2.5.1 Gonorrhoea

Blennorrhagia; gonococcal infection.

After chlamydial urethritis, gonorrhoea is the second most common bacterial sexually transmitted infection. The World Health Organization estimates that in 2020, 82 million new cases occurred among adolescents and adults aged 15-49 years worldwide. In Europe in 2020, 92,969 gonorrhea cases were reported in 28 countries. The notification rate was 25 cases per 100,000 population. In many European countries, the incidence of gonorrhoea is increasing especially among young adults and men having sex with men.

Gonorrhoea is caused by the Gram-negative diplococcus bacterium Neisseria gonorrhoeae. The incubation period is usually 2-7 days, but may be as short as 24 hours. Transmission happens by infected secretions during genital, anorectal or oral sex. Autoinoculation from the anogenital area can cause conjunctivitis. Mothers with gonococcal infection can infect the infant at delivery causing neonatal conjunctivitis with purulent ocular discharge and swollen eyelids (ophtalmia neonatorum). Co-infection with Chlamydia trachomatis is detected in 10-40% of the cases.

Gonorrhoea infection involves the columnar epithelium of urethra, endocervix, rectum, pharynx and conjunctivae.

• Typical manifestations of gonococcal infection in men include acute urethritis with symptoms of urethral discharge, pain on urination and dysuria. The clinical signs are mucopurulent urethral discharge, meatal edema and balanoposthitis.

• Gonorrhoea is generally asymptomatic in women. The typical complaints include abnormal vaginal discharge, dysuria, and lower abdominal pain. In clinical examination vaginal discharge and mucopurulent cervicitis can be detected.

• Rectal infections in men and women are often asymptomatic, but can cause rectal and anal pain or discharge.

• Pharyngeal gonorrhoea is mainly asymptomatic, but patient might complain of a sore throat and pharyngitis.

Classification is usually based on either the disease course (acute and chronic) or disease localization (localized, i.e. urogenital, anorectal or oral infection; or disseminated infection).

N. gonorrhoeae can be detected by nucleic acid amplification tests (NAATs) and/or culture.

NAATs are highly sensitive and specific tests that can detect N. gonorrhoeae in first void urine and urethral, vulval, cervical, pharyngeal and rectal swab. Tests should be taken as directed by sexual practices.

Samples can be either clinician-collected or self-collected. NAATs are less demanding in transport and storage than culture. In diagnosing genital gonorrhoea, first-void urine is an optimal specimen type for men, but in women a swab from the vagina (self-collected vulvo-vaginal specimen) or endocervix is more sensitive. Current commercial NAATs cannot provide information on antimicrobial susceptibility. Thus, specimens should be collected also for culture and antimicrobial susceptibility testing.

In symptomatic men with urethritis, diplococci within polymorphonuclear leukocytes can be detected in Gram-stained smears of discharge in microscopy.

The symptoms may occur acutely or the infection may follow a chronic (in women often asymptomatic) chronic course. N. gonorrhoeae has shown a notable capacity to develop resistances to multiple classes of antibiotics. Be aware of resistant strains.

• Untreated infection can ascend in women to the upper genital tract causing serious complications and sequelae such as pelvic inflammatory disease (PID), including endometritis, salpingitis and tubo-ovarian abscess, which can lead to ectopic pregnancy and infertility.

• In men it can cause epididymo-orchitis and prostatitis.

• Gonorrhoea can rarely disseminate as bacteremia with fever, arthritis, perihepatitis (Fitz-Hugh- Curtis syndrome), tenosynovitis and skin lesions (disseminated gonococcal infection, DGI).

Gonorrhoea cannot be distinguished clinically from chlamydia or other possible causes of urethritis and cervicitis like Mycoplasma genitalium, or Trichomonas vaginalis. Herpes simplex virus infection can cause dysuria and meatitis.

Transmission can be prevented by barrier contraception.

The treatment of gonococcal infections is challenging due to the rapidly changing antimicrobial susceptibility patterns of N. gonorrhoeae. There are concerns worldwide about the eventual development of untreatable gonococcal infections. In the past, N. gonorrhoeae has developed resistance to several antibiotics (penicillins, tetracyclins, macrolides and fluoroquinolones). Current European guideline recommends empirical first-line dual therapy with ceftriaxone 1 g intramuscularly (i.m.) together with azithromycin 2 g as a single oral dose. However, many countries have abandoned azithromycin due to the increase in macrolide resistance. Fluoroquinolones (ciprofloxacin 500 mg as a single oral dose) can be used only if the resistance is excluded by susceptibility testing. Patients with penicillin anaphylaxis or cephalosporin allergy can be treated with spectinomycin 2 g i.m. together with azithromycin 2 g orally.

Patients are advised to abstain from all sexual contact for seven days after the completion of their treatment. All sex partners within the preceding 60 days should be evaluated. The test of cure (TOC) is recommended to identify persisting infection and emerging resistance >2 weeks after the treatment.

Tests for other STIs, like chlamydial urethritis, syphilis and HIV should be strongly recommended. Written information about the gonorrhea infection should be provided. Test-of-cure > 2 weeks after completion of treatment is recommended routinely for all patients. In order to control the spread of the infection, it is important to evaluate the sex partners of the patient within the preceding two months and offer them testing and treatment.

All gonorrhea cases should be reported according to the local communicable disease legislation.