blood pressure), injury, surgery, fasting, drinking alcohol, overeating (especially foods rich in purines, such as liver) and taking certain medications (e.g., diuretics, aspirin, immunosuppressives).

People who experience sudden, intense joint pain with fever should see their physician as soon as possible. If gout is left untreated, it can lead to worsening of the pain and permanent joint damage.

When gout goes untreated for several years, it can progress to a condition called chronic tophaceous gout. During this last phase, patients experience chronic pain and inflammation and there is permanent joint damage due to the formation of large masses of uric acid crystals, which also collect in bone and cartilage, such as in the ears. These masses or nodules of crystals are called tophi. They can form near the knuckles and small joints of the fingers and can cause disfigurement. These large masses or lumps may drain and ooze a chalky substance.