Gonorrhoea
NICE CKS Gonorrhoea. Last revised Mar 2024.
BASHH Gonorrhoea 2025: Updated Guideline. Last updated Apr 2025.
Background Information
Aetiology
Gonorrhoea is an STI caused by the Gram -ve bacterium Neisseria gonorrhoea
Epidemiology
Gonorrhoea is the 2nd most common bacterial STI worldwide (after chlamydia).
Clinical Features
Genital Infection
Gonorrhoea is symptomatic in most men (>90%) and ~50% of women
| Men |
|
| Women |
Gonorrhoea rarely causes intermenstrual bleeding and menorrhagia (more commonly seen in chlamydia) |
Extra-Genital Infection (Less Common)
| Rectal gonorrhoea | Usually asymptomatic
|
| Gonococcal conjunctivitis | Unilateral or bilateral red eye(s) with purulent, often hyper-purulent discharge
The bacteria can penetrate intact corneal epithelium – patients are at risk of rapidly progressive corneal ulceration and thinning, leading to possible perforation. |
| Oropharyngeal infection | Usually asymptomaticIf symptomatic: pharyngitis and sore throat |
Complications
Possible complications in men:
- Epididymo-orchitis (see the Epididymo-Orchitis article)
- Prostatitis (see the Prostatitis article)
- Urethral stricture
Possible complications in women:
- PID (see the Pelvic Inflammatory Disease (PID))
- Pregnancy complications
- Miscarriage, premature labour, early rupture of fetal membranes
- Perinatal mortality
- Gonococcal conjunctivitis in the newborn
Disseminated gonorrhoea is a potentially serious complication that is thought to occur in 0.5–3% of untreated gonorrhoea cases.
- Classic triad of 1) tenosynovitis 2) migratory polyarthralgia 3) dermatitis (petechial / pustular skin lesion)
- Rarely endocarditis, or meningitis
Diagnosis
Gonorrhoea Testing
Test of choice: NAAT
Sample collection methods:
- Male: first pass urine (alternative: urethral swab)
- Female: vulvovaginal swab (alternative: endocervical swab or first pass urine)
If MSM → also take rectal and pharyngeal samples
Other tests:
| Test | Description |
|---|---|
| Culture | Should be obtained simultaneously with NAAT and BEFORE starting treatment
For drug susceptibility testing |
| Urethral swab | For quick diagnosis in the presence of penile urethral discharge
Interpretation:
|
Management
Refer ALL patients to GUM clinic / local specialist for management.
General Advice
Abstain from all sexual activity until 7 days after they and their partner(s) have completed treatment
Pharmacological Management
Take swabs for culture BEFORE starting treatment, and initiate empirical treatment immediately without awaiting susceptibility result:
- 1st line: ceftriaxone 1g IM single dose
- 2nd line:
- Needle-sparing option (e.g. if needle phobia) → cefixime 400mg PO (2 doses 6-12 hours apart) + azithromycin 2g PO
- BASHH recommends only using this regimen if antimicrobial susceptibility results are available
- Penicillin-sparing option → gentamicin 200mg IM + azithromycin 2g PO
- Needle-sparing option (e.g. if needle phobia) → cefixime 400mg PO (2 doses 6-12 hours apart) + azithromycin 2g PO
Partner Notification and Sexual Contacts Management
Partner Notification
Partner notification period:
- If symptomatic men → notify all partners within the past 2 weeks (or most recent partner if more than 2 weeks ago)
- If all other patients (i.e. asymptomatic men and women) → notify all partners within the past 12 weeks (3 months)
The partner notification period for gonorrhoea is 1/2 that of chlamydia
In chlamydia:
- Symptomatic men → 4 week lookback (vs 2 weeks in gonorrhoea)
- All other patients (i.e. asymptomatic men and women) → 6-month lookback (vs 3 months in gonorrhoea)
Sexual Contacts Management
All sexual contacts should be tested:
- Empirical treatment is NOT needed routinely for all sexual contacts:
- Principle: only offer empirical treatment to those who test +ve for gonorrhoea
- If present within 2 weeks of exposure → repeat testing after 2 weeks
Follow Up
Offer test of cure using NAAT to all patients at least 2 weeks after treatment completion
- If treated with ceftriaxone + susceptible to ceftriaxone, there is no need for test of cure
At follow-up also check:
- If symptoms resolved or not
- Adherence
- Any adverse reactions
- Confirm partner notification has been carried out
- Ask about recent sexual history
- Reinforce advice on safe sexual practice
Note the window period of gonorrhoea testing is 2 weeks, meaning false -ve is possible if tested within this period. Therefore, the test of cure should be performed ≥2 weeks after completion of treatment.
References