Pathophysiology & Classification
Causative Agent
Neisseria gonorrhoeae - Gram-negative diplococcus bacterium transmitted through direct inoculation of secretions between mucous membranes during sexual contact.
Uncomplicated Gonorrhoea
- Localised infection
- Affects mucous membranes:
- - Urethra
- - Endocervix
- - Rectum
- - Pharynx
- - Conjunctiva
- Most common in ages 15-24
Disseminated Gonorrhoea
- Uncommon but serious
- Systemic spread
- Petechial/pustular skin lesions
- Asymmetrical arthralgia
- Tenosynovitis
- Septic arthritis
- Rare: meningitis, endocarditis
Epidemiology
Highest incidence: Young adults aged 15-24 years. Increasing antimicrobial resistance globally makes appropriate testing and treatment crucial.
Clinical Features
Presentation in Men
Genital Infection
- Usually symptomatic
- Mucopurulent/purulent urethral discharge (>80%)
- Dysuria (>50%)
- Symptoms appear within 2-5 days
- No effect on urinary frequency/urgency
Extra-genital Sites
- Rectal infection:
- - Usually asymptomatic
- - Anal discharge (12%)
- - Acute proctitis
- - Perianal pain (7%)
- - Tenesmus, rectal bleeding
Other Manifestations
- Pharyngeal infection:
- - Asymptomatic (>90%)
- - Tonsillitis/pharyngitis
- Complications:
- - Prostatitis
- - Epididymitis
- - Orchitis
Presentation in Women
Urogenital Symptoms
- Asymptomatic in up to 50%
- Symptoms develop within 10 days
- Increased/altered vaginal discharge (50%)
- Lower abdominal pain (25%)
- Dysuria (12%)
- Intermenstrual bleeding (rare)
- Dyspareunia
Examination Findings
- Often normal examination
- Mucopurulent endocervical discharge (<50%)
- Easily induced endocervical bleeding
- Pelvic/abdominal tenderness (<5%)
- Pharyngeal infection:
- - Asymptomatic (90%)
- - Tonsillitis/pharyngitis
Diagnosis
Referral Recommendation
Ideally refer all suspected cases to genito-urinary medicine (GUM) clinic or specialist sexual health service for confirmation and management.
Testing Strategy
Nucleic Acid Amplification Test (NAAT)
- First-line diagnostic test
- Women: Vulvovaginal swab (self-taken acceptable)
- Men: First-pass urine specimen
- Follow local protocols if GUM referral declined
Culture & Sensitivity
- Essential for all NAAT-positive cases
- Required before antibiotic prescription
- Tests antimicrobial susceptibility
- Identifies resistant strains
- Guides appropriate treatment
Site-Specific Testing
- Pharyngeal and rectal sites should be tested in individuals reporting relevant sexual practices
- Extra-genital sites may be asymptomatic but still infectious
- Multi-site testing increases detection rates
Management
First-line Treatment Protocol
Known Susceptibility
- Ciprofloxacin 500mg
- Oral single dose
- Only if susceptibility confirmed
Unknown Susceptibility
- Ceftriaxone 1g IM
- Single intramuscular injection
- Current first-line recommendation
Alternative Regimens
For Allergies/Contraindications
- Option 1: Gentamicin 240mg IM single dose PLUS Azithromycin 2g oral single dose
- Option 2: Cefixime 400mg oral single dose PLUS Azithromycin 2g oral single dose
- Monitor local resistance patterns regularly
- Consider needle phobia, allergies, other contraindications
Essential Adjuncts to Treatment
| Intervention | Details |
|---|---|
| Sexual Abstinence | Until patient and all partners complete treatment |
| STI Screening | Screen for other STIs including HIV |
| Partner Notification | Encourage patient-led notification of all partners |
| Health Education | Provide appropriate information and advice |
| Test of Cure | Required for all treated cases at 1-week follow-up |
Special Populations
- Children & Young People: Consider possibility of sexual abuse
- Pregnancy: Requires specialist management
- HIV Co-infection: Coordinate care with HIV team
Complications
Complications in Men
Local Complications
- Epididymitis
- Orchitis
- Prostatitis
- Urethral stricture
- Infertility
Glandular Infections
- Infection of Mullerian glands
- Infection of Cowper glands
- Local abscess formation
- Chronic pain syndromes
Complications in Women
Pelvic Inflammatory Disease
- Occurs in up to 33% of women
- Chronic pelvic pain
- Tubal infertility
- Ectopic pregnancy risk
- Long-term reproductive morbidity
Other Complications
- Peritoneal spread
- Perihepatic abscesses (Fitz-Hugh-Curtis)
- Pregnancy complications
- Congenital infections
Systemic Complications
Disseminated Gonococcal Infection
- Uncommon but serious
- Petechial or pustular skin lesions
- Asymmetrical arthralgia
- Arthritis and tenosynovitis
- Rare: meningitis, endocarditis
- Requires hospital admission and IV antibiotics
Pregnancy Implications
- Associated with miscarriage
- Increased risk of fetal loss
- Congenital infections in newborn
- Ophthalmia neonatorum risk
- Requires prompt treatment and follow-up
Prevention & Public Health
Primary Prevention
- Consistent condom use
- Sexual health education
- Regular STI screening
- Partner communication
- Reducing number of sexual partners
Secondary Prevention
- Prompt diagnosis and treatment
- Effective partner notification
- Test of cure verification
- Re-screening after treatment
- Contact tracing
Antimicrobial Stewardship
- Culture before treatment when possible
- Follow current guidelines
- Monitor resistance patterns
- Appropriate test of cure
- Report treatment failures
Public Health Responsibilities
- Report cases to public health authorities
- Participate in surveillance programs
- Educate about rising antimicrobial resistance
- Support sexual health services
- Promote accessible testing