2.5.1 Gonorrhoea

Grading & Level of Importance: A




Blenorrhoea; Tripper.


After chlamydial urethritis, the second most common bacterial sexually transmitted infection. In many European countries incidence is increasing especially among young adults and men having sex with men.


Uro-genital, ano-rectal or oral infection by Neisseria gonorrheae; rarely systemic infection (disseminated gonorrhea).

Aetiology & Pathogenesis

Gram-negative bacterium Neisseria gonorrhoeae. Incubation period 4-7 days, may be as short as 24 hours. Transmission by infected secretions during genital, ano-rectal or oral sex. Co-infection with Chlamydia trachomatis is detected in 10-40% of the cases. Perinatal gonococcal infection can cause neonatal conjunctivitis (ophthalmia neonatorum).

Signs & Symptoms

Infection of columnar epithelium of urethra, endocervix, rectum, pharynx and conjunctivae. Typical manifestation in men: acute urethritis with urethral discharge, pain on urination and dysuria. Generally asymptomatic in women; sometimes abnormal vaginal discharge, dysuria, and lower abdominal pain. Rectal infections often asymptomatic, but can cause rectal and anal pain or discharge. Pharyngeal gonorrhea is mainly asymptomatic, but sore throat and pharyngitis can occur.


See symptoms


Acute and chronic course; localized and disseminated infection.

Laboratory & other workups

Direct microscopy of smear (intracellular diplococci). Further investigation by nucleic acid amplification tests (NAATs) and culture. NAATs are highly sensitive and specific tests that can detect N. gonorrhoeae in first void urine and urethral, cervical, pharyngeal and rectal swab. Appropriate tests should be directed by the locations of sexual activity. NAATs cannot provide information on antimicrobial susceptibility. Thus, specimens should be collected also for culture and antimicrobial susceptibility testing.


Not necessary.


Acute or chronic course; beware of resistant strains.


Untreated infection in women can cause pelvic inflammatory disease. In men epididymo-orchitis and prostatitis. Rarely bacteremia with fever, arthritis, peri-hepatitis (Fitz-Hugh-Curtis syndrome) and skin lesions (disseminated gonococcal infection).


Diagnosis is based on clinical features and microbiological confirmation.

Differential diagnosis

Chlamydial and other microbial urethritis/vaginitis causes. Herpes simplex meatitis.

Prevention & Therapy

Empirical first-line dual therapy with ceftriaxone 500 mg intramuscularly (i.m.) together with azithromycin 2 g as a single oral dose. Fluoroquinolones (ciprofloxacin 500 mg as a single oral dose) can be used only if resistance is excluded by susceptibility testing. Test of cure (TOC) to identify persisting infection and emerging resistance >2 weeks after the treatment.


Tests for other STIs, like chlamydial urethritis, syphilis and HIV should are strongly recommended. Evaluation of sex partners within the preceding two months and offer them testing and treatment. Infection report according to the national communicable disease legislation.

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