Last Updated: 2023-07-07

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

ICD11: 1A7Z

Neisser, 1879

Gonorrhoea, Neisser's disease.

Worldwide sexually transmitted infection (STI or STD) caused by Neisseria gonorrhoeae. Seen as an indicator for the prevention of HIV and other STDs, as it is often a co-infection (ulcers serve as a port of entry).

  • Worldwide: approx. 300-600 million
  • Incidence: 2-5/100000/year
    • Saxony: 10.1/100000/year
  • Men : Women = 2:1
  • Declining disease in Europe since the invention of penicillin, increasing again since 2001
  • Mostly occurring in the 3rd and 4th decade of life

  • Transmission, with the exception of neonatal conjunctivitis, is only sexual.
  • Risk factors
    • High number of sexual partners
    • Promiscuity
    • Non use of a condom
    • Anal intercourse
    • Oral intercourse

  • Incubation period: 2-7 days
  • Often indistinguishable from chlamydial infection
  • Most often presents with urethritis or cervicitis. The distal rectal mucosa may also be affected. Haematogenous spread is possible.
  • ♂:
    • Serous or purulent discharge
    • Burning on emptying the bladder
    • The urethral opening may be reddened
    • Balanitis, sometimes paraphimosis
    • Pain in the perineum and lower abdomen
    • In 80% asymptomatic
    • Serous or purulent discharge
    • Burning and pain on urination
    • Local redness and swelling, erosions and ulcerations
    • Peritoneal pain (pelvic inflammatory disease)
    • Blood flow disturbance
    • Swelling of the adnexa
  • Extragenital manifestation

    • Pharyngitis (almost all cases of pharyngeal gonorrhoea are asymptomatic)
    • Proctitis (often asymptomatic in both sexes)
    • Sepsis
    • ↓ AZ, febrile episodes

  • Urethritis: In all patients with urethritis, the diagnostic steps listed in Table 1 should be taken. If symptoms persist, the steps in Table 2 are taken.
  • Pharyngeal or anal symptoms: For pharyngitis and anal complaints, see Table 3.

Table 1. Diagnostic steps in all urethritis patients Sample collection Processing To detect

Step 1)

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

  • Urethral discharge; spontaneous or swab urethra or
  • Urethral swab; cotton swab 2cm into urethra and gently twist

Women: If culture desired, arrange for smear of endocervix in gynaecology department.

Step 1a:

Smear on slide dab/smear for Gram stain

Gram-negative diplococci (Neisseria gonorrhoeae),

Other bacteria,


Step 1b):

Then immediately add the smear to the medium

Neisseria gonorrhoeae culture (incl. resistance)

Step 2)

Men: first stream urine (min. 2 hrs. after last micturition)

Alternatively, if micturition is not possible:

In case of urethral swab of step 1, additionally require PCR

Women: Vaginal swab


Neisseria gonorrhoeae - PCR,

Chlamydia trachomatis - PCR

Step 3) Blood collection



HIV test

Table 2. Diagnostic steps for persistence of symptoms after therapy (after consultation with a squad doctor) Step
Sample collection Processing For detection
1) Urethral swab

Put the swab into the medium

Mycoplasma genitalium - PCR,

Trichomonas vaginalis - PCR

Genito-anal, pharyngeal, less frequently other localisations.

  • 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).

  1. Thayer JD, Jr JEM. A Selective Medium for the Cultivation of N. gonorrhoeae and N. meningitidis. Public Health Reports (1896-1970) 1964;79:49.
  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