**4.2 Diagnosis**

Specific microbiologic diagnosis of *N. gonorrhoeae* infection should be performed for all persons at risk of having gonorrhea, which can potentially reduce many related complications [2]. Urine can be used to test for ureteral infection of gonorrhea. However, if there is oral and/or anal sex, swabs may be used to collect samples from the throat, rectum, and cervix. Cell culture, nucleic acid hybridization tests (NAHTs), and nucleic acid amplification tests (NAATs) are available for the detection of genitourinary infection with *N. gonorrhoeae* [20].

The standard diagnostic procedure for men with symptomatic urethritis is the gram stain, because of its high specificity and sensitivity. However, in asymptomatic men or women with genital infections, the Gram stain is less useful because of its lower sensitivity. Gram stain of endocervical specimens, pharyngeal specimens, or rectal specimens is not sufficient to detect infection and therefore is not recommended [25].

The result of cultural diagnosis may be reduced if lubricants with antibacterial agents are used during anoscopy, which makes water a recommended lubricant in this setting. There are no approved nucleic acid amplification tests for rectal infection, while nonculture techniques are gaining acceptance in genital gonococcal infections [26].

Certain NAATs that have been demonstrated to detect Neisseria species might have low specificity when diagnosing oropharyngeal specimens for *N. Gonorrhoeae* but

NAAT sensitivity for identifying *N*. *Gonorrhoeae* from nongenital and urogenital sites is superior to culture even though it may vary by NAAT type. Optimal specimen types for gonorrhea screening using NAATs include vaginal swab specimens for women and first-void urine for men [27].
