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Introduction

Gonorrhoea is a sexually transmitted infection, caused by Nisseria Gonorrhoae (aka Gonococcus, GC, “the clap”) – a Gram-negative intracellular diplococcus. It only infects humans, and likes moist areas, typically infecting the genitourinary tracts, retum, pharynx and conjunctiva. It is particularly intolerant to a dry environment.
It is usually spread by person to person contact, but there are occasional reports of its spread via inanimate objects (fomites). Most commonly spread by sexual transmission, but also spread via vertical transmission from mother to baby. This can result in a conjunctivitis (ophthalmia neonatum), which if untreated can result in blindness, and is an ophthalmological emergency.
  • Oral sex can result in pharyngeal infection, which can cause a sore throat and fever.
It is most commonly seen in men who have sex with men (MSM). In Australia, it is also often seen in heterosexual individuals from Aboriginal and Torres Strait Islander populations, and in those returning from overseas from high prevalence locations.
Previous infection does not provide immunity.
  • Resistance to first line treatments is starting to become a problem

Epidemiology

  • A relatively common STD, but less common than chlamydia and genital warts
  • Most commonly affects 16-24 year olds
    • This age group accounts for about 50% of new diagnoses
  • Incidence has declined in recent years

Aetiology

High number of sexual partners
Non-practice of safe sex
Sharing sex toys
Associated with other STI’s

  • 20% of affected men also have chlamydia
  • 40% of affected women also have chlamydia

Clinical features

50% of women and 10% of men are asymptomatic
It has an incubation period of 2-14 days. Most people get symptoms about 2-5 days after infection.  
Symptoms consistent with Urethritis:

  • Pain and frequency of micturition
  • Discharge – usually white and purulent

Gonorrhoea of the rectum – sometimes seen in MSM. Can vary from being symptom free, to causing a discharge of painful bloody pus from the rectum (proctitis)
Extra symptoms in women – inter-menstrual bleeding, pelvic pain (with an ascending infection)

  • The most common site of infection in women is the endocervical canal. This is the canal between the external os and the uterine cavity.
  • Sometimes it can spread to the anus from the vagina
  • Dyspareunia is common

Complications

Men – the infection can ascend the urinary tract, and cause epididymitis or prostatitis. These can be acute or chronic.

  • Proctitis in those that practice anal sex.

Women:

  • PIDcan be serious, and lead to infertility
  • Bartholin’s abscess – a tender, red, fluctuant mass, usually found in the fold between the labia majora and minora, at the 5 or 7 o’clock position. May cause severe unilateral vulvar pain.
  • Septic arthritis aka disseminated GCrare in men, but can occur in untreated women. Tend to be mono- or olioarthritis and asymmetrical. This is associated with a papular or pustular rash, and sometimes fever and malaise.
  • Fitz-hugh-Curtis Syndrome – Periphepatitisrare – can be caused by chlamydia or gonorrhoea, and is the result of infection of the Glisson’s capsule tissue , which surround the liver. This tissue becomes scarred, and will cause acute onset URQ pain and tenderness. Symptoms will be aggravated by coughing, laughing or heavy breathing. Sometimes pain is referred to the right shoulder tip. Laparoscopy may show violin string tip adhesions, which can be removed surgically.

Diagnosis

Testing can either be performed by swab for culture, or swab for NAAT (nucleic acid amplification testing – I.e. PCR)

Smear testing – a swab from the urethra, cervix, throat or rectum can be used for diagnosis.

  • Culture – The sample is cultured with a sensitivity of 95%.
  • Microscopy:
    • Men – Urethral Sampling – is 90% sensitive
    • Women – Endocervical sampling – only 50% sensitive
  • Taking a swab sample in women – when testing for gonorrhoea, you should use the standard swab (looks like a big cotton wool bud), and, whilst using a speculum, swab where there is most discharge. This is usually on the posterior surface of the vagina.

Nucleic acid amplification testing – (NAAT’s) this uses a urine sample, and is highly sensitive

  • NAAT is not validated for non-genital sites, although is often used for this purpose
  • False positives are possible
  • Culture has the added benefit of testing sensitivities
  • If culture not collected at time of diagnosis, collect at time of treatment to determine anti tic susceptibility

Blood culture, and joint aspiration – should be performed if disseminated GC is suspected
Tests for other common STD’s should be performed in light of a positive diagnosis of GC – e.g. syphilis, chlamydia and trichomonas.

Recommended testing methods
Men
  • First pass urine for NAAT is recommended in most cases for men
    • If there is penile or ano-rectal discharge, collect a swab for culture
    • In MSM it is routine practice to collect NAAT for first pass urine, as well as swabs for culture from the anus and throat – even if they are symptomatic at these sites
  • Ano-rectal swab for either culture or NAAT in symptomatic (ano-rectal symptoms) patients

Women

  • Endocervical swab for NAAT and / or culture if symptomatic discharge
  • Self-collected low vaginal swab is sufficient if asymptomatic and for screening purposes
  • First pass urine is much less reliable in women and only recommended if swab cannot be taken
  • Pharyngeal swab if history of oral sex (can be NAAT or culture)
  • Ano-rectal swab if history of anal sex (can be NAAT or culture)

Treatment

Should be given to anyone with a positive test for GC. It may also be given to anyone who has had close sexual contact with the patient, via contract tracing. It can usually be treated with a single dose of AB’s:

Agents – about 10% of GC is resistant to penicillin and ciprofloxacin, and about 40% is resistant to tetracyclines.

As a result of increasing resistance, dual therapy is now usually recommended, with azithromycin and ceftriaxone. Anogenital infection and conjunctivitis

  • Ceftriaxone 500mg IM STAT
    • Usually given 2mls in 1% lignocaine
  • PLUS
  • Azithromycin 1g PO stat

Pharyngeal infection

As above, but the dose of azithromycin is doubled:

  • Ceftriaxone 500mg IM STAT
    • Usually given 2mls in 1% lignocaine
  • PLUS
  • Azithromycin 2g PO stat

In areas where resistance is low you could consider the following (in Australia, this only applies to some remote locations or in cases of severe allergic reactions):

  • single dose amoxicillin (1g) + probenecid (1g) OR
  • Ciprofloxacin (500mg) OR
  • Ofloxacin (400mg)
Complicated and disseminated cases will require longer courses of treatment. The patient should be followed up 72 hours after treatment to check efficacy.

Advice to patients
  • Advise no sexual contact for 7 days after treatment
  • Advise no sex with partners from the last 6 months until partners have been tested (and treated if required)
  • Advise about contact tracing
    • Trace partners for the last 6 months
    • Offer treatment to all sexual contacts
  • Provide written information factsheet
  • In Australia – notify the state or territory health department (notifiable disease)

Follow-up

Advised at one week and again at 3 months.

Follow-up at one week to ensure:

  • Compliance
  • Partner tracing has occurred, or offer support for this

Test of cure (TOC) is recommended for some groups (including for most cases in women):

  • Cervical infection
  • Pharyngeal infection

Perform repeat NAAT testing 2 weeks after finishing treatment if indicated

  • If TOC is positive – seek specialist advice
Re-infection is common. Some centres suggest re-testing all patients at 3 months to rule out re-infection.

Screening

  • Although not an official ‘screening’ program, the NHS promotes free chlamydia and gonorrhoea testing in the R U Clear campaign.
    • Eligible to under 25’s
    • Text (SMS) details to the service, and they send out a pack in the post
    • ‘Pee in the pot’ and send it back
    • Results sent out via SMS text messaging
  • Although urethral swab (men) and endocervical swab (women) is the best way of detecting chlamydia, the urine test is deemed accurate enough in an environment of such high prevalence of STD.
  • In Australia:
    • It is recommended to screen all sexually active people aged 15-29 annually for chlamydia (+/- gonorrhea)
    • There is no ‘official’ screening programme – instead it is recommended that health professionals (especially GPs) opportunistically offer screening to those aged 15-29 when they present for whatever reason

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
  • Australian STI guidelines - Gonorrohea

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