Gonorrhoea

GC |

Overview

Cause

Neisseria gonorrhoeae, a Gram-negative intracellular diplococci (GNID) bacterium.

Clinical presentation

Male Female
Symptoms

Urethral discharge

Vaginal discharge

Dysuria

Dyspareunia with cervicitis

Ano-rectal symptoms: discharge, irritation, painful defecation, disturbed bowel function Ano-rectal symptoms: discharge, irritation, painful defecation, disturbed bowel function
Conjunctivitis: purulent, sight threatening Conjunctivitis: purulent, sight threatening
Complications
Epididymo-orchitis: painful, red swollen testicle/s Pelvic inflammatory disease (PID), dyspareunia, intermenstrual bleeding, post-coital bleeding, discharge

Disseminated disease:

- macular rash that may include necrotic pustules

- septic arthritis

Disseminated disease:

- macular rash that may include necrotic pustules

- septic arthritis

Meningitis or endocarditis (rarely) Meningitis or endocarditis (rarely)
Prostatitis (very rarely)  

See STI Atlas for images.

Special considerations

Up to 80% of women and 10-15% of men have no genital symptoms but most people are asymptomatic in other sites, especially the pharynx, rectum and endocervix

Diagnosis

Always test for culture before treating Gonorrhoea because of the need to monitor for anti-microbial sensitivity and rising resistance

Diagnosis in males
TestSite/SpecimenConsideration
NAAT

FPU

Always collect even if no discharge.

If MSM, also collect anal and phayrngeal swab even if asymptomatic at these sites.

Culture

Urethral swab

Only required if discharge present.

Gram stained urethral discharge may show gram negative intracellular diplococci and is not a sensitive test at non-urethral sites.

If MSM, also collect anal and pharyngeal swab even if asymptomatic at these sites.

NAAT +/- culture

Ano-rectal swab

In asymptomatic patients, a self-collected or practitioner -collected rectal swab for NAAT is sufficient.

However, if the patient has ano-rectal symptoms, best practice is for the clinician to examine with a proctoscope and collect the appropriate rectal swab(s).

NAAT +/- culture

Pharyngeal swab
 

Collect if is MSM.

NAAT – Nucleic Acid Amplification Test
FPU – First pass urine
MSM – Men who have sex with men

 

Diagnosis in females
TestSite/SpecimenConsideration
NAAT +/- culture

Endocervical swab

If discharge/dysuria present.

NAAT +/- culture

Self-collected vaginal swab

If not examined.

NAAT

FPU

Only if endocervical swab/self-collected vaginal swab cannot be taken.

NAAT +/- culture

Pharyngeal swab

If patient has had oral sex.

NAAT +/- culture

Ano-rectal swab

If patent has had anal sex or has ano-rectal symptoms.

If patient declines anal examination, instruct self-collection or refer patient for testing to sexual health centre.

NAAT – Nucleic Acid Amplification Test
FPU – First pass urine
 

Specimen collection 

Clinician collected |
Self-collection

Investigations

  • NAATs are highly sensitive, allow for patient self-sampling and can be used in non-clinical and non-urban settings. They are not validated for non-genital sites however, and false positives can occur. NAATs are the most common gonorrhoea test offered by commercial laboratories in Australia.
  • Gonococcal culture has high specificity and allows for antibiotic susceptibility testing but is not as sensitive as a NAAT. If not already collected, culture samples should be obtained at time of treatment to determine antibiotic susceptibility. Culture accuracy depends on stringent incubation and transport conditions and should reach the laboratory within 24 hours.
  • Positive predictive value is highest for tests when undertaken in high prevalence populations.

Special considerations

If possible, culture samples should be obtained from genital and non-genital sites to determine antibiotic susceptibility before treating someone with a positive NAAT. 

Management

Principal Treatment Options
SituationRecommendedAlternative
Uncomplicated ano-genital, ano-rectal or pharyngeal infection

Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine
PLUS
Azithromycin 1g PO, stat

Alternative treatments are not recommended because of high levels of resistance, EXCEPT for some remote Australian locations and severe allergic reactions.

Seek local specialist advice.

Adult gonococcal conjunctivitis

Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine
PLUS
Azithromycin 1g PO, stat

 

Treatment advice

  • Reduced susceptibility to the first line treatment of IMI ceftriaxone is emerging in urban Australia.
  • Dual antibiotic treatment is recommended to create a pharmacological barrier to the development of more widespread resistance to this treatment.
  • If a patient has an intrauterine device (IUD), leave IUD in place and treat as recommended. Seek specialist advice as needed.

Other immediate management

  • Advise no sexual contact for 7 days after treatment is administered.
  • Advise no sex with partners from the last 2 months until the partners have been tested and treated if necessary.
  • Contact tracing
  • Provide patient with fact sheet
  • Notify the state/territory health department
  • Consider testing for other STIs, if not undertaken at first presentation, or retesting post the window period.

Special treatment situations

Special considerations

Consider seeking specialist advice before treating any complicated presentation.

SituationRecommended
Rectal coinfection For rectal coinfection with chlamydia, treatment should be given for gonorrhoea AND chlamydia i.e.:
Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine
PLUS
Azithromycin 1g PO, stat
AND
Doxycycline 100mg PO, BD 7 days if asymptomatic, but 21 days if symptomatic (see ano-rectal syndromes)
Pregnant women 
pregnancy
Same as principle treatment option.
Allergy to principal treatment choice

Seek specialist advice.

Regional/remote Amoxycillin 3g PO, stat
PLUS
Probenecid 1g PO, stat
PLUS
Azithromycin 1g PO, stat (when chlamydia not excluded).

If the infection is likely to have been acquired beyond local or other remote locations, use principal treatment option.

Contact tracing

  • Contact tracing for gonorrhoea is a high priority and should be performed in all patients with confirmed infection.
  • Male and female partners should be traced back for a minimum of 2 months.
  • Offer recommended treatment to all sexual contacts.

See Australasian Contact Tracing Manual – Gonorrhoea for more information.

Follow up

Review in 1 week provides an opportunity to:

  • Assess for symptom resolution
  • Confirm contact tracing has been undertaken or offer more contact tracing support
  • Provide further sexual health education and prevention counselling.

Test of Cure (TOC)

For pharyngeal, anal or cervical infection, TOC by Nucleic Acid Amplification Test (NAAT) should be performed 2 weeks after treatment is completed.

Retesting

Retest patients 3 months after exposure.

Special considerations

If TOC or retesting is positive, seek specialist advice.

Auditable outcomes

  • 100% of patients diagnosed with gonorrhoea are treated with an appropriate antibiotic regimen
  • 100% of patients are advised to avoid sexual contact for 7 days after treatment is administered.
Last Updated: Monday, 11 December 2017