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. Other less common forms of infection involve the rectum, the oropharynx, the conjunctiva, and a disseminated form with arthritis and cutaneous lesions. Clinical criteria supported by information obtained during history taking and microbiological studies are needed to make the diagnosis.
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  . It is most frequently diagnosed in the population of younger sexually active adults (aged between 15-24 years)   . 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   . 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     :
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  . 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   . 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   . 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.