Abstract Background Most oropharyngeal Neisseria gonorrhoeae infections are asymptomatic, and many infections remain undetected, creating a reservoir for ongoing transmission and potential drug resistance. It is unclear what the optimal testing policy is in men who have sex with men (MSM), as routine universal testing data are lacking. Methods Surveillance data from all Dutch sexually transmitted infection (STI) clinics between 2008 and 2017 were used (N = 271 242 consultations). Oropharyngeal testing policy was defined as routine universal testing when ≥85% of consultations included oropharyngeal testing or as selective testing (<85% tested). Independent risk factors for oropharyngeal N. gonorrhoeae were assessed among MSM routinely universally screened using backward multivariable logistic regression analyses. Results Routine universal testing was performed in 90% (238 619/265 127) of consultations. Prevalence was higher using routine universal testing (5.5%; 95% CI, 5.4–5.6; 12 769/233 476) than with selective testing (4.7%; 95% CI, 4.4–5.0; 799/17 079; P < .001). Proportions of oropharyngeal-only infections were 55% and 47%, respectively. Independent risk factors were age <31 years (OR, 2.1; 95% CI, 1.9–2.3), age 31–43 years (OR, 1.7; 95% CI, 1.6–1.9, compared with >43 years), being notified for any STI (OR, 2.0; 95% CI, 1.9–2.1), concurrent urogenital N. gonorrhoeae (OR, 2.4; 95% CI, 2.1–2.7), and concurrent anorectal N. gonorrhoeae (OR, 11.4; 95% CI, 10.6–12.3). When using any of the risk factors age, notified, or oral sex as testing indicators, 98.4% (81 022/82 332) of MSM would be tested, finding 99.5% (4814/4838) of infections. Conclusions Routine universal testing detected more oropharyngeal N. gonorrhoeae infections than selective testing, of which more than half would be oropharyngeal only. Using independent risk factors as testing indicator is not specific. Therefore, routine universal oropharyngeal testing in MSM is feasible and warranted, as currently advised in most ...