Gonorrhea, caused by a gram-negative diplococcus Neisseria gonorrhoeae, is a well-recognized sexually transmitted infection throughout the world, with incidence rates peaking in the United States and Eastern Europe [1] [2]. It is most frequently diagnosed in the population of younger sexually active adults (aged between 15-24 years) [1] [2] [3]. African American or Hispanic ethnicity is a significant risk factor for the infection, as studies have found a 19-fold increased risk compared to Caucasians [1] [2] [3]. The transmission of N. gonorrhea mandates sexual contact, including rectal and orogenital, and several clinical forms of male gonorrhea have been described in the literature [1] [2] [3] [4] [5]:

• Gonococcal urethritis - By far, the most important type of infection in males involves the urethra, in the form of acute anterior urethritis [1] [3]. Signs and symptoms, appearing after an incubation period of 1-10 days (although the mean onset is observed after 2-5 days), are urethral discharge followed by dysuria [2] [3]. At first, the discharge is mucoid or mucopurulent, but within the first 24 hours of symptom onset, it is evidently purulent and profuse and is the hallmark of male gonorrhea [1] [2] [3]. Discharge is accompanied by dysuria, but without the sense of urgency and increased urinary frequency [2] [4]. Complete resolution of symptoms after several months is the usual clinical progression, but various complications may arise, such as prostatitis (acute or chronic), epididymitis, seminal vesiculitis and other local infections [4]. In some cases, however, gonococcal urethritis can be completely asymptomatic, in which case a significant risk for transmission to other individuals exists [2] [3].
• Rectal infection - Typically encountered in the men who are having sex with men (MSM) population (but also in women), rectal gonococcal infection is acquired by receptive anal intercourse [2]. Although many patients are asymptomatic, acute proctitis, presenting as tenesmus, pruritus, constipation, rectal pain, purulent rectal discharge and even bleeding, might develop [2] [3].
• Gonococcal pharyngitis and conjunctivitis - Transmission of N. gonorrhea to the oropharynx or the eyes usually result in a mild or asymptomatic clinical presentation in males [3]. In rare cases, erythema and the presence of an exudate in the throat are noted, whereas photophobia, exudation, and local pain are seen in gonococcal conjunctivitis [2] [3].
• Disseminated gonococcal infection (DGI) - In very few patients, hematogenous dissemination from localized infections can lead to bacteremia and systemic manifestations of the disease, most important being arthritis and various skin lesions [1] [2] [3] [4]. Gonorrhea is the most common cause of septic arthritis in adults, and the initial presentation of polyarthralgia and constitutional symptoms followed by asymmetric pain and swelling of one or two joints is typical for gonococcal arthritis [2] [5]. Conversely, almost 75% of DGI patients exhibit skin lesions - macules, papules, pustules, petechiae, vesicles, and bullae [3].

• Fever

  If you develop fevers, chills or pain in your sides or back I would go in even sooner. [zocdoc.com]

  Aspirin should never be used in anyone under 18 years of age who has a fever. Learn about and use safe sex practices. The safest sex is with a partner who has tested negative and only has sex with you. [fairview.org]

  You have a fever. You have a discharge from your penis. You have new or increased burning or pain with urination, or you cannot urinate. You have pain, swelling, or tenderness in your scrotum. You have joint pain. You have pus coming from your eyes. [myhealth.alberta.ca]

• Malaise

  Very rarely, the infection can settle in the heart and cause inflammation of the heart valves ( endocarditis ), manifesting with symptoms of malaise, fever, chills, and a heart murmur. [verywellhealth.com]

  Other common symptoms include skin rashes and arthritis, nausea, vomiting, loss of appetite, malaise, abdominal pain, and jaundice (yellowing of the eyes and skin). [luckymojo.com]

• Unsafe Sexual Practices

  Individuals who engage in unsafe sexual practices and those with a history of past gonococcal infections are at increased risk for contracting N gonorrhoeae. [uspharmacist.com]

• Constitutional Symptom

  Gonorrhea is the most common cause of septic arthritis in adults, and the initial presentation of polyarthralgia and constitutional symptoms followed by asymmetric pain and swelling of one or two joints is typical for gonococcal arthritis. [symptoma.com]

• Localized Pain

  In rare cases, erythema and the presence of an exudate in the throat are noted, whereas photophobia, exudation, and local pain are seen in gonococcal conjunctivitis. [symptoma.com]

• Purpura

  Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Case 3-2019: A 70-Year-Old Woman with Fever, Headache, and Progressive Encephalopathy Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura Randomized [nejm.org]

• Encephalopathy

  Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Case 3-2019: A 70-Year-Old Woman with Fever, Headache, and Progressive Encephalopathy Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura Randomized [nejm.org]

• Dysuria

  Discharge is accompanied by dysuria, but without the sense of urgency and increased urinary frequency. [symptoma.com]

  Gonorrheal epididymitis may be identified by dysuria, a foul-smelling discharge, painful ejaculation, and swollen lymph nodes in the groin. As with PID, the blockage of one or both tubes can lead to functional infertility. [verywellhealth.com]

  Symptoms range from mild to severe and include dysuria and vaginal discharge. [merckmanuals.com]

  NAAT – Nucleic Acid Amplification Test FPU – First pass urine MSM – Men who have sex with men Diagnosis in females Test Site/Specimen Consideration NAAT /- culture Endocervical swab If discharge/dysuria present. [sti.guidelines.org.au]

• Urethral Discharge

  Signs and symptoms, appearing after an incubation period of 1-10 days (although the mean onset is observed after 2-5 days), are urethral discharge followed by dysuria. [symptoma.com]

  Gram stained urethral discharge may show gram negative intracellular diplococci but is not a sensitive test at non-urethral sites. If MSM, also collect anal and pharyngeal swab even if asymptomatic at these sites. [sti.guidelines.org.au]

  They then complain only of mild dysuria with a mucoid urethral discharge as observed in nongonococcal urethritis. [dartmouth.edu]

  Symptoms of urethritis in men typically include urethral discharge, penile itching or tingling, and dysuria. [aafp.org]

  The first symptoms in the male are a burning sensation upon urination and a purulent urethral discharge that may be profuse or may be so meagre as to go unnoticed. [britannica.com]

• Swelling of the Scrotum

  […] of the scrotum 2000-2018 The StayWell Company, LLC. 800 Township Line Road, Yardley, PA 19067. [fairview.org]

  […] of the scrotum Date Last Reviewed: 10/1/2016 Â 2000-2018 The StayWell Company, LLC. 800 Township Line Road, Yardley, PA 19067. [mountnittany.org]

• Painful Ejaculation

  Gonorrheal epididymitis may be identified by dysuria, a foul-smelling discharge, painful ejaculation, and swollen lymph nodes in the groin. As with PID, the blockage of one or both tubes can lead to functional infertility. [verywellhealth.com]

Despite the fact that microbiological confirmation is necessary to make the diagnosis of gonorrhea in males, a complete physical examination and a thorough patient history are vital in raising clinical suspicion. In adult males who present with purulent discharge from the urethra or conjunctiva, or who suffer from an asymmetric polyarthralgia, gonorrhea must be included in the differential diagnosis. For this reason, data regarding recent sexual activity is of vital importance. Patients should be asked about the number of partners and if there have been any "risky" sexual contacts. Then, appropriate microbiological studies need to be carried out. In the setting of gonococcal urethritis, a sample of the urethral discharge, a urethral swab, or even urine (the first 10-15 mL) are all viable specimens for testing, and either gram-stained smears (carrying a high rate of diagnosis) or cultivation of the obtained material are recommended [6] [7]. Some authors advocate the use of nucleic acid amplification test (NAAT), which can detect bacterial DNA in urine or exudate, but its efficacy is variable [2] [3] [6]. These tests are used when conjunctivitis, disseminated infections, or arthritis (if the joint fluid aspirate is the optimal sample in that case) are suspected, whereas cultivation is recommended over gram staining and NAAT in gonococcal pharyngitis and rectal infections [2] [5] [6]. Because it is not uncommon for patients to suffer from more than one STD, an extensive diagnostic panel should be performed, in order to exclude chlamydia trachomatis (the most common STD worldwide), syphilis, but also hepatitis and human immunodeficiency virus (HIV) infection.

1. Gullette DL, Rooker JL, Kennedy RL. Factors Associated With Sexually Transmitted Infections in Men and Women. Journal of community health nursing. 2009;26(3):121-130.
2. Mandell GL, Bennett JE, Dolin R. Mandel, Douglas and Bennett's Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, Pennsylvania: Churchill Livingstone; 2015.
3. Mayor MT, Roett MA, Uduhiri KA. Diagnosis and management of gonococcal infections. Am Fam Physician. 2012;86(10):931-938.
4. Shim BS. Current Concepts in Bacterial Sexually Transmitted Diseases. Korean Journal of Urology. 2011;52(9):589-597.
5. Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology. Seventh edition. Philadelphia: Elsevier/Saunders; 2013.
6. Ng L-K, Martin IE. The laboratory diagnosis of Neisseria gonorrhoeae. The Canadian Journal of Infectious Diseases & Medical Microbiology. 2005;16(1):15-25.
7. Cook RL, Hutchison SL, Østergaard L, Braithwaite RS, Ness RB. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. 2005;142(11):914-925.