Uncomplicated gonorrhoea typically causes symptoms in men.

• Symptoms usually develop after 2–5 days incubation, although they may appear after 10 days or more.
• Genital infection is most common and causes:
• Urethral discharge in 80% of men. Initially it is often scant and mucoid, becoming overtly purulent after 1–2 days.
• Pain or difficulty urinating (dysuria) in about 50% of men. Usually there is no frequency or urgency.
• No symptoms in 10% of men.
• Rectal infection is asymptomatic in most men (about 75%), but may cause acute proctitis. This presents as anal pruritus, pain and spasm of the anal sphincter (tenesmus), purulent discharge, or bleeding.
• Pharyngeal infection is asymptomatic in 90% of men, but may cause overt pharyngitis.
• Examination commonly reveals a mucopurulent or purulent urethral discharge. Less commonly, there may be epididymal tenderness or swelling, or balanitis.
• Diagnosis of gonorrhoea is confirmed by positive identification of Neisseria gonorrhoeae through culture and nucleic acid amplification tests.
• For more information, see the section on Assessment in the CKS topic on Urethritis - male.

[BASHH, 2005b; Handsfield and Sparling, 2005; Bignell et al, 2006]

• Uncomplicated gonorrhoea causes no symptoms in up to 50% of women.
• Where present, symptoms usually develop within 10 days.
• Genital infection is most common and causes:
• Increased or altered vaginal discharge in up to 50% of women.
• Pain or difficulty urinating (dysuria) in 12% of women. Urgency or frequency are uncommon.
• Intermenstrual bleeding, sometimes triggered by intercourse (less commonly).
• Pelvic or abdominal pain, with possible pain on intercourse (dyspareunia), if there is ascending infection (see the CKS topic on Pelvic inflammatory disease).
• Rectal gonorrhoea may occur, but tends to cause symptoms (anal pruritus, pain and spasm of the anal sphincter [tenesmus], purulent discharge, or bleeding) that are less severe than in men.
• Pharyngeal infection is asymptomatic in 90% of women, but it may cause overt pharyngitis.
• Examination may show:
• Most commonly, purulent or mucopurulent endocervical discharge, or easily induced endocervical bleeding. However, this is not a sensitive predictor of cervical infection (occurring in less than 50% of women).
• Less commonly, purulent discharge from the urethra.
• Abdominal tenderness if pelvic inflammatory disease is present.
• Diagnosis of gonorrhoea is confirmed by positive identification of Neisseria gonorrhoeae through culture, which requires an endocervical swab.
• Nucleic acid amplification tests, which require a first-pass urine sample, may also be used initially depending on local protocols, although culture will also usually be required for confirmation.
• See the CKS topic on Vaginal discharge for further information.

[BASHH, 2005b; Handsfield and Sparling, 2005; Bignell et al, 2006]

• Consider the possibility of sexual abuse in any child or young person with gonorrhoea, particularly in the following circumstances:
• The child is younger than 13 years of age, unless there is clear evidence of mother-to-child transmission during birth, or of blood contamination.
• The young person is 13 to 15 years of age, unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the STI was acquired from consensual sexual activity with a peer.
• The young person is 16 to 17 years of age and there is no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity and there is a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or with a person in a position of trust (such as a teacher, sports coach, minister of religion) or there is concern that the young person is being exploited.
• Follow appropriate child protection procedures and refer to a paediatrician if necessary.

[NICE, 2009]

• Men
• Other causes of penile discharge, including:
• Non-gonococcal urethritis caused by Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, or Trichomonas vaginalis (see the CKS topic on Urethritis - male).
• Physiological discharge (small amounts of clear or mucoid discharge upon sexual excitement).
• Subpreputial infection (for example candidiasis).
• Acute prostatitis — may present with: blood-tinged urethral discharge; dysuria, frequency, and urgency; fever; or penile, perineal, and rectal pain. The prostate is swollen and tender.
• Herpes simplex virus infection — can present with herpetic lesions on the urethral meatus.
• Women
• Chlamydia. It is not possible to distinguish gonorrhoeal infection from chlamydia in women by clinical features alone, and the infections coexist in about a third of women.
• See the CKS topic on Chlamydia - uncomplicated genital for further information.
• Other causes of vaginal discharge.
• See the CKS topics on Vaginal discharge, Candida - female genital, Bacterial vaginosis, Trichomoniasis, and Pelvic inflammatory disease.

[Adler, 2004; Handsfield and Sparling, 2005; GRASP Steering Group, 2007]