In men, urethritis is the most common syndrome (Sherrard and Barlow, 1996). Discharge or dysuria usually appears within 1 week of exposure, although as many as 5-10% of patients never have any signs or symptoms (McNagny et al., 1992). The discharge is characteristically purulent, and Gram-negative intracellular diplococci can be easily seen in Gram stain of the exudate (Figure 1 ). Inguinal lymphadenopathy is often present, and occasionally a frank lymphangitis can develop on the penile shaft and corona. Asymptomatic disease can exist in men up to several weeks after infection. There is some controversy as to whether asymptomatic disease represents presymptomatic disease or true asymptomatic infection. Nevertheless, the organism is potentially transmissible to sexual partners. The differential diagnosis of gonococcal urethritis is chlamydial urethritis or non-gonococcal urethritis (NGU) due to non-chlamydial etiologies  (Stamm  et  al.,  1995).  NGU  can  be  often  differentiated  from  gonococcal  urethritis  by  Gram  stain,  which  has  extremely  high  sensitivity  and  specificity  (>95%)  (Jacobs  and  Kraus,  1975).  However,  rapid  Gram  stain  microscopy  is  not  available  in most  acute  clinical  settings,  and  so  syndromic  treatment  is  typically offered.

FIGURE 1 Gonococcal urethritis: Gram-stained slide of an urethral exudate from a 33-year-old male with gonococcal urethritis. The slide consists of a cellular component of polymorphonuclear leukocytes with intracellular Gramnegative diplococci characteristic of Neisseria gonorrhoeae.

Symptomatic anorectal gonococcal disease occurs  in men with a history of receptive  rectal  intercourse  (Lebedeff  and  Hochman,  1980).  Approximately  50%  have  symptoms, which  include  rectal  pain,  discharge,  constipation  and  tenesmus. The  differential diagnosis  includes other  acute  rectal  sexually transmitted  infections,  such  as  herpes  simplex,  chlamydia  proctitis  and  syphilitic proctitis. Anorectal diseases can also occur in women with endocervical gonorrhea  and  who  have  not  necessarily  had  receptive  rectal  intercourse.  In  these cases infection is presumed to have occurred via tracking of secretions across the perineum.  Indeed, up to 30%  of such women often have coexistent rectal infection,  but  it  is usually asymptomatic.

Because  rectal  gonorrhea  in men  implies  a  history  of  unprotected  rectal intercourse,  surveillance  of  rectal  gonorrhea  has  been  useful  as  a  surrogate marker  for  HIV  risk  in  homosexual  men.  For  example,  early  in  the  AIDS epidemic  the  rate  of  rectal  gonorrhea  declined  (CDC,  1984).  Similarly, troubling  trends were  reported  in  1997 of an  increase  of gonorrhea  in homosexual  men,  which  correlated  with  observed  increases  in  HIV-risk  behavior among homosexual  adolescents  (CDC,  1997a).

Gonococcal  pharyngitis  (Wiesner  et  al.,  1973;  Hutt  and  Judson,  1986) occurs  in men  or women  after  oral  sexual  exposure.  The  disease  is  clinically indistinguishable  from any other bacterial pharyngitis, and  is asymptomatic  in as  many  as  60%  of  cases.  Natural  history  studies  have  demonstrated  that gonococcal  pharyngitis  is  a  self-limited  syndrome  and  uninfected  patients become  culture  negative  after  4-6  weeks.  Throat  swabs  should  be  routinely obtained  in persons  at  risk.