Gonorrhoea: symptoms, diagnosis and effective treatment

What is gonorrhoea and why does it need urgent treatment?

Gonorrhoea (gonococcal infection) is an infectious disease transmitted mainly through sexual contact and caused by the Gram-negative diplococcus Neisseria gonorrhoeae (the gonococcus). According to WHO data, more than 82 million new cases of gonorrhoea are recorded worldwide each year among people aged 15–49, making it the second most common bacterial STI after chlamydia. In Ukraine gonorrhoea remains a serious public health problem, particularly among young people aged 18–30, with a rising trend in antibiotic-resistant strains. The gonococcus infects the columnar epithelium of the urogenital organs, and also the mucous membranes of the rectum, the oropharynx and the conjunctiva. The main danger of gonorrhoea lies in its capacity to cause serious complications when treatment is delayed: pelvic inflammatory disease, infertility, ectopic pregnancy and disseminated gonococcal infection. Up to 50% of women and up to 10% of men with gonorrhoea have no marked symptoms, which allows the infection to spread unchecked. The global trend towards multidrug resistance is particularly worrying — WHO has included N. gonorrhoeae in its list of priority pathogens with high levels of antibiotic resistance.

Clinical features in men and women

The clinical picture differs substantially according to sex, the site of infection and how long the disease has been present:

• Gonorrhoea in men: the incubation period is 2–5 days. The classic picture of acute gonococcal urethritis includes profuse yellow-green purulent discharge from the penis, stinging and burning on urination (dysuria), and redness and swelling of the urethral opening. The discharge appears in the morning — the so-called "morning drop". Untreated, the infection spreads to the posterior urethra, the prostate (gonococcal prostatitis) and the epididymis (epididymitis), which can lead to urethral stricture and infertility.
• Gonorrhoea in women: is asymptomatic or has few symptoms in 50–80% of cases, which makes timely diagnosis considerably harder. Where symptoms do occur there is mucopurulent vaginal discharge, dysuria, bleeding between periods and lower abdominal pain. Gonococcal cervicitis is the most common form; where the infection ascends, endometritis, salpingitis and tubo-ovarian abscess develop — pelvic inflammatory disease (PID), which is the leading cause of tubal infertility and ectopic pregnancy.
• Extragenital forms: gonococcal pharyngitis is usually asymptomatic or causes a sore throat and follows oro-genital contact (found in 5–10% of heterosexual patients and up to 25% of men who have sex with men). Gonococcal proctitis causes rectal pain, purulent discharge and tenesmus; it is more common in men who have sex with men and in women after anal contact. Gonococcal conjunctivitis (ophthalmia) is rare in adults, but in newborns of infected mothers without prophylaxis it can cause severe corneal damage and blindness.
• Complications and the disseminated form: disseminated gonococcal infection (DGI) develops in 0.5–3% of untreated patients when the organism spreads through the bloodstream. It presents as a triad: migratory polyarthritis or septic monoarthritis (usually the knee or wrist), dermatitis (haemorrhagic pustules on the limbs) and tenosynovitis. More rarely there is endocarditis, meningitis or hepatitis. Fitz-Hugh–Curtis syndrome is perihepatitis complicating ascending gonorrhoea in women, presenting with acute pain in the right upper abdomen that mimics gallstone disease.

Diagnosis: laboratory confirmation

Diagnosis rests on detecting the organism or its genetic material, since the clinical picture is often non-specific. Nucleic acid amplification testing (NAAT/PCR) is the gold standard: it detects N. gonorrhoeae DNA in samples from the urethra, cervical canal, oropharynx and rectum with a sensitivity of 95–100% and specificity above 99%. It allows simultaneous testing for chlamydia. It is suitable for screening people without symptoms and for testing urine samples (non-invasive collection). Microscopy of a Gram-stained smear detects Gram-negative intracellular diplococci. It has high sensitivity (over 95%) in symptomatic urethritis in men, but much lower sensitivity (30–50%) in cervicitis in women and in extragenital infection. It remains valuable as a rapid preliminary test. Culture is necessary to determine antibiotic sensitivity, which is critical given the rising resistance of the gonococcus. It is recommended by CDC and WHO where treatment fails, where resistance is suspected and for epidemiological monitoring. It requires special transport conditions and chocolate agar. Routine screening for gonorrhoea is recommended for sexually active women under 25, for men who have sex with men and for people with multiple sexual partners.

Treatment: current antibiotic therapy

Treatment requires strict adherence to current protocols because of the global problem of gonococcal antibiotic resistance. Uncomplicated urogenital, anorectal and pharyngeal gonorrhoea: the recommended first-line regimen is ceftriaxone 500 mg (1 g where body weight is 150 kg or more) intramuscularly as a single dose. If chlamydia has not been excluded — azithromycin 1 g orally as a single dose, or doxycycline 100 mg twice a day for 7 days, in addition. Where there is allergy to cephalosporins — gentamicin 240 mg intramuscularly plus azithromycin 2 g orally as a single dose. Complicated gonorrhoea (PID, epididymitis): ceftriaxone 1 g intravenously or intramuscularly daily for 7–14 days plus doxycycline 100 mg twice a day for 14 days (± metronidazole 500 mg twice a day for 14 days in PID). Disseminated gonococcal infection: ceftriaxone 1 g intravenously every 24 hours until clinical improvement (usually 24–48 hours), then switching to oral cefixime 400 mg twice a day to complete a 7-day course. Checking that treatment has worked: a test of cure (PCR or culture) is recommended 7–14 days after treatment ends, and is essential in pharyngeal gonorrhoea and where alternative regimens have been used.

Prevention and avoiding re-infection

Prevention and avoiding re-infection are an integral part of managing patients. Barrier contraception — consistent and correct use of condoms (male or female) during vaginal, anal and oral sex substantially reduces the risk of transmission. Condoms are effective only when used consistently — occasional use gives minimal protection. Testing and treating sexual partners — all sexual partners from the past 60 days should be tested and treated, even if they have no symptoms. Where they cannot be examined — expedited partner therapy: providing a prescription or medication for the partner without a face-to-face consultation. Abstaining from sexual contact for 7 days after both partners have completed treatment is essential to prevent re-infection. Screening for other STIs — gonorrhoea often coexists with chlamydia (co-infection in up to 40%), so simultaneous testing for C. trachomatis, syphilis and HIV is recommended. Repeat testing 3 months after treatment is recommended by CDC for all treated patients because of the high risk of re-infection (up to 15–20% within a year). No vaccine against gonorrhoea is currently available, although studies of the meningococcal vaccine MeNZB have shown cross-protection of 30–40%, which is driving the development of specific gonococcal vaccines. Reducing the number of sexual partners and avoiding anonymous contacts lower the risk of infection.

When to seek help immediately

See a dermatovenerologist or urologist if purulent discharge from the genital tract, stinging on urination or lower abdominal pain appears — early diagnosis and treatment prevent serious complications. Immediate assessment is needed for a high temperature, severe joint pain or a rash on the skin of the limbs — these symptoms may indicate disseminated gonococcal infection, which requires hospital treatment. Seek help urgently if symptoms do not resolve or return after a course of antibiotics — this may indicate antibiotic resistance, which calls for culture with sensitivity testing. Women with lower abdominal pain, fever and abnormal discharge need an emergency gynaecological consultation to exclude PID — delaying treatment increases the risk of infertility. Pregnant women should be tested for gonorrhoea at the first antenatal visit and again in the third trimester if risk factors are present — gonorrhoea can cause premature labour and ophthalmia in the newborn. Remember: gonorrhoea is completely curable with the right treatment, but self-treatment is unacceptable because of the risk of creating antibiotic resistance and of the infection becoming chronic.