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Key Features

Essentials of Diagnosis

  • Purulent urethral discharge with intracellular gram negative diplococci on smear in male patients (usually adolescents)

  • Purulent, edematous, sometimes hemorrhagic conjunctivitis with intracellular gram-negative diplococci in 2- to 4-day-old infants

  • Fever, arthritis (often polyarticular) or tenosynovitis, and maculopapular peripheral rash that may be vesiculopustular or hemorrhagic

  • Positive culture of blood, pharyngeal, or genital secretions

  • Nucleic acid amplification test on urine on genital secretions

General Considerations

  • Workup of every case of gonorrhea should include a careful and accurate inquiry into the patient's sexual practices, because pharyngeal infection resulting from oral sex must be detected if present and may be difficult to eradicate

  • Efforts should be made to identify and provide treatment to all sexual contacts

  • Programs of expedited partner treatment where prescriptions are provided without first examining the sexual contact increase successful treatment

  • Prepubertal gonococcal infection outside the neonatal period should be considered presumptive evidence of sexual contact or child abuse

  • Incubation period is short, usually 2–5 days


  • Reported cases of gonorrhea exceeded 333,000 in the United States in 2013

  • Gonococcal disease in children may be transmitted sexually or nonsexually

Clinical Findings

Symptoms and Signs

  • Asymptomatic gonorrhea

    • Ratio of asymptomatic to symptomatic gonorrheal infections in adolescents and adults is probably 3–4:1 in women and 0.5–1:1 in men

    • Asymptomatic and symptomatic infections are equally infectious

  • Uncomplicated genital gonorrhea

    • Urethritis in males

      • Discharge is sometimes painful and bloody

      • May be white, yellow, or green

      • May be associated dysuria

      • Patient usually is afebrile

    • Prepubertal female with vaginitis

      • Dysuria and polymorphonuclear neutrophils in the urine

      • Vulvitis characterized by erythema, edema, and excoriation accompanied by a purulent discharge

    • Postpubertal female with cervicitis

      • Symptomatic disease is characterized by a purulent, foul-smelling vaginal discharge, dysuria, and occasionally dyspareunia

      • Fever and abdominal pain are absent

      • Cervix is frequently hyperemic and tender when touched

    • Rectal gonorrhea

      • Often is asymptomatic

      • May be purulent discharge, edema, and pain during evacuation

    • Pharyngeal gonorrhea

      • Usually is asymptomatic

      • May be some sore throat and, rarely, acute exudative tonsillitis with bilateral cervical lymphadenopathy and fever

  • Conjunctivitis and iridocyclitis

    • Copious, usually purulent exudate is characteristic

    • Newborns are symptomatic on days 2–4 of life

    • In the adolescent, infection probably is due to infected genital secretions spread by the fingers

  • Pelvic inflammatory disease (salpingitis)

    • The interval between initiation of genital infection and its ascent to the uterine tubes is variable and may range from days to months

    • Menses frequently are the initiating factor

      • With onset of a menstrual period, gonococci invade the endometrium, causing transient endometritis

      • Salpingitis may occur, resulting in pyosalpinx or hydrosalpinx

      • Rarely infection progresses to peritonitis or perihepatitis

  • Gonococcal perihepatitis (Fitz-Hugh–Curtis syndrome)

    • Typically presents with right upper quadrant tenderness in association with signs of acute or subacute salpingitis

    • Pain may be pleuritic and referred to the shoulder

    • Hepatic friction ...

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