History and exam

Key diagnostic factors

Suggests epididymitis. This requires specialized treatment and needs to be distinguished from testicular torsion.

Mucopurulent cervicitis is the classical sign of gonorrhea infection in women but as a sign it is not common enough nor specific enough for the predictive value to be sufficient to make a diagnosis without supportive laboratory tests.

Physical findings include frank mucopus on swab and cervical os friability.

Other diagnostic factors

Considered for an STI and needs a bimanual exam. A significant number of women may have endometritis without overt symptoms.[40] If no overt pelvic pain is reported it also important to elicit whether pain occurs with sex.

Early symptom of gonorrhea usually followed by discharge hours to days later.[18]

The most common symptom of gonorrhea in men and will precede discharge.

Orchitis is usually one-sided.

Prostatitis is an uncommon finding with gonorrhea but is suspected if urinary obstructive symptoms or pelvic pain is present.

Associated with rectal gonorrhea infection.

Associated with rectal gonorrhea infection. Usually occurs with a bowel movement.

Associated with rectal gonorrhea infection. More common in men who have sex with men.

Associated with rectal gonorrhea infection. More common in men who have sex with men.

Associated with rectal gonorrhea infection. More common in men who have sex with men.

Women with gonorrhea may have some vaginal discharge, but lack of a discharge does not exclude infection.

In most vaginal discharges, other types of vaginitis such as trichomonas, yeast, and bacterial vaginosis predominate.

The discharge should be sent for microscopy. Leukorrhea is defined as >10 white blood cell count on high-power field of a vaginal fluid smear.[23]

Bleeding that occurs with gentle passage of a cotton swab through the cervical os suggest cervicitis.[23]

Tenderness suggests pelvic inflammatory disease, which requires specialized treatment.

The presence of a mass suggests pelvic inflammatory disease, which requires specialized treatment.

May be present in pharyngeal gonorrhea infection.

Gonococcal conjunctivitis presents with thick/white yellow discharge.com.bmj.content.model.Caption@2586f25d[Figure caption and citation for the preceding image starts]: Gonococcal conjunctivitis of the right eyeCDC/ Joe Miller, VD [Citation ends].

Can be seen with ascending gonorrhea infection or disseminated gonorrhea infection.

Indication of disseminated gonococcal infection.com.bmj.content.model.Caption@3a815f66[Figure caption and citation for the preceding image starts]: Cutaneous lesions on the left ankle and calf due to a disseminated Neisseria gonorrhoeae infectionCDC/ Dr S. E. Thompson, VDCD/ J. Pledger [Citation ends].

Indication of disseminated gonococcal infection. Most commonly affected joints are wrists, ankles, and small joints of hands and feet.com.bmj.content.model.Caption@2d0923ba[Figure caption and citation for the preceding image starts]: Gonococcal arthritis of the hand, which caused the hand and wrist to swellCDC/ Susan Lindsley, VD [Citation ends].

Manifestation of gonococcal meningitis.

Manifestation of gonococcal meningitis.

Manifestation of gonococcal meningitis.

Manifestation of gonococcal meningitis.

Manifestation of gonococcal endocarditis

Neonatal conjunctivitis. One of the most severe manifestations of pediatric gonococcal infection.com.bmj.content.model.Caption@5420fc0b[Figure caption and citation for the preceding image starts]: A newborn with gonococcal ophthalmia neonatorum caused by a maternally transmitted gonococcal infectionCDC/ J. Pledger [Citation ends].

Less severe manifestation of pediatric gonococcal infection.

Less severe manifestation of pediatric gonococcal infection.

Most common manifestation of gonococcal infection in preadolescent girls. May occur in infants with gonococcal infection.

Risk factors

One of the strongest predictors of gonorrhea, with rates 4 to 5 times higher than the national average. According to US data from 2017, the highest rates in women are seen in the 15 to 24 years age group, and the highest rates in men are seen in the 20 to 29 years age group.[3]

In the US, gonorrhea incidence among MSM was estimated to be around 5241 cases per 100,000 in 2017.[3]

In 2016, the Centers for Disease Control and Prevention's MSM Prevalence Monitoring Project in several urban STI clinics in the US showed high median site-specific positivity for rectal gonorrhea (15.9%) and pharyngeal gonorrhea (8.8%) among MSM.[24]

In the US, people of black ancestry have a rate that remains higher than other races/ethnicities and is between 8 and 9 times higher than the rate in white people (548.1 vs. 66.4 cases per 100,000).[3] There is no biologic basis for this; rate differences by race/ethnicity may represent contextual factors such as geography, socioeconomic status, and social structure that affect sexual networks.[25] Highest rates among black people are seen in the age group 20 to 24 years.[3] In the US-based National Longitudinal Study of Adolescent Health (Add Health) study the highest rate among those ages 18 to 26 years was seen in black people (2.13%).[26]

This is consistently found to be a risk factor for repeat infections and therefore is a clear indication for screening.[27][28][29] In the Add Health study (a US-based cohort study of adults ages 18 to 26 years), chlamydia was found as a coinfection in 69% of those with gonorrhea.[26] In this study most gonorrhea was asymptomatic, which may be because symptomatic people had received treatment. Women with prior bacterial vaginitis had a 26% increased risk of having gonorrhea. Bacterial vaginosis is associated with an increased risk of subsequent gonorrhea infection.[30]

The definition of multiple sex partners is variable, but 2 or more partners in the most recent 2 months is a commonly accepted definition.[29][31][32] Working in the commercial sex industry qualifies as exposure to multiple partners.

Sexual contact without a condom is a primary risk factor for gonorrhea infection. This includes any penetrative sex (usually referring to a penis) that involves a mucosa-lined orifice (oropharynx, vagina, and anus).[5][6][7][8]

Unprotected sex is required for gonorrhea infection, but it does not constitute a high risk on its own if it is within a monogamous relationship. However, it is important to also consider the partner's risk factors because even if the patient has one partner, that partner may be linked to a high-risk sexual network by any of the same factors listed.

Reinfection of women with gonorrhea or chlamydia is associated with a history of physical or sexual abuse.[33]

Often linked to high-risk sexual networks and therefore in many circumstances can be reasonably considered a risk factor.[5][6][7][8]

Some studies have demonstrated that people with a history of imprisonment may have higher rates of STIs (including gonorrhea) than those with no history of imprisonment.[23] In the US, 4.4% of females and 1.2% of males entering a juvenile correctional institution in 2011 were positive for gonorrhea.[34]

It is always important to consider the local epidemiologic factors in a decision to screen a person. Within the context of a local outbreak of gonorrhea the threshold to initiate screening may be different.

Use of this content is subject to our disclaimer