Gonorrhoea

• Gonorrhoea is most commonly diagnosed in men who have sex with men, young (heterosexual) Aboriginal and Torres Strait Islander people living in remote and very remote areas, and travellers returning from high prevalence areas overseas.
• Increasing prevalence in general population, especially in women of reproductive age.
• Previous infection does not provide immunity to new infection.
• Reduced susceptibility to first-line treatment is emerging in urban Australia and is being monitored closely.

Mode of Transmission

• Primary Transmission:
  • Through unprotected vaginal, anal, or oral sexual contact with an infected person.
  • Direct inoculation of infected secretions from one mucous membrane to another.
  • Primary sites of infection: urethra, endocervix, rectum, pharynx, and conjunctiva.
• Perinatal Transmission:
  • From an infected mother to her child during childbirth, causing ophthalmia neonatorum.
• Non-Sexual Transmission:
  • Rare cases via fomites, such as contaminated towels or other objects.
  • Flies and fomites have been implicated in the spread of gonococcal conjunctivitis.
• Asymptomatic Transmission:
  • People with asymptomatic infections can still transmit the infection.

Incubation Period

• Men: Symptomatic urethral gonorrhoea: usually 2–5 days, can be 1–14 days or longer.
• Women: Urogenital gonorrhoea incubation is more uncertain due to frequent asymptomatic cases.
• Symptoms typically develop within 10 days if present.

Infectious Period

• Untreated Infection:
  • Patients are infectious from the time of exposure until the organisms are cleared.
  • Duration varies by infection site: asymptomatic rectal gonorrhoea can last up to a year; pharyngeal gonorrhoea usually clears within 12 weeks.
• Treated Infection:
  • Considered infectious until 7 days after treatment begins.

Clinical Presentation and Outcome

• General Presentation:
  • Wide range of symptoms: asymptomatic, symptomatic local infections, local complications, systemic dissemination.
  • Up to 80% of women and 10-15% of men with urogenital gonorrhoea are asymptomatic.
• Men:
  • Urethral Infection: Symptoms in 80% of cases; includes urethral discharge, dysuria, oedema, erythema of the urethral meatus.
  • Local Complications: Penile oedema, abscesses, urethral stricture, epididymo-orchitis, prostatitis, potential fertility impairment.
• Women:
  • Endocervix and/or Urethra Infection: Often asymptomatic; symptoms include vaginal discharge and dysuria.
  • Local Complications: Bartholin’s abscess, lymphangitis, ascending infections (PID, endometritis, salpingitis), potential tubal infertility.
• Other Sites:
  • Rectal Infections: Usually asymptomatic; symptoms can include pruritus, discharge, rectal pain, bleeding, or proctitis.
  • Pharyngeal Infections: Often asymptomatic; estimated 90% are asymptomatic with spontaneous cure by 12 weeks.
  • Gonococcal Conjunctivitis: Rare but urgent; symptoms range from mild to severe, potentially leading to blindness without treatment.
  • Disseminated Gonococcal Infection (DGI): Can cause arthritis, tenosynovitis, skin lesions, bacteraemia, endocarditis, meningitis.

Persons at Increased Risk

• High-Risk Groups in Australia:
  • Men who have sex with men (MSM)
  • Female partners of MSM
  • Sex workers
  • Young Aboriginal and Torres Strait Islander people in remote areas
• General Risk:
  • Any person engaging in unprotected sex with an infected individual.
  • Reinfection is possible as natural infection does not confer immunity.

Public Health Significance

• Trends in Australia:
  • Gonorrhoea notification rates increased by 110% between 2013 and 2019.
  • Higher rates in MSM, urban non-Indigenous communities, and young people (15-24 years).
  • Significant disparities in infection rates among Aboriginal and Torres Strait Islander populations, especially in remote areas.
• Challenges:
  • Increased testing and sensitive diagnostic methods contribute to higher notification rates.
  • Social disadvantage and barriers to healthcare access contribute to higher STI rates.
  • Emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of N. gonorrhoeae raises concerns about treatment challenges.

Symptoms of Gonococcal Infection

• Penile urethral discharge
• Dysuria
• Vaginal discharge
• Dyspareunia with cervicitis
• Conjunctivitis: Purulent, sight-threatening
• Anorectal symptoms: Discharge, irritation, painful defecation, disturbed bowel function

Complications

• Epididymo-orchitis (uncommon): Painful, red swollen testicle(s)
• Prostatitis (very rarely)
• Pelvic inflammatory disease (PID): Dyspareunia, intermenstrual bleeding, post-coital bleeding, discharge
• Bartholin gland abscess
• Disseminated disease (rarely):
  • Macular rash that may include necrotic pustules
  • Septic arthritis
  • Meningitis or endocarditis

Diagnosis

Specimen Collection and Testing

• First pass urine (FPU):
  • Test: NAAT
  • Consideration: For individuals without a vagina or if endocervical/vaginal swab cannot be taken. Less sensitive than self-collected vaginal swab. Collect anal and pharyngeal swab for MSM, even if asymptomatic.
• Penile urethral swab:
  • Test: Culture
  • Consideration: Required if discharge or symptoms present. Collect anal and pharyngeal swab for MSM, even if asymptomatic.
• Clinician-collected endocervical swab:
  • Test: NAAT +/- culture
  • Consideration: Best test if examined. For asymptomatic patients, NAAT is sufficient. Collect additional swab for culture if symptoms present.
• Self-collected vaginal swab:
  • Test: NAAT +/- culture
  • Consideration: Best test if not examined. For asymptomatic patients, NAAT is sufficient. Collect additional swab for culture if symptoms present.
• Anorectal swab:
  • Test: NAAT +/- culture
  • Consideration: Collect for all MSM and any patient with anorectal symptoms. For asymptomatic patients, NAAT is sufficient. Collect additional swab for culture if symptoms present.
• Pharyngeal swab:
  • Test: NAAT +/- culture
  • Consideration: Collect for all MSM and individuals with multiple sexual partners.

NAATs (Nucleic Acid Amplification Tests): Highly sensitive, allow for self-sampling, and can be used in non-clinical settings. Not validated for non-genital sites, and rarely false positives can occur. Most common test in Australia.

Gonococcal Culture: High specificity, allows for antibiotic susceptibility testing. Less sensitive than NAAT. Samples should be obtained from all infected sites before antibiotics, with rapid transport to the laboratory.

Management

Gonococcal culture samples should always be collected before antibiotics are administered, but treatment should not be delayed.

Principal Treatment Options

Uncomplicated Genital and Anorectal Infection:

• Ceftriaxone 500 mg IMI, stat. in 2 mL 1% lignocaine PLUS Azithromycin 1 g PO, stat.
• Alternative treatments: Not recommended due to high resistance levels. Seek local specialist advice.

Uncomplicated Pharyngeal Infection:

• Ceftriaxone 500 mg IMI, stat. in 2 mL 1% lignocaine PLUS Azithromycin 2 g PO, stat.
• Alternative treatments: Same considerations as above. Azithromycin 1 g followed by 1 g 6 hours later may reduce gastrointestinal side effects.

Adult Gonococcal Conjunctivitis:

• Ceftriaxone 1 g IMI, stat. in 2 mL 1% lignocaine PLUS Azithromycin 1 g PO, stat.
• Alternative treatments: Same considerations as above.

Other Immediate Management:

• No sexual contact for 7 days after treatment or until symptoms resolve.
• No sex with partners from the last 2 months until tested and treated.
• Recommend partner notification.
• Provide patient with a factsheet.
• Notify health department.
• Consider testing for other STIs, and HIV PrEP for those diagnosed with gonorrhoea.

Special Treatment Situations:

• Rectal Co-Infection: Treat for both gonorrhoea and chlamydia.
• Pregnancy: Same as principal treatment option.
• Allergy to Treatment: Seek specialist advice.
• Remote Areas: Use amoxicillin-based regimen if local strains are penicillin-susceptible.

Contact Tracing

• High priority for all confirmed cases.
• Trace partners back for a minimum of 2 months.
• The diagnosing doctor is responsible for initiating contact tracing.
• Offer testing for all exposed anatomical sites.
• Consider presumptive treatment for recent contacts.

Follow-Up

• Review in 1 week to confirm adherence, symptom resolution, and contact tracing.
• Educate on safe practices and vaccinations.
• Test of Cure (TOC): Perform 2 weeks after treatment for each site of infection.
• Re-Testing: Recommended at 3 months to detect re-infection.
• If positive, seek specialist advice.