A 17-year-old male presents to his pediatrician with 3 days of dysuria and penile discharge. A heavy purulent urethral discharge is seen (Figure 180-1). He has been sexually active with four female partners. He was diagnosed with gonococcal urethritis by clinical appearance and a urine specimen was sent for testing to confirm the gonorrhea and test for Chlamydia. He was treated with Ceftriaxone 250 mg IM for gonorrhea and 1 g of oral azithromycin for possible coexisting Chlamydia. He was offered and agreed to testing for other sexually transmitted diseases. He was told to inform his partners of the diagnosis. He was counseled about safe sex. On his 1-week follow-up visit, his symptoms were gone and he had no further discharge. His gonorrhea nucleic acid amplification test was positive and his Chlamydia, rapid plasma reagin (RPR), and HIV tests were negative. His case was reported to the Health Department for contact tracing.

Infections with Neisseria gonorrhoeae are the second most commonly reported sexually transmitted disease in the US. Gonorrhea can cause cervicitis, urethritis, proctitis, and conjunctivitis. Untreated infections can lead to pelvic inflammatory disease, increasing the risk for infertility, ectopic pregnancy and chronic pelvic pain. Exposed newborns can develop ophthalmia neonatorum. Diagnosis is suspected clinically and confirmed by a urine nucleic acid amplification test. Treat for both gonorrhea and Chlamydia until one or both are ruled out by laboratory testing.

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  The prevalence of gonorrhea in boys and girls ages 15 to 19 was 248.6 and 556.5 per 100,000 persons in the US in 2011. In 2011, gonorrhea rates remained highest among black men and women (427.3), which was 17 times the rate among whites (25.2 per 100,000 population). The rates among Hispanics (53.8) was 2.1 times those of whites.¹

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  Neisseria gonorrhoeae is a gram-negative cocci.

  
  
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  Urethritis is most common infection in males, with an incubation period of 2 to 7 days.

  
  
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  Cervicitis is the most common infection in females, with symptoms typically developing within 10 days of exposure.

  
  
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  Vaginitis is rare in adolescents but can be seen in prepubertal girls due to lack of estrogen effect on the vaginal mucosa.

  
  
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  May also cause anorectal or pharyngeal infections.

  
  
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  Ophthalmia neonatorum presents 2 to 5 days after birth (see Chapter 72, Neonatal Conjunctivitis).

  
  
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  Gonococcal bacteremia can cause a polyarthritis often accompanied by skin lesions.

Clinical Features

Male patients with urethritis can be asymptomatic or present with urethral discharge, dysuria, or urethral pruritus.

Urethritis is diagnosed when one of the following is present:²

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  Mucopurulent or purulent urethral discharge (Figures 180-1 and 180-2).

  
  
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  First-void urine positive leukocyte esterase test ≥10 white blood cells (WBCs) per high-power field. (This can also be seen with a urinary tract infection [UTI]; however, the incidence of UTI in men younger than 50 years of age is approximately 50 per 100,000 per year, much lower than the incidence of gonococcal or chlamydial urethritis in this age group.)

  
  
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  Female patients can be asymptomatic, present with mild symptoms such as scant discharge or dysuria, or present with mucopurulent vaginal discharge (Figures 180-3 and 180-4).