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==Overview==
Women with gonococcal infection usually appear to be well until complications such as [[Pelvic inflammatory disease|PID]] develop.  Physical examination of women with gonococcal infection is usually remarkable for [[mucopurulent discharge|mucopurulent]] [[urethral]], [[cervical]], or [[vaginal]] discharge; friable appearance of the [[cervix]]; and cervical motion tenderness. One common physical examination finding of gonococcal infection in men is [[Mucopurulent discharge|mucopurulent]] urethral discharge. Less commonly, penile edema and epididymal tenderness and edema ([[epididymitis]]) may also be observed as part of complicated gonococcal infection.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid9038638">{{cite journal| author=Sherrard J, Barlow D| title=Gonorrhoea in men: clinical and diagnostic aspects. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 6 | pages= 422-6 | pmid=9038638 | doi= | pmc=1195730 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9038638  }} </ref><ref name="pmid76760">{{cite journal| author=Barlow D, Phillips I| title=Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects. | journal=Lancet | year= 1978 | volume= 1 | issue= 8067 | pages= 761-4 | pmid=76760 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=76760  }} </ref>
 
Physical examination of patients with pharyngeal gonococcal infection is usually remarkable for mild pharyngeal exudates and rectal gonococcal infection is usually remarkable for [[Mucopurulent discharge|mucopurulent]] anal discharge.
Physical examination of patients with disseminated gonococcal infection (DGI) is usually remarkable for [[fever]], pustular or vesicular rash, and musculoskeletal findings.<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>


==Physical examination==
==Physical examination==
===Male===
===Common urogenital and extragenital Infection===
* Purulent or mucopurulent discharge from urethera. The discharge can be demonstrated by milking the shaft of penis.
The most common site of gonococcal infection is the [[urethra]], [[endocervix]], [[rectum]], and [[pharynx]].
* Epididymal tenderness and edema usually unilateral
Physical examination of patients with gonococcal infection is usually remarkable for:
===Female Pelvic examination===
 
====Inspection====
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
* Purulent or mucopurulent discharge  
|+
* Vaginal bleeding
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Type of Gonococcal Infection}}
====Palpation====
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Physical Examination}}
* Cervical mucosa may become fragile and bleed even with some manipulation.
|-
* cervical motion tenderness during bimanual pelvic examination
| style="padding: 5px 5px; background: #DCDCDC;" | '''Urogenital infection in men'''<ref name="pmid9038638">{{cite journal| author=Sherrard J, Barlow D| title=Gonorrhoea in men: clinical and diagnostic aspects. | journal=Genitourin Med | year= 1996 | volume= 72 | issue= 6 | pages= 422-6 | pmid=9038638 | doi= | pmc=1195730 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9038638  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Mucopurulent dishareg|Mucopurulent]] urethral discharge
* Bull-headed clap (penile edema)
* Unilateral epididymal tenderness and edema ([[epididymitis]])
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Urogenital infection in women''':<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid76760">{{cite journal| author=Barlow D, Phillips I| title=Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects. | journal=Lancet | year= 1978 | volume= 1 | issue= 8067 | pages= 761-4 | pmid=76760 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=76760  }} </ref><ref name="pmid17448399">{{cite journal| author=Huppert JS, Biro F, Lan D, Mortensen JE, Reed J, Slap GB| title=Urinary symptoms in adolescent females: STI or UTI? | journal=J Adolesc Health | year= 2007 | volume= 40 | issue= 5 | pages= 418-24 | pmid=17448399 | doi=10.1016/j.jadohealth.2006.12.010 | pmc=1976261 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17448399  }} </ref><ref name="pmid806017">{{cite journal| author=Eschenbach DA, Buchanan TM, Pollock HM, Forsyth PS, Alexander ER, Lin JS et al.| title=Polymicrobial etiology of acute pelvic inflammatory disease. | journal=N Engl J Med | year= 1975 | volume= 293 | issue= 4 | pages= 166-71 | pmid=806017 | doi=10.1056/NEJM197507242930403 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=806017  }} </ref><ref name="pmid17561186">{{cite journal| author=Risser WL, Risser JM, Benjamins LJ, Feldmann JM| title=Incidence of Fitz-Hugh-Curtis syndrome in adolescents who have pelvic inflammatory disease. | journal=J Pediatr Adolesc Gynecol | year= 2007 | volume= 20 | issue= 3 | pages= 179-80 | pmid=17561186 | doi=10.1016/j.jpag.2006.08.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17561186  }} </ref><ref name="pmid4963696">{{cite journal| author=Rees E| title=Gonococcal bartholinitis. | journal=Br J Vener Dis | year= 1967 | volume= 43 | issue= 3 | pages= 150-6 | pmid=4963696 | doi= | pmc=1047872 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4963696  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* [[Mucopurulent discharge|Mucopurulent]] [[urethral]],  [[cervical]] or [[vaginal]] discharge
* Positive cervical motion tenderness
* Friable cervical mucosa
* Abdominal pain with negative [[rebound tenderness]]
** Lower abdominal pain (consistent with [[PID]])
** Right upper quadrant pain ([[Fitz-Hugh-Curtis syndrome]])
*Labial edema and Bartholin’s gland enlargement and tenderness ([[Bartholinitis]])
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Proctitis'''<ref name="pmid7427703">{{cite journal| author=Stansfield VA| title=Diagnosis and management of anorectal gonorrhoea in women. | journal=Br J Vener Dis | year= 1980 | volume= 56 | issue= 5 | pages= 319-21 | pmid=7427703 | doi= | pmc=1045815 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7427703  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Anal [[mucopurulent discharge]]
* Anorectal tenderness
* Anorectal bleeding  
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Pharyngitis'''<ref name="pmid386537">{{cite journal| author=Kraus SJ| title=Incidence and therapy of gonococcal pharyngitis. | journal=Sex Transm Dis | year= 1[[Link title]]979 | volume= 6 | issue= 2 Suppl | pages= 143-7 | pmid=386537 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=386537  }} </ref><ref name="pmid119330">{{cite journal| author=Osborne NG, Grubin L| title=Colonization of the pharynx with Neisseria gonorrhoeae: experience in a clinic for sexually transmitted diseases. | journal=Sex Transm Dis | year= 1979 | volume= 6 | issue= 4 | pages= 253-6 | pmid=119330 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=119330  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
* Pharyngeal exudates
* [[lymphadenitis|Cervical lymphadenitis]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Conjunctivitis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*[[conjunctivitis|Adult conjunctivitis]]
**[[Conjunctival injectio]]n
**[[Mucopurulent discharge|Purulent eye discharge]]
**Periorbital edema
**Corneal involvement
*[[Neonatal conjunctivitis]]
**[[Chemosis]]
**Severe lid edema
**[[Mucopurulent discharge]]
**Corneal involvement
|}
 
===Disseminated Gonococcal Infection===
Dissemination gonococcal infection usually can result in two clinical syndromes:<ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref><ref name="pmid22353959">{{cite journal| author=Bleich AT, Sheffield JS, Wendel GD, Sigman A, Cunningham FG| title=Disseminated gonococcal infection in women. | journal=Obstet Gynecol | year= 2012 | volume= 119 | issue= 3 | pages= 597-602 | pmid=22353959 | doi=10.1097/AOG.0b013e318244eda9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22353959  }} </ref><ref name="pmid6415361">{{cite journal| author=O'Brien JP, Goldenberg DL, Rice PA| title=Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. | journal=Medicine (Baltimore) | year= 1983 | volume= 62 | issue= 6 | pages= 395-406 | pmid=6415361 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6415361  }} </ref>
*[[Septic arthritis]] (purulent arthritis)
*Arthritis-dermatitis syndromes (with a triad of [[tenosynovitis]], [[dermatitis]], and [[polyarthralgias]])
Other, less common manifestations of disseminated gonococcal infection include:
*[[Endocarditis]]
*[[Meningitis]]
Physical examination of patients with disseminated gonococcal infection is usually remarkable for:<ref name="pmid26042815">{{cite journal| author=Workowski KA, Bolan GA, Centers for Disease Control and Prevention| title=Sexually transmitted diseases treatment guidelines, 2015. | journal=MMWR Recomm Rep | year= 2015 | volume= 64 | issue= RR-03 | pages= 1-137 | pmid=26042815 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26042815  }} </ref><ref name="pmid16297736">{{cite journal| author=Rice PA| title=Gonococcal arthritis (disseminated gonococcal infection). | journal=Infect Dis Clin North Am | year= 2005 | volume= 19 | issue= 4 | pages= 853-61 | pmid=16297736 | doi=10.1016/j.idc.2005.07.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16297736  }} </ref>
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Disseminated Gonococcal Infection}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Organ systems}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''General Appearance'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Fever (usually less than 39°C)
* Chills
* Generalized malaise
Note: Occurs in the acute phase of infection
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Skin'''
| style="padding: 5px 5px; background: #F5F5F5;" |
* Painless skin lesions (on the torso, limbs, palms, and soles) which varis based on clinical stages
** [[Maculopapular]], [[pustular]], [[necrotic]], or [[vesicular]] rash
**[[Hemorrhagic lesions]]
**[[Erythema nodosum]]
**[[Urticaria]]
**[[Erythema multiform]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Eye'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*'''[[Conjunctivitis]]'''
** Conjunctival injection
** Purulent eye discharge
** Periorbital edema
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Musculoskeletal'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*'''[[Arthritis]]'''
** [[Polyarthralgia]] with joint tenderness
** Decreased range of motion
** [[Erythema]]
Note: purulent arthritis may be abrupt onset of monoarthritis or oligoarthritis without skin lesions and fever
*'''[[Tenosynovitis]]'''
**Erythema along a tendon sheath
**Local tenderness along a tendon sheath
**Painful active or passive range of motion
Note: most commonly occurs in hands and less commonly lower extremities
*'''[[Muscle abscess]]'''
**Localized tenderness
**Localaized edema
**Pain with motion
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Central Nervous System'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*'''[[Meningitis]]'''
* Decreased mental status
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Cardiac'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*'''[[Endocarditis]]'''
**New murmur
**[[Tachycardia]]
|}
 
==Images==
The following are images associated with gonorrhea physical examination.<ref>STD Gonorrhea Infection Gallery http://www.std-gov.org/std_picture/gonorrhea_w.htm Accessed on September 22, 2016</ref><ref name=CDCGonorrheapic>Centers for Disease Control and Prevention. Public Health Image Library (PHIL)  http://phil.cdc.gov/phil/home.asp Accessed on September 22, 2016</ref>
<div align="center">
<gallery heights="175" widths="175">
Image: Gonorrhea07.jpeg|Purulent discharge emanating from the cervical os, and pooling in the vagina - Source: https://www.cdc.gov/
Image:Gonorrhea penile discharge.jpg|Penile discharge in a patient with gonorrhea - Source: https://www.std.gov/
Image:Gonorrhea20.jpg|Gonococcal pharyngitis - Source: https://www.cdc.gov/
Image:220px-Gonococcal_ophthalmia_neonatorum.jpg|[[Ophthalmia neonatorum]] - Source: https://www.cdc.gov/
Image:Gonorrhea36.jpg|Close-up of a gonococcal lesion on the skin of a patient’s arm - Source: https://www.cdc.gov/
Image:Gonorrhea35.jpg|Lesions of skin and arthritic knee joints due to Neisseria gonorrhea - Source: https://www.cdc.gov/
Image:Gonorrhea3.jpg|Gonococcal arthritis of the hand - Source: https://www.cdc.gov/
</gallery>
</div>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Sexually transmitted infections|Gonorrhea]]
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Latest revision as of 21:55, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Women with gonococcal infection usually appear to be well until complications such as PID develop. Physical examination of women with gonococcal infection is usually remarkable for mucopurulent urethral, cervical, or vaginal discharge; friable appearance of the cervix; and cervical motion tenderness. One common physical examination finding of gonococcal infection in men is mucopurulent urethral discharge. Less commonly, penile edema and epididymal tenderness and edema (epididymitis) may also be observed as part of complicated gonococcal infection.[1][2][3]

Physical examination of patients with pharyngeal gonococcal infection is usually remarkable for mild pharyngeal exudates and rectal gonococcal infection is usually remarkable for mucopurulent anal discharge. Physical examination of patients with disseminated gonococcal infection (DGI) is usually remarkable for fever, pustular or vesicular rash, and musculoskeletal findings.[1][4]

Physical examination

Common urogenital and extragenital Infection

The most common site of gonococcal infection is the urethra, endocervix, rectum, and pharynx. Physical examination of patients with gonococcal infection is usually remarkable for:

Type of Gonococcal Infection Physical Examination
Urogenital infection in men[2]
  • Mucopurulent urethral discharge
  • Bull-headed clap (penile edema)
  • Unilateral epididymal tenderness and edema (epididymitis)
Urogenital infection in women:[1][3][5][6][7][8]
Proctitis[9]
Pharyngitis[10][11]
Conjunctivitis

Disseminated Gonococcal Infection

Dissemination gonococcal infection usually can result in two clinical syndromes:[4][12][13]

Other, less common manifestations of disseminated gonococcal infection include:

Physical examination of patients with disseminated gonococcal infection is usually remarkable for:[1][4]

Disseminated Gonococcal Infection Organ systems
General Appearance
  • Fever (usually less than 39°C)
  • Chills
  • Generalized malaise

Note: Occurs in the acute phase of infection

Skin
Eye
  • Conjunctivitis
    • Conjunctival injection
    • Purulent eye discharge
    • Periorbital edema
Musculoskeletal

Note: purulent arthritis may be abrupt onset of monoarthritis or oligoarthritis without skin lesions and fever

  • Tenosynovitis
    • Erythema along a tendon sheath
    • Local tenderness along a tendon sheath
    • Painful active or passive range of motion

Note: most commonly occurs in hands and less commonly lower extremities

Central Nervous System
Cardiac

Images

The following are images associated with gonorrhea physical examination.[14][15]

References

  1. ↑ 1.0 1.1 1.2 1.3 Workowski KA, Bolan GA, Centers for Disease Control and Prevention (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815.
  2. ↑ 2.0 2.1 Sherrard J, Barlow D (1996). "Gonorrhoea in men: clinical and diagnostic aspects". Genitourin Med. 72 (6): 422–6. PMC 1195730. PMID 9038638.
  3. ↑ 3.0 3.1 Barlow D, Phillips I (1978). "Gonorrhoea in women. Diagnostic, clinical, and laboratory aspects". Lancet. 1 (8067): 761–4. PMID 76760.
  4. ↑ 4.0 4.1 4.2 Rice PA (2005). "Gonococcal arthritis (disseminated gonococcal infection)". Infect Dis Clin North Am. 19 (4): 853–61. doi:10.1016/j.idc.2005.07.003. PMID 16297736.
  5. ↑ Huppert JS, Biro F, Lan D, Mortensen JE, Reed J, Slap GB (2007). "Urinary symptoms in adolescent females: STI or UTI?". J Adolesc Health. 40 (5): 418–24. doi:10.1016/j.jadohealth.2006.12.010. PMC 1976261. PMID 17448399.
  6. ↑ Eschenbach DA, Buchanan TM, Pollock HM, Forsyth PS, Alexander ER, Lin JS; et al. (1975). "Polymicrobial etiology of acute pelvic inflammatory disease". N Engl J Med. 293 (4): 166–71. doi:10.1056/NEJM197507242930403. PMID 806017.
  7. ↑ Risser WL, Risser JM, Benjamins LJ, Feldmann JM (2007). "Incidence of Fitz-Hugh-Curtis syndrome in adolescents who have pelvic inflammatory disease". J Pediatr Adolesc Gynecol. 20 (3): 179–80. doi:10.1016/j.jpag.2006.08.004. PMID 17561186.
  8. ↑ Rees E (1967). "Gonococcal bartholinitis". Br J Vener Dis. 43 (3): 150–6. PMC 1047872. PMID 4963696.
  9. ↑ Stansfield VA (1980). "Diagnosis and management of anorectal gonorrhoea in women". Br J Vener Dis. 56 (5): 319–21. PMC 1045815. PMID 7427703.
  10. ↑ Kraus SJ (1Link title979). "Incidence and therapy of gonococcal pharyngitis". Sex Transm Dis. 6 (2 Suppl): 143–7. PMID 386537. Check date values in: |year= (help)
  11. ↑ Osborne NG, Grubin L (1979). "Colonization of the pharynx with Neisseria gonorrhoeae: experience in a clinic for sexually transmitted diseases". Sex Transm Dis. 6 (4): 253–6. PMID 119330.
  12. ↑ Bleich AT, Sheffield JS, Wendel GD, Sigman A, Cunningham FG (2012). "Disseminated gonococcal infection in women". Obstet Gynecol. 119 (3): 597–602. doi:10.1097/AOG.0b013e318244eda9. PMID 22353959.
  13. ↑ O'Brien JP, Goldenberg DL, Rice PA (1983). "Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms". Medicine (Baltimore). 62 (6): 395–406. PMID 6415361.
  14. ↑ STD Gonorrhea Infection Gallery http://www.std-gov.org/std_picture/gonorrhea_w.htm Accessed on September 22, 2016
  15. ↑ Centers for Disease Control and Prevention. Public Health Image Library (PHIL) http://phil.cdc.gov/phil/home.asp Accessed on September 22, 2016


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