What is the role of gram stain smear in the diagnosis of gonorrhea in males?

Updated: Jun 15, 2021
  • Author: Shahab Qureshi, MD, FACP; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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The presence of typical gram-negative intracellular diplococci and polymorphonuclear leukocytes on Gram stain from a specimen collected from a symptomatic male establishes a diagnosis of gonorrhea (sensitivity, >95%; specificity, >99%). [36] A negative Gram stain result is not sufficient for excluding neisserial infections in asymptomatic men. Results are considered equivocal if typical morphotypes not associated with neutrophils are present or if cell-associated, but morphologically atypical, organisms are observed.


In men, urethritis can be diagnosed using either of 2 methods of Gram staining. The first is via a urine sample. Preferably, examine the patient at least 2 hours after micturition or before his first morning void. The patient should provide a first-morning void, with the first 10-15mL of the urine being saved. The urine is centrifuged so that the sediment may be analyzed microscopically under high power or oil immersion. The presence of 10 or more polymorphonuclear leukocytes (PMNs) seen under high power suggests urethritis.

Urethral exudate

The second method is a Gram stain of urethral exudate. The presence of 4 or more PMNs per oil-immersion field is diagnostic for urethritis. In symptomatic males, Gram staining of urethral exudate yields a sensitivity of 90-98% and a specificity of 95-98%. However, in asymptomatic males, the sensitivity of the Gram stain is only 60%. Therefore, culture studies are recommended if an asymptomatic gonococcal infection is suggested.

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