Neisseria gonorrhoeae is the causative organism.

Uncomplicated infections are limited to the transitional and columnar epithelium of the anterior urethra.

The gonococcus may also infect other sites (pharynx, cervix, rectum, or conjunctiva) or extend locally, producing epididymitis, prostatitis, or pelvic inflammatory disease (PID).

Regardless of the initial site of infection, unless treated, an asymptomatic carrier state may evolve and provide a source for endemic transmission of the organism.

For unclear reasons, disseminated gonococcal infection (DGI) may occur in some individuals, producing septicemia, arthritis, dermatitis, endocarditis, perihepatitis, or meningitis.

Symptoms of urethritis usually occur within 2 to 5 days of exposure, although delays of more than 9 days are occasionally reported.

Dysuria and penile discharge are the usual symptoms in men, whereas women report dysuria, vaginal discharge, and lower abdominal pain.

The discharge, when present, is usually creamy yellow, gray, or white and often copious.

In men, aside from urethral discharge, occurring either spontaneously or exuded on “milking” the urethra, the physical examination is otherwise normal.

Women may demonstrate a chronic cervicitis, vaginitis, or inflammation of Bartholin and the periurethral Skene glands.

In men, Gram stain reveals leukocytes with intracellular Gram-negative diplococci, the presence of which is considered evidence for a presumptive diagnosis of gonorrhea; specific therapy should be initiated after a urethral or cervical culture is obtained.

In women, Gram stain is not diagnostically helpful, because the test has a 50% false-negative rate and a 5% false-positive rate.

The culture, which is plated directly on Thayer-Martin medium, is essential both to establish the diagnosis and, in patients presenting with recurrent symptoms after appropriate therapy, to document the existence of a resistant or penicillinase-producing strain.

Cultures should be taken with calcium alginate swabs, because rayon and cotton inhibit growth of the organism.

Nucleic acid amplification tests (NAATs) that amplify DNA sequences of N. gonorrhoeae have supplanted culture in many clinical settings due to their ease of use.

It is also important to note that up to 45% of patients infected with the gonococcus may concomitantly be infected with one of the agents causing nonspecific urethritis
(NSU), especially Chlamydia, and this should be considered in the treatment strategy.

Importantly, in selected patients with suspected gonorrhea, pharyngeal and rectal cultures should also be obtained in addition to urethral or cervical/vaginal cultures; this optimizes the likelihood of culturing the organism and determining its sensitivity.

A serologic test for syphilis (RPR) and HIV should be obtained in all patients as well.

Treatment regimens for patients with uncomplicated gonococcal urethritis/cervicitis/pharyngitis/rectum (two-drug therapy is necessary to treat both gonococcus and chlamydia).

Fluoroquinolones are no longer recommended for first-line treatment unless there is documented sensitivity by culture to this drug class.

Use one antibiotic listed as “A” and one listed as “B” for men and nonpregnant women, and one “A” plus one “C” for pregnant women:

If spectinomycin is used for proctitis, use 4 g intramuscularly.

Ceftriaxone or spectinomycin alone do not treat chlamydial infection or incubating syphilis; an RPR should therefore be repeated in approximately 4 weeks after treatment to exclude the former, and a re-examination in 5 to 7 days is advised.

Spectinomycin is not effective as treatment for pharyngeal gonorrhea; use ceftriaxone 125 mg IM.

The pregnant patient should not receive tetracycline, doxycycline, or a quinolone.

Patients presenting with clinical gonococcal infection after appropriate treatment should have cultures taken from all potential sites of infection and treatment with ceftriaxone or spectinomycin instituted.

Follow-up cultures should be advised 4 to 7 days after the completion of therapy.

All sexual partners exposed to the patient should be examined, cultured, and treated prophylactically; sexual activity should be prohibited for 5 to 7 days.

DGI should be treated with parenteral ceftriaxone, cefotaxime, ceftizoxime, or spectinomycin for at least 24 hours after clinical improvement and then switched to oral cefixime for at least 7 days of total treatment.

Gonococcal conjunctivitis in adults can be a severe, sight-threatening condition. Patients demonstrate copious purulent discharge. Most patients should be admitted. Treatment is with parenteral ceftriaxone.

Neonatal conjunctivitis is often gonococcal, requires hospitalization, and is also treated with ceftriaxone (25-50 mg/kg up to 125 mg IM or IV).

Patients who present with persistent or recurrent symptoms or signs of urethritis after recent appropriate therapy for gonococcal urethritis are said to have postgonococcal urethritis; all such patients should be reexamined and recultured.

In the evaluation of these patients, it must first be appreciated that approximately 40% of patients with gonococcal urethritis have coexistent chlamydial or ureaplasmal infection, the course of which is unaffected by treatment with penicillin, spectinomycin, or a cephalosporin, such as ceftriaxone.

Failure to treat these patients with tetracycline or doxycycline, therefore, or to provide simultaneous treatment for the patient’s sexual partner(s), typically results in persistent or recurrent symptoms.

In such patients, one must always consider simple reinfection as a result of interval exposure to a new contact.

NSU is caused by Chlamydia trachomatis or Ureaplasma urealyticum, although in approximately 20% of patients, the cause remains obscure.

Patients may report dysuria, penile discharge, or burning; however, asymptomatic cases are common in both men and women.

The discharge when present is scant and mucoid, and typically, only leukocytes are noted on Gram stain.

The causative agents of NSU are fastidious and cannot be grown on routine culture media.

NAATs have become a widespread method to diagnose Chlamydia.

Treatment regimens include 100 mg of doxycycline twice daily for at least 7 days, azithromycin, 1 g orally, in a single dose, or 500 mg of erythromycin four times daily for at least 7 days.

All sexual partners of patients with NSU should be examined and treated with one of these regimens plus coverage for Gonococcus and serologic testing for syphilis and HIV as outlined above.

Persistent or recurrent NSU is usually caused by failure to treat the sexual partner (or partners); however, less common causes of recurrent urethritis should also be considered.

PID is a syndrome resulting from infection of the reproductive organs and their supporting structures; involvement may be unilateral or bilateral.

Most commonly, acute salpingitis, secondary to bacterial infection with N. gonorrhoeae, C. trachomatis, or other indigenous pelvic organisms, including streptococci and a variety of anaerobes, is present.

Severe lower quadrant cramping or aching, usually bilateral, with fever, menometrorrhagia, leukorrhea, and adnexal tenderness is noted in most patients.

Profound tenderness associated with lateral motion of the cervix should suggest the diagnosis.

It is important to note that PID is an important differential diagnosis in any woman presenting with abdominal pain.

Although the white blood cell count is typically elevated and Gram-negative intracellular organisms may be noted on Gram stain of endocervical or vaginal smears, the diagnosis of PID should be based on the patient’s history and physical findings.