Gonococcal Urethritis

Etiology & Epidemiology

• Incubation period: 2-6 days (range 2-14 days)
• N. gonorrhoeae adheres to columnar and cuboidal mucosal epithelium of the urethra and endocervical canal
• Up to 10% of infected men are asymptomatic; in women, ~50% carry the infection silently
• Campbell-Walsh-Wein Urology, p. 1647
• Goldman-Cecil Medicine, p. 3092

Clinical Features

In Men

• Profuse, purulent urethral discharge - typically white, yellow, or green
• Dysuria (burning on urination)
• Meatal irritation, meatal erythema, penile lymphedema
• In ~25% of men, symptoms may be milder and discharge only apparent after urethral "milking/stripping"
• Without treatment, symptoms spontaneously resolve in ~6 months, but the patient remains infectious

A: Gonococcal urethritis (purulent discharge). B: Non-gonococcal urethritis (clear discharge). Courtesy of Stephanie N. Taylor, MD - Goldman-Cecil Medicine

In Women

• Primary site = endocervical canal
• Symptoms: increased vaginal discharge, dysuria, intermenstrual bleeding, menorrhagia
• Urethritis may cause dysuria
• Often asymptomatic until complications develop (PID, tubal scarring, infertility, ectopic pregnancy)

Local Complications (by spread/ascent)

Disseminated Gonococcal Infection (DGI)

• Fever, arthritis, tenosynovitis, acral cutaneous pustules
• Rarely: endocarditis, meningitis
• Dermatology 2-Volume Set 5e, p. 1758

Diagnosis

Clinical Criteria for Urethritis (any one of):

• Mucopurulent/purulent urethral discharge on exam
• Gram stain of urethral secretion: ≥2 WBCs per oil-immersion field
• Positive leukocyte esterase on first-void urine

• 10 WBCs/hpf from first-void urine

Point-of-Care: Gram Stain

• Positive: polymorphonuclear leukocytes (PMNs) with intracellular gram-negative diplococci (IGNDs) = diagnostic for GU in symptomatic men
• Sensitivity ~95% in symptomatic men with discharge; lower in asymptomatic cases
• A negative Gram stain does not rule out GU

A: Gram stain showing a PMN with intracellular gram-negative diplococci (red). B: Methylene blue/gentian violet stain showing abundant PMNs with IGNDs. Courtesy of Stephanie N. Taylor, MD - Goldman-Cecil Medicine

NAAT (Nucleic Acid Amplification Test) - Preferred Method

• Higher sensitivity than culture or microscopy; now the preferred diagnostic modality
• Specimen: first-catch urine or urethral/penile meatal swab in men; urine or self-collected vaginal swab in women
• Can simultaneously test for Chlamydia trachomatis
• Multiple FDA-cleared platforms available for concurrent GC/CT detection
• Not FDA-cleared for rectal, oropharyngeal, or conjunctival specimens - culture preferred there

Culture

• Requires urethral swab; lower sensitivity than NAAT
• Collect before NAAT swab to maximize sample
• Preferred/required in:
  • Sexual assault of prepubescent boys
  • Suspected treatment failure
  • Antimicrobial resistance monitoring
  • Rectal, pharyngeal, conjunctival infections
• Campbell-Walsh-Wein Urology, pp. 1648-1649

Treatment

First-Line (CDC Recommended)

Ceftriaxone 500 mg IM single dose (for most patients) Ceftriaxone 1 g IM if weight >150 kg If Chlamydia co-infection cannot be excluded: + Doxycycline 100 mg PO BID x 7 days

Antibiotic Resistance - Key Concern

Alternative Regimens (if ceftriaxone unavailable)

• Cefixime 800 mg PO single dose (less preferred due to resistance trends)
• Gentamicin 240 mg IM + azithromycin 2 g PO (for cephalosporin allergy)

Treatment Failure

• No symptom resolution within 3-5 days AND no sexual contact in that period
• Positive test-of-cure without sexual contact

• Campbell-Walsh-Wein Urology, pp. 1648-1649

Post-Treatment Management

1. Test for co-infections: Chlamydia, syphilis, HIV (all patients with gonorrhea)
2. Sexual abstinence: for 7 days after treatment AND until all partners are treated
3. Partner notification: all sexual contacts within 60 days of symptom onset should be evaluated, tested, and presumptively treated
4. Test-of-cure: recommended at 3-4 months given high rates of reinfection
5. Expedited partner therapy (EPT) should be considered

Differential Diagnosis of Urethral Discharge

• Textbook of Family Medicine 9e; Campbell-Walsh-Wein Urology

Recent Guideline Update (2025-2026)