Last Updated: 2020-11-19

Author(s): Anzengruber F., Navarini A.

ICD11: 1A7Z

Neisser 1879.

Gonorrhea, Neisser's disease.

A sexually transmitted infectious disease (STI or STD) caused by Neisseria gonorrhoeae that occurs worldwide. It is seen as an indicator for the prevention of HIV and other STDs, as it is often a co-infection (ulcers serve as entry portal).

  • Worldwide approx. 300-600 million
  • Incidence: 2-5/100000/year
    • Saxony: 10,1 /100000/year
  • Men: Women = 2:1
  •  Since the invention of penicillin in Europe, the incidence of the disease has been declining, and has been rising again since 2001.
  • Occurring mainly in the 3rd and 4th decade of life

  • With the exception of neonatal conjunctivitis, the transmission is only sexual.
  • Risk factors
    • High number of sexual partners
    • Promiscuity
    • Not using a condom
    • Anal sex
    • Oral sex

  • Incubation period: 2-7 days
  • Often indistinguishable from Chlamydia infection.
  • Mostly a urethritis or a cervicitis appears. The distal rectal mucosa can also be affected. Hematogenic scattering is possible.
  • Men:

    • Serous or purulent exclusion
    • Burning during urination 
    • The urethra opening may be red.
    • Balanitis, sometimes paraphimosis
    • Pain in the perineum and lower abdomen
  • Women:

    • 80% asymptomatic
    • Serous or purulent discharge
    • Burning and pain during urination
    • Local redness and swelling, erosions and ulcerations
    • Peritoneal pain (pelvic inflammatory disease)
    • Bleeding disorder
    • Swelling of the adnexa
  • Extra-genital manifestation

    •  Pharyngitis (almost all cases of pharyngeal gonorrhoea are asymptomatic)
    • Proctitis (often asymptomatic in both sexes)
    • Sepsis
    • Deteriorated general condition, fever attacks

  • Urethritis: All patients with urethritis should undergo the diagnostic steps listed in Table 1. If the complaint persists, the steps are described in Table 2.
  • Pharyngeal or anal complaints: For pharyngitis and anal complaints see Table 3.


Table 1. diagnostic steps in all urethritis patients step

Sample collection


For the detection of


Men: Swab from the urethra with the eSwab with thin swab (Figure 1):

  • urethral discharge; spontaneously or smear out urethra or

  • Urethral swab; cotton swab 2cm into urethra and turn slightly

Women: If culture is desired, take a smear of endocervix in gynaecology.

Step 1a:

Smear swab on slide for Gram staining

Gram-negative diplococci (Neisseria gonorrhoeae),

Other bacteria,


Step 1b):

Swab immediately into the medium 

Neisseria gonorrhoeae culture (including resistance)

Step 2)

Men: first urine (at least 2 hours after last micturition)

alternatively, if micturition is not possible:

for urethral swab from step 1 additionally require PCR

Women: Vaginal swab


Neisseria gonorrhoeae - PCR,

Chlamydia trachomatis - PCR

Step 3)

Blood sample collection


Lues serology,

HIV Test


Table 2: Diagnostic steps in case of persistent symptoms after therapy (after consultation with a management physician)

Sample collection


Detection of

Step 1)

Urethral smear

Put the smear into the medium

Mycoplasma genitalium - PCR,

Trichomonas vaginalis - PCR


Genito-anal, pharyngeal, less frequently other localizations.

  • Men

    • Urethritis gonorrhoica posterior
    • Prostatitis
    • Epididymitis
    • Spermatocystis
    • Vesiculitis
    • Funiculitis
    • Cowperitis
    • Cavernitis
    • Anal infestation
    • Perihepatitis gonorrhoica
    • Endocarditis
    • Gonarthritis
    • Meningitis
    • Gonococcal sepsis
  • Women

    • Salpingitis
    • Endometritis gonorrhoica
    • Perioophoritis
    • Oophoritis
    • Adnexitis gonorrhoica
    • Peritonitis gonorrhoica
    • Rectal gonorrhoea
    • Vulvovaginitis gonorrhoica adultorum
    • Gonococcal sepsis
    • Perihepatitis gonorrhoica
    • Endocarditis
    • Gonarthritis
    • Meningitis

Barrier measures (attention oral sex).

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  2. Lewis DA, Ison CA, Forster GE, Goh BT. Tetracycline-Resistant Neisseria gonorrhoeae. Sexually Transmitted Diseases 1996;23:378-83.
  3. Sherrard J, Barlow D. Gonorrhoea in men: clinical and diagnostic aspects. Sexually Transmitted Infections 1996;72:422-6.
  4. Yealy DM, Greene TJ, Hobbs GD. Underrecognition of CervicalNeisseria gonorrhoeaeandChlamydia trachomatisInfections in the Emergency Department. Academic Emergency Medicine 1997;4:962-7.
  5. Palladino S, Pearman JW, Kay ID, et al. Diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae genitourinary infections in males by the Amplicor PCR assay of urine. Diagnostic Microbiology and Infectious Disease 1999;33:141-6.
  6. Whiley DM, Garland SM, Harnett G, et al. Exploring 'best practice' for nucleic acid detection of Neisseria gonorrhoeae. Sexual Health 2008;5:17.
  7. Lebwohl, Mark. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. Elsevier, 2014. Print.
  8. British Association for Sexual Health and HIV national guideline for the management of infection with Neisseria gonorrhoeae (2019)
  9. Horner P. et al. 2016 European guideline on the management of non-gonococcal urethritis. International Journal of STD & AIDS 2016; 27: 928–937