The information below is based on British Association for Sexual Health & HIV (BASHH) Guidelines: Gonorrhoea (updated January 2019).

Uncomplicated gonorrhoea is most common in young adults aged 15-24-year olds. Complications of infection include epididymo-orchitis, prostatitis, urethral stricture, pelvic inflammatory disease (PID), tubal infertility, ectopic pregnancy, and chronic pelvic pain.

Partner notification should be pursued in all patients identified with gonococcal infection. Notified partners should be offered testing and current or recent partners (within the past 14 days) considered for empirical treatment.

If gonorrhoea infection is suspected or confirmed, strongly recommend referral to a Genito-Urinary Medicine (GUM) clinic or other local specialist sexual health service for management and to facilitate screening for infections and for contact tracing.

• Devon Sexual Health (Barnstaple, Exeter, and Torbay) (electronic referral system available)
  • A patient can self-refer by phoning 0300 303 3989 for a consultation within 24 hours. Please give relevant treatment information to the patient to bring to clinics, i.e. results of previous cultures and any treatments.
• SHiP (Sexual Health in Plymouth)

If the person declines, or is unable to attend a GUM clinic, manage in primary care.

All patients, including sexual partners, should be advised to abstain from sex until 7 days after completion of antibiotic treatment

Arrange a dual test for Neisseria gonorrhoeae and Chlamydia trachomatis (Gonorrhoea must be specifically requested for the laboratory to test):

• in women, a vulvovaginal swab should be used
• in men, a first pass urine specimen should be used, and additionally rectal and pharyngeal sampling should be routine in all men who have sex with men

It is also recommended to offer blood tests for HIV and syphilis if testing for gonorrhoea and chlamydia.

Signs and Symptoms

Symptoms and signs of infection with gonorrhoea depend, in part, on the site of infection

Signs and symptoms of gonorrhoea in men:

• Genital gonorrhoea
  • Urethral discharge
• Rectal gonorrhoea
  • Anal discharge
  • Perianal/ anal pain or discomfort
• Pharyngeal gonorrhoea
  • Usually asymptomatic
  • Pharyngitis

Signs and symptoms of gonorrhoea in women:

• Urogenital gonorrhoea
  • Increased or altered vaginal discharge
  • Lower abdominal pain
  • Dysuria
  • Intermenstrual bleeding and menorrhagia
  • Dyspareunia
  • On examination, a mucopurulent endocervical discharge may be seen and easily induced endocervical bleeding
• Rectal gonorrhoea
  • Anal discharge
  • Perianal/ anal pain or discomfort
• Pharyngeal gonorrhoea
  • Usually asymptomatic
  • Pharyngitis

Other symptoms may be caused by complications of gonorrhoea infection, including prostatitis, epididymitis and orchitis, and pelvic inflammatory disease and rarely disseminated gonococcal infection (skin lesions, arthralgia, arthritis and tenosynovitis)

Recommended antibiotic treatment

Uncomplicated anogenital and pharyngeal infection

Promptly refer patient to a sexual health clinic for 1st line treatment with Intramuscular (IM) Ceftriaxone or consider administration in primary care if appropriate to do so.

All individuals with gonorrhoea diagnosed by laboratory tests should have cultures taken for susceptibility testing prior to antibiotic treatment. Cultures should be taken from all anatomical sites that have tested positive for gonorrhoea.

Ceftriaxone IM*

• 1g intramuscularly as a single dose (off-label dose)
• Do not delay treatment whilst awaiting culture result

See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams

If the person declines, or is unable to attend a GUM clinic, and is unsuitable for administration of IM Ceftriaxone in primary care oral antibiotic alternatives may be considered, but only after sensitivities are known, and after advice has been sought from GUM clinics.

Oral regimens 

When antimicrobial susceptibility is known prior to treatment

Cefixime*

• 400mg orally as a single dose (off-label indication)

See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams

PLUS

Azithromycin

• 2g orally as a single dose (off-label dose) (prescribe as 4 x 500mg tablets)

*Ceftriaxone and cefixime are suitable treatment options in penicillin-allergic patients, unless there is a history of severe hypersensitivity (e.g. anaphylactic reaction) to any beta-lactam antibacterial agent (penicillins, cephalosporins, monobactams, and carbapenems).

See section: 5.1.5 Macrolides

Alternative oral regimens: If the above treatments have failed, will not work due to resistance, or are unsafe to use in an individual patient.

When antimicrobial susceptibility is known prior to treatment

Ciprofloxacin (monotherapy)

• 500mg orally as a single dose
• Systemic fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate (see MHRA Drug Safety Updates below)
• Patients should be advised to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint, feet, or abdomen swelling, peripheral neuropathy, rapid onset of shortness of breath, new-onset of heart palpitations, and central nervous system effects: including new or worsening depression or psychosis, and to seek immediate medical attention.

Drug Safety Updates for Ciprofloxacin (refer to 5.1.12 Quinolones for further details).

• MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients.
• MHRA Drug Safety Update (December 2020): Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk.
• MHRA Drug Safety Update (September 2023): Fluoroquinolone antibiotics: suicidal thoughts and behaviour.
• MHRA Drug Safety Update (January 2024): Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate.

Complicated infections and pregnancy

If gonorrhoea infection is complicated (i.e. conjunctival), or if infection is suspected or confirmed in pregnancy, refer to a Genito-Urinary Medicine (GUM) clinic for management, see contact details above.

Test of Cure (TOC)

All patients diagnosed with gonorrhoea should be advised to return for TOC.

• If the person is asymptomatic, swab and send to laboratory for testing, from all originally positive sites (followed by culture if positive), 3 weeks after completion of treatment
• If signs or symptoms persist, test with culture, performed at least 3 days after completion of treatment