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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

    • Urethritis

    • Epididymitis

    • Prostatitis

    • 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 and has its greatest incidence in the 15- to 29-year-old age group

Clinical Findings

Symptoms and Signs

  • Asymptomatic infection is common and occurs in both sexes

  • Other sites of primary infection (eg, the pharynx) 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 homosexual men

  • In women

    • Dysuria

    • Urinary frequency and urgency, with a purulent urethral discharge


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

  • 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

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

Differential Diagnosis

  • Nongonococcal urethritis

  • Cervicitis or vaginitis due to

    • Chlamydia trachomatis

    • Gardnerella vaginalis

    • Trichomonas

    • Candida

    • Other pathogens associated with sexually transmitted diseases

  • Pelvic inflammatory disease

  • Proctitis

  • Reactive arthritis


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 gonococcal infection at all sites due to its excellent sensitivity and specificity

    • Recommended by the CDC for oropharyngeal and rectal site swab testing (urine testing does not detect oropharyngeal and rectal gonorrhea unless there is concurrent genital infection)

    • Have largely replaced culture

  • Cultures should still be ...

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