Gonorrhoea 2025: Updated Guideline

Gonorrhoea is an infection caused by the gram-negative diplococcus Neisseria gonorrhoeae. It is the second most common bacterial sexually transmitted infection in the UK, and disproportionally affects gay, bisexual and othermen who have sex with men (GBMSM), young people aged 15–24 years, people of Black Caribbean ethnicity, and people living in deprived areas.

Clinical features are determined by the specificity of the organism for certain anatomical sites: the columnar epithelium of the mucous membranes of the urethra, endocervix, rectum, pharynx, and conjunctiva.

Transmission occurs with direct contact between a susceptible mucous membrane and an inoculum containing viable organism, predominantly through penile-vaginal, penile-anal and penile-oral sex.

Antimicrobial resistance (AMR) in N. gonorrhoeae is an urgent global concern and varies widely between countries.

Clinical features

Symptoms and signs depend, in part, on the site of infection. Co-infections are not uncommon and should be considered as a cause of symptoms.

Penile urethral infection in people assigned male at birth

Symptoms of discharge and/or dysuria occur in over 90% of individuals appearing two to five days following exposure, with mucopurulent urethral discharge present on examination. Rarely, individuals may complain of testicular and epididymal pain with tenderness and swelling present on examination.

Urethral infection in people assigned female at birth

Urethral infection may present with dysuria without urinary frequency.

Endocervical infection

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 reported. However, pelvic and lower abdominal tenderness is an uncommon examination finding in the absence of coinfection with C. trachomatis. Gonorrhoea rarely causes intermenstrual bleeding and menorrhagia.

On examination, a mucopurulent endocervical discharge may be seen and easily induced endocervical bleeding may be present.

Rectal infection

Most cases are asymptomatic, but symptoms may include anal discharge and perianal/anal pain or discomfort. Rectal infection in cis-gender women is seen with and without a recent history of anal sex and is usually associated with urogenital infection, although isolated rectal infection also occurs.

Pharyngeal infection

This is predominantly asymptomatic, but some individuals may report a sore throat.

Complications

Transluminal spread of N. gonorrhoeae from the urethra or endocervix may occur and cause epididymo-orchitis, prostatitis or pelvic inflammatory disease (PID). In a study of nearly 4000 cis-gender women attending a sexual health clinic in the UK, PID was reported in approximately 14% of those with gonorrhoea. Although gonococcal PID presents in a similar way to non-gonococcal PID, those with gonococcal PID are more often febrile and unwell.

Disseminated gonococcal infection

Haematogenous dissemination may occur from infected mucous membranes. Historically, this was estimated to occur in between 0.5% and 3% of people with gonorrhoea, with cis-gender women and those who are pregnant being at higher risk. Individuals with terminal complement deficiency or taking eculizumab (which inhibits terminal complement activation) may also be at higher risk.

Disseminated gonococcal infection (DGI) may result in severe sepsis, morbidity, and death. Two distinct clinical syndromes are classically described in DGI: a triad of tenosynovitis, polyarthralgia and dermatitis, or purulent arthritis with or without additional symptoms.

Ocular infection

Acute gonococcal conjunctivitis can occur following inoculation with infected secretions. Gonococcal conjunctivitis usually presents as unilateral or bilateral red eye(s) with purulent, often hyper-purulent discharge. N. gonorrhoeae can penetrate intact corneal epithelium: patients are at risk of rapidly progressive corneal ulceration and thinning leading to possible perforation.

Individuals 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. Individuals should be advised to abstain from sexual intercourse until 7 days after they and their partner(s) have completed treatment.

Treatment

It is recommended to confirm the presence of N. gonorrhoeae before treatment using the following indications:
· Identification of intracellular gram-negative diplococci on microscopy;
· A positive culture for N. gonorrhoeae
· A confirmed positive NAAT for N. gonorrhoeae

Treatment of uncomplicated ano-genital and pharyngeal infections in adults

· Ceftriaxone 1 g intramuscularly (IM) as a single dose (GRADE 1B)

Alternative regimens:

Alternative regimens may be given because of allergy, needle phobia or other absolute or relative contraindications. In people with penicillin allergy there is ample evidence to allow the safe use of all but a few early generation cephalosporins (e.g., cephalexin, cefaclor and cefadroxil). Third generation cephalosporins such as cefixime and ceftriaxone show negligible cross-allergy with penicillin.

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

• Cefixime 400 mg orally followed by another 400 mg dose 6–12 h later; plus azithromycin 2 g orally (which may be divided as two 1 g doses 6–12 h apart) should also be given (GRADE 1B)
• Gentamicin 240 mg IM as a single dose plus azithromycin 2 g orally (GRADE 1A)
• Azithromycin 2 g as a single oral dose (GRADE 1B)
• Ciprofloxacin 500 mg orally as a single dose (GRADE 1B)

Treatment of complicated infections:

See full guideline

Management of ceftriaxone treatment failures:

See full guideline

Test-of-cure:

Routine TOC is recommended for the following people:

(1) With persistent symptoms or signs;
(2) With pharyngeal infection;
(3) Antimicrobial susceptibility is unknown;
(4) Treated with anything other than ceftriaxone; and
(5) Who are pregnant

Tracing and treatment of contacts:

See full guideline