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For further information, see CMDT Part 33-26: Gonococcal Infections

Key Features

Essentials of Diagnosis

  • Purulent, profuse urethral discharge with dysuria, especially in men; yields positive gram-stained smear

  • In men

    • Epididymitis

    • Prostatitis

    • Periurethral inflammation

    • Proctitis

    • Pharyngitis

  • In women

    • Asymptomatic or cervicitis with purulent discharge

    • Vaginitis, salpingitis, proctitis also occur

  • Disseminated disease

    • Fever

    • Rash

    • Tenosynovitis

    • Septic arthritis

  • Nucleic acid amplification is preferred diagnostic test

General Considerations

  • Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus


  • Gonorrhea is transmitted as a result of sexual activity; greatest incidence is in the 15- to 29-year-old age group

Clinical Findings

Symptoms and Signs

  • Asymptomatic infection is common and occurs in both sexes

  • Atypical sites of primary infection (eg, the pharynx or rectum) must always be considered


  • In men

    • Initially, burning on urination and a serous or milky discharge

    • One to 3 days later, more pronounced urethral pain and the discharge becomes yellow, creamy, and profuse, sometimes blood tinged

    • May regress and become chronic or progress to involve the prostate, epididymis, and periurethral glands with acute, painful inflammation

    • Rectal infection is common in men who have sex with men

  • In women

    • Dysuria

    • Urinary frequency and urgency


  • Infection may be asymptomatic, with only slightly increased vaginal discharge and moderate cervicitis on examination

  • Infection often becomes symptomatic during menses

  • Vaginitis and cervicitis with purulent discharge and inflammation of Bartholin glands are common

  • Infection may remain as a chronic cervicitis

  • It may progress to involve the uterus and fallopian tubes with acute and chronic salpingitis and ultimate scarring of tubes and sterility

  • In pelvic inflammatory disease, anaerobes and chlamydiae often accompany gonococci


  • Direct inoculation of gonococci into the conjunctival sac occurs by autoinoculation from a genital infection or during childbirth

  • The purulent conjunctivitis may rapidly progress to panophthalmitis and loss of the eye unless treated promptly

Differential Diagnosis

  • Nongonococcal urethritis, eg, Chlamydia, Ureaplasma urealyticum

  • Septic arthritis of other bacterial cause

  • Reactive arthritis

  • Vaginal discharge due to candidiasis, bacterial vaginosis, or trichomoniasis

  • Chronic meningococcemia


Laboratory Tests

  • In men, Gram stain of urethral or rectal discharge, especially during the first week after onset, typically shows gram-negative diplococci within polymorphonuclear leukocytes

  • Gram stain is less often positive in women

  • Nucleic acid amplification tests

    • The preferred testing method for diagnosing all types of gonococcal infection due to its excellent sensitivity and specificity

    • Detects N gonorrhoeae in endocervical, vaginal, and urethral swab specimens and in urine

    • Can also detect N gonorrhoeae in oropharyngeal and rectal sites, although test ...

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