Gonorrhoea

Neisseria gonorrhoeae is a gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas.

Gonorrhoea is a sexually transmitted infection. Being young, sexually active and having multiple partners increases the risk of infection with gonorrhoea. Having other sexually transmitted infections, such as chlamydia or HIV, also increases the risk.

There is a high level of antibiotic resistance to gonorrhoea. Traditionally ciprofloxacin or azithromycin was used to treat gonorrhoea. However, there are now high levels of resistance to these antibiotics.

 

Presentation

Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. Female genital infections can present with:

  • Odourless purulent discharge, possibly green or yellow
  • Dysuria
  • Pelvic pain

 

Male genital infections can present with:

  • Odourless purulent discharge, possibly green or yellow
  • Dysuria
  • Testicular pain or swelling (epididymo-orchitis)

 

Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge.

 

Diagnosis

Nucleic acid amplification testing (NAAT) is used to detect the RNA or DNA of gonorrhoea. Genital infection can be diagnosed with endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas.

A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.

TOM TIP: It is worth remembering that NAAT tests are used to check if a gonococcal infection is present or not by looking for gonococcal RNA or DNA. They do not provide any information about the specific bacteria and their antibiotic sensitivities and resistance. This is why a standard charcoal swab for microscopy, culture and sensitivities is so essential, to guide the choice of antibiotics to use in treatment.

 

Management

This section is based on the British Association for Sexual Health and HIV (BASHH) guidelines (2018). Given local differences in antibiotic resistances and frequently changing regimes, always look up the latest local and national guidelines when treating patients. This is a summary to help with your learning and exam preparation.

Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known. For uncomplicated gonococcal infections:

  • A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known
  • A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Different regimes are recommended for complicated infections, infections in other sites and pregnant women. Most regimes involve a single dose of intramuscular ceftriaxone.

 

All patients should have a follow-up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:

  • 72 hours after treatment for culture
  • 7 days after treatment for RNA NAAT
  • 14 days after treatment for DNA NAAT

 

Other factors to consider are:

  • Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection
  • Test for and treat any other sexually transmitted infections
  • Provide advice about ways to prevent future infection
  • Consider safeguarding issues and sexual abuse in children and young people

 

Complications

  • Pelvic inflammatory disease
  • Chronic pelvic pain
  • Infertility
  • Epididymo-orchitis (men)
  • Prostatitis (men)
  • Conjunctivitis
  • Urethral strictures
  • Disseminated gonococcal infection
  • Skin lesions
  • Fitz-Hugh-Curtis syndrome
  • Septic arthritis
  • Endocarditis

A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

 

Disseminated Gonococcal Infection

Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes:

  • Various non-specific skin lesions
  • Polyarthralgia (joint aches and pains)
  • Migratory polyarthritis (arthritis that moves between joints)
  • Tenosynovitis
  • Systemic symptoms such as fever and fatigue

 

Last updated July 2020