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

  Report of a Case A 26-year-old Negro man was admitted to USAF Hospital Andrews on May 5, 1965, for recurrent fever, polyarthralgia, and a skin eruption of nine weeks' duration. [jamanetwork.com]

  You should seek medical attention if you feel sick, have a fever or pelvic pain, or experience pain during sex. [stdcheck.com]

  Fever with abdominal pain, pelvic pain, and vaginal discharge can be symptoms of this disease. Men: Fever, discharge from the penis, and painful urination may signal an infection, especially involving inflammation of the testicles. [emedicinehealth.com]

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

• Chills

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

  PID is characterized by pain in the pelvis and lower abdomen, as well as nausea, vomiting, fevers, chills, cramping, and a foul-smelling discharge. [verywellhealth.com]

  Symptoms usually include chills, fever, joint pain or swelling, painful wrist and heel tendons, skin rash, and symptoms of meningitis (such as headaches, stiff and painful neck, vomiting, confusion and seizures). [stdcheck.com]

  If the infection continues to spread, it can cause skin rash (on the chest, palms, limbs) as well as flu-like symptoms (such as. fever and chills). [zavamed.com]

• 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]

• 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]

• 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]

• Rectal Bleeding

  […] pain, and rectal bleeding. 5 Those with pharyngeal gonococcal infections are usually asymptomatic, but if symptoms are present, they may include sore throat and pharyngeal exudates. 5 Symptoms of N gonorrhoeae often prompt men to seek medical attention [uspharmacist.com]

• Skin Rash

  Symptoms usually include chills, fever, joint pain or swelling, painful wrist and heel tendons, skin rash, and symptoms of meningitis (such as headaches, stiff and painful neck, vomiting, confusion and seizures). [stdcheck.com]

  Symptoms of DGI commonly include joint or tendon pain, a skin rash, and fever. More advanced stages of DGI cause septic, or infectious, arthritis, in which the bacteria directly invade the joint space. [everydayhealth.com]

  If the infection continues to spread, it can cause skin rash (on the chest, palms, limbs) as well as flu-like symptoms (such as. fever and chills). [zavamed.com]

• Erythema

  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]

  Examination with a proctoscope may detect erythema or mucopurulent exudate on the rectal wall. Gonococcal pharyngitis is usually asymptomatic but may cause sore throat. [merckmanuals.com]

  Children [ 13 ] Acute conjunctivitis in association with purulent discharge, usually bilateral, Vaginal discharge and vulval erythema (prepubertal vulvovaginal epithelium is more susceptible to infection compared with that of adult women). [patient.info]

• Eruptions

  Report of a Case A 26-year-old Negro man was admitted to USAF Hospital Andrews on May 5, 1965, for recurrent fever, polyarthralgia, and a skin eruption of nine weeks' duration. [jamanetwork.com]

  Patients with meningococcal infection have more skin lesions, high peripheral white blood cell counts, and sterile genital cultures.19 Reiter’s syndrome (urethritis, arthritis, conjunctivitis, and keratoderma blennorrhagica, a psoriasis-like eruption) [dartmouth.edu]

  The bump then erupts into an ulcer (an open sore), which is usually painful. Often, there is an associated tenderness of the glands ( lymph nodes ), for example, in the groin of patients with penile bumps or ulcers. [emedicinehealth.com]

• 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]

  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

  Gonorrhea is one of the most commonly recognized sexually transmitted diseases (STDs) worldwide, and gonococcal urethritis, characterized by urethral discharge and dysuria, is the predominant manifestation in males. [symptoma.com]

  Culture Urethral swab Only required if discharge or other local symptoms present. Gram stained urethral discharge may show gram negative intracellular diplococci but is not a sensitive test at non-urethral sites. [sti.guidelines.org.au]

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

  C 32, 33 Based on limited studies Nomenclature Historically, the term urethritis was reserved for patients with urethral discharge. [aafp.org]

• Salpingitis

  Sometimes gonorrhea spreads to the adnexa, causing salpingitis, or disseminates to skin and/or joints, causing skin lesions or septic arthritis. [merckmanuals.com]

  As the infection spreads, as occurs more commonly in women than in men, nausea, vomiting, fever, and tachycardia may occur as salpingitis, oophoritis, or peritonitis develops. [medical-dictionary.thefreedictionary.com]

  In the female, cervical involvement may extend through the uterus to the fallopian tubes resulting in salpingitis, or to the ovaries resulting in ovaritis. [textbookofbacteriology.net]

  Untreated, and gonorrhea can lead to much more complicated issues. 10-20% of women with gonorrhea develop ascending infections like salpingitis and pelvic inflammatory disease (PID). [austincc.edu]

  Differences in some clinical and laboratory parameters in acute salpingitis related to culture and serologic findings. Am J Obstet Gynecol, 138(7), 1017–1021 (1980). Berger R, Alexander E, Harnisch J et al. [cdc.gov]

• 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.

Treatment advice Reduced susceptibility to the first line treatment of IMI Ceftriaxone and Azithromycin is emerging in urban Australia. [sti.guidelines.org.au]

Treatment of uncomplicated gonococcal infections. UpToDate. www.uptodate.com/contents/treatment-of-uncomplicated-gonococcal-infections. Accessed February 12, 2016. 5. Ghanem KG. [uspharmacist.com]

These studies found that treatment of chlamydial infection was associated with significantly lower rates of preterm delivery, early rupture of membranes, and infants with low birthweight compared with no treatment or treatment failure. [uspreventiveservicestaskforce.org]

Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6)1–78. Accessed online September 14, 2005, at: http://www.cdc.gov/std/treatment/. 3. [aafp.org]

Of those, 367 partners (53.0%) were notified by 311 index cases; 95 partners (25.9% of the notifications) of the 89 index cases presented for treatment. [ncbi.nlm.nih.gov]

Prognosis If gonorrhea infections are diagnosed and treated quickly and correctly, recovery usually is complete unless pelvic inflammatory disease (PID) develops. PID is more likely to develop if treatment is delayed. [drugs.com]

(See Pathophysiology, Etiology, and Prognosis, and Treatment.) [emedicine.medscape.com]

Prognosis [ 6 ] Where treatment is rapidly received for a recently acquired gonorrhoeal infection, prognosis is good with full recovery as normal. [patient.info]

The etiologic agent, neisseria gonorrhoeae, was isolated by neisser in 1879. Acute infectious disease characterized by primary invasion of the urogenital tract; the etiologic agent is neisseria gonorrhoeae. [icd10data.com]

The organism was grown in pure culture in 1885, and its etiological relationship to human disease was later established using human volunteers in order to fulfill the experimental requirements of Koch's postulates. [textbookofbacteriology.net]

Etiology C. trachomatis and N. gonorrhoeae are the primary pathogens identified in men with urethritis. [aafp.org]

In 1885, the disease was grown and, via human volunteers, its etiological relationship with humans was established. Neisser also worked with August von Wasserman on the development of his diagnostic blood serum tests for syphilis. [austincc.edu]

Etiology, manifestations and therapy of acute epididymitis: prospective study of 50 cases. J Urol, 121(6), 750–754 (1979). Holmes KK, Counts GW, Beaty HN. Disseminated gonococcal infection. Ann Intern Med, 74, 979–993 (1971). [cdc.gov]

Epidemiologic research: principles and quantitative methods. New York, NY: Van Nostrand Reinhold Company Inc, 1982. 53. Rothman KJ, Greenland S, eds. Modern epidemiology. 2nd ed. Philadelphia, PA: Lippincott-Raven, 1998. 54. [academic.oup.com]

Hook III, a professor of medicine, epidemiology, and microbiology at the University of Alabama at Birmingham School of Medicine. "The problem we have is that the antibiotic pipeline dried up about 20 years ago." [tonic.vice.com]

Epidemiology In 2013, the total number of new cases of gonorrhoea diagnosed in GUM clinics in England was 29,291. This represented an increase of 15% compared to those diagnosed in 2012. [patient.info]

From an epidemiologic point of view the disease is becoming more difficult to control because of the increasing number of asymptomatic male carriers. All forms of the disease previously responded to penicillin, but resistant strains have emerged. [dartmouth.edu]

(See Pathophysiology, Etiology, and Prognosis, and Treatment.) [emedicine.medscape.com]

It's a good idea to start thinking about prevention now. Not having sex is the best way to prevent any sexually transmitted infection. Follow-up care is a key part of your treatment and safety. [myhealth.alberta.ca]

Prevention and Management Considerations Appropriate treatment is of paramount importance for existing gonococcal infections, but preventive measures must also be considered and discussed with the patient. [uspharmacist.com]

External resources CDC National Prevention Information Network (NPIN) National Center for HIV, STD and TB Prevention P.O. [drugs.com]

The only way to prevent gonorrhea and other STDs is to not have sex (oral, vaginal, or anal). If someone decides to have sex, using a latex condom every time can prevent most STDs. [kidshealth.org]

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.