Therapeutics in Dermatology
A reference textbook in dermatology
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Gonococcal urethritis

28 April 2014, by HALIOUA B.

Neisseria gonorrhoeae is a species of Gram-negative, strictly aerobic diplococci bacteria that shows particular tropism for the glandular column-type cells of the endocervix and the urethra. In men, gonococcal infection most frequently gives rise to acute anterior urethritis with very typical symptoms including a greenish yellow purulent discharge from the genitals, edematous meatitis, dysuria and sometimes inguinal lymphadenopathy, but no fever. Infected subjects may be totally asymptomatic. Gonococcal infection may cause a certain number of complications, i.e. epididymo-orchitis, acute prostitis, infection of Cowper’s glands, of Tyson’s gland and of the paraurethral glands, and balanitis [1].

Most women with gonococcal infection are asymptomatic. However, infection may also produce a picture of cervicitis causing a feeling of heaviness in the pelvic area and purulent leukorrhea often combined with urethritis expressed as urinary burning and dysuria. If left untreated, infection may also give rise to complications including inflammation of the paraurethral glands and of Bartholin’s glands, salpingitis or even subacute pelvic peritonitis with an increased risk of infertility and ectopic pregnancy. In men, urethral discharge specimens should be collected in the morning before the first passage of urine and before washing or, in the absence of discharge, an endourethral swab should be taken. In women, cervical and urethral swabs need to be taken. Pharyngeal and rectal swab samples also need to be systematically collected from women and homosexual men.

The diagnosis of Neisseria gonorrhoeae infection is confirmed by direct examination after methylene blue or Gram staining revealing Gram-negative extra- and particularly intracellular diplococci in the shape of coffee beans within numerous altered polymorphonuclear leukocytes.

The sensitivity of the test compared to culture is close to 100% in symptomatic men. The sensitivity of direct examination is much lower for pharyngeal, anorectal and cervicalvaginal samples [2]. Culture of urethral discharge or endourethral swab samples on chocolate agar (Thayer-Martin, Isovitalex) with or without antibiotics is the test of reference. This test is used to confirm the diagnosis in 24 to 48 hours, to identify the species and the strain for epidemiological studies, to test for the presence of penicillinase and to construct the antibiogram [3]. It is the only method that enables infection in women and in pharyngeal and anorectal samples to be diagnosed with absolute certainty [4]. Other sensitive and specific tests exist (PCR) but they are costly and cannot be used to construct an antibiogram. They should only be used in very special circumstances (research, epidemiological studies).

Data from the national network for monitoring gonococci (RENAGO) set up in 1985 for the epidemiological monitoring of gonococcal infection in France established that the number of cases reported since 1997 was on the increase. In 2011, the RENAGO network demonstrated an increase in the number of cases reported compared to 2010 [5]. The strains were isolated in 85.5 % of cases in men. Infection was anorectal in 5.9 % of the cases in men and in 0.8% of the cases in women. Pharyngeal infection was reported in 0.3% of men and in 0.4% of women. 

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