Gonorrhoea is caused by the Gram-negative diplococcus Neisseria gonorrhoeae. The primary sites of infection are the columnar epithelium-lined mucous membranes of the urethra, endocervix, rectum, pharynx and conjunctiva.
Transmission is by direct inoculation of infected secretions from one mucous membrane to another. Secondary infection to other anatomical sites, through systemic or transluminal spread, can also occur.
Symptoms and signs of infection with gonorrhoea depend, in part, on the site of infection.
Symptoms occur in over 90% of individuals, with discharge and/or dysuria appearing two to five days following exposure. A mucopurulent urethral discharge is often present on examination. Rarely, individuals may complain of testicular and epididymal pain with tenderness and swelling present on examination.
Urethral infection may present with dysuria without urinary frequency.
The most common symptom, occurring in about 50% of individuals, is an increased or altered vaginal discharge. In about a quarter of individuals, lower abdominal pain is present. Gonorrhoea rarely causes intermenstrual bleeding and menorrhagia. On examination, a mucopurulent endocervical discharge may be seen and easily induced endocervical bleeding may be present.
Most cases are asymptomatic but symptoms may include anal discharge and perianal/ anal pain or discomfort. Rectal infection in cisgender women is present in up to a third of cases of urogenital infection, and individuals may not report a history of anal sex.
This is predominantly asymptomatic but is occasionally associated with a sore throat.
Transluminal spread of N. gonorrhoeae from the urethra or endocervix may occur and cause epididymo-orchitis, prostatitis or pelvic inflammatory disease (PID). Haematogenous dissemination may occur from infected mucous membranes to cause skin lesions, arthralgia, arthritis and tenosynovitis (disseminated gonococcal infection).
This section should be read in conjunction with Public Health England Guidance for the Detection of Gonorrhoea in England Aug 2014
The diagnosis of gonorrhoea is established by the detection of N. gonorrhoeae at an infected site, either by nucleic acid amplification tests (NAATs) or by culture. The approach and method used to test for gonorrhoea will be influenced by the clinical setting, storage and transport system to the laboratory, local prevalence of infection and the range of tests available in the laboratory. No test for gonorrhoea offers 100% sensitivity and specificity.
Microscopy of Gram-stained genital specimens allows direct visualisation of N. gonorrhoeae as monomorphic Gram-negative diplococci within polymorphonuclear leukocytes.
Female urethra and endocervix
Rectum and pharynx
Nucleic acid amplification tests
NAATs are more sensitive than culture, particularly for oropharyngeal and rectal sites.NAATs show high sensitivity (>95%) in both symptomatic and asymptomatic infection. Therefore, although NAATs are not licensed for use at extra-genital sites, their use is recommended. Commercially available NAATs differ in their cross-reactivity to commensal Neisseria species which may be present at significant levels, particularly in the pharynx.
It is recommended that laboratories confirm any reactive test with an alternative molecular target if the positive predictive value of the initial test for the population tested is less than 90% (Grade 1B)
Female urethra and endocervix
Rectum and pharynx
Considerations for people following genital reconstructive surgery (GRS)
Timing of testing
Infection cannot be ruled out in individuals who test within two weeks of sexual contact with an infected partner. Therefore, it is recommended that patients return for repeat testing after this window period if epidemiological treatment is not given (Grade 1D)
Patients should be given a detailed explanation of their condition with particular emphasis on the implications for the health of themselves and their partner(s). This should be reinforced, if necessary, with clear and accurate written information (Grade 1D). Patients should be advised to abstain from sexual intercourse until seven days after they and their partner(s) have completed treatment (Grade 1D)
Indications for therapy:
Treatment of uncomplicated ano-genital and pharyngeal infection in adults
When antimicrobial susceptibility is not known prior to treatment:
When antimicrobial susceptibility is known prior to treatment:
The prevalence of ciprofloxacin resistance in the UK is high (36.4% in 2017). Therefore, we only recommend considering ciprofloxacin as first-line treatment if phenotypic or genotypic antimicrobial susceptibility data indicates susceptibility to ciprofloxacin at all suspected sites of infection.
The move to ceftriaxone monotherapy represents a major change from the 2011 guideline. For a detailed explanation of the considerations underpinning this change, please see the full guideline. A high level of vigilance through use of culture, follow up of patients and test of cure coupled with maintenance of strong surveillance is vital in order to monitor the impact of this approach.
The following options have all been associated with treatment failure when used as monotherapy particularly when used for pharyngeal infection, therefore it is recommended to use dual therapy with azithromycin 2g where possible (Grade 2C).
Alternative regimens may be given because of allergy, needle phobia or other absolute or relative contraindications. In patients with pencillin allergy there is ample evidence to allow the safe use of all but a few early-generation cephalosporins (e.g. cephalexin, cefaclor and cefadroxil), and third-generation cephalosporins such as cefixime and ceftriaxone show negligible cross-allergy with penicillins
Treatment of complicated infections
Disseminated gonococcal infection
Therapy should continue for seven days but may be switched 24–48 hours after symptoms improve to one of the following oral regimens guided by sensitivities:
Pregnancy and breastfeeding
Pregnant and breastfeeding individuals should not be treated with quinolone or tetracycline antimicrobials. Pregnancy does not diminish treatment efficacy.
HIV-positive individuals with gonorrhoea should be managed in the same way as HIV-negative individuals.
Partner notification should be pursued in all patients identified with gonococcal infection. The following partners should be notified:
Epidemiological treatment is not needed for all sexual contacts, and ideally treatment should only be given to those partners who test positive for gonorrhoea. However, an infection may be missed if a test is performed too soon after a potential exposure. The time between exposure and a positive test result may vary depending on a number of host, pathogen and diagnostic factors. There is a lack of evidence to support recommendations for the optimal time for testing. Therefore, in order to reduce the unnecessary use of antibiotics, we recommend the following as a pragmatic approach:
Follow-up and test of cure (TOC)
All patients diagnosed with gonorrhoea should be advised to return for TOC, with extra emphasis given to patients:
A positive TOC could be due to treatment failure, reinfection or residual non-viable organism and should be interpreted in the clinical context.
Cases of possible ceftriaxone treatment failure in England should be reported to Public Health England using the on-line form: https://hivstiwebportal.phe.org.uk/login.aspx