Gonorrhoea: comprehensive diagnosis, treatment and prevention
Gonorrhoea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus that infects columnar epithelium of the urethra, cervix, rectum, pharynx and conjunctiva. It may be asymptomatic—especially in women, pharyngeal infection and rectal infection—yet still transmit and cause pelvic inflammatory disease, infertility, ectopic pregnancy, neonatal blindness and disseminated infection.
Take specimens from every exposed site before antibiotics when possible, treat promptly, test for chlamydia/HIV/syphilis, and plan partner treatment and test-of-cure.
Learning objectives
- Recognise the site-specific clinical syndromes and complications of gonorrhoea.
- Choose NAAT, microscopy and culture appropriately, including for antimicrobial-resistance surveillance.
- Apply current ceftriaxone-based treatment while adapting to local Uganda guidelines and susceptibility data.
- Manage pregnancy, disseminated infection, pelvic inflammatory disease, epididymo-orchitis and neonatal disease.
- Prevent reinfection through partner services, abstinence during treatment and retesting.
Organism, transmission and resistance
Transmission occurs through vaginal, anal or oral sex and from an infected mother to the newborn. The organism attaches to mucosa using pili and opacity proteins, invades epithelial cells and provokes neutrophilic inflammation. It rapidly acquires resistance through mutation and horizontal gene transfer; treatment must follow current national recommendations and local resistance surveillance. A previous infection does not confer reliable immunity.
| Site | Common features | Important complications |
|---|---|---|
| Urethra | Dysuria, purulent discharge, meatal erythema | Epididymo-orchitis, urethral stricture |
| Cervix | Often silent; discharge, postcoital/intermenstrual bleeding, pelvic pain | PID, infertility, ectopic pregnancy |
| Rectum | Discharge, pain, tenesmus or asymptomatic | Proctitis and transmission |
| Pharynx | Usually asymptomatic; sore throat occasionally | Persistent infection, treatment failure |
| Eye/blood | Severe conjunctivitis or fever, rash, arthritis | Corneal ulceration, blindness, septic arthritis |
Clinical presentation
Urogenital infection
Men commonly present with urethral discharge and dysuria after a short incubation. Women may have increased vaginal discharge, dysuria, lower abdominal pain, postcoital bleeding or no symptoms at all. Cervicitis is suggested by mucopurulent endocervical discharge or easy bleeding on swabbing.
Rectal and pharyngeal disease
Rectal infection may cause anorectal pain, pruritus, tenesmus, bleeding or discharge. Pharyngeal infection is often silent; sore throat and cervical nodes are non-specific. Ask about oral and anal exposure rather than relying on symptoms.
Pelvic inflammatory disease
Lower abdominal pain with cervical-motion, uterine or adnexal tenderness is PID until proven otherwise. Fever, tubo-ovarian abscess or peritonism requires urgent escalation. Gonorrhoea may coexist with chlamydia and anaerobic infection.
Disseminated gonococcal infection
Fever, migratory polyarthralgia, tenosynovitis, pustular lesions and asymmetric septic arthritis suggest dissemination. Endocarditis and meningitis are rare but life-threatening.
Neonatal infection
Severe purulent conjunctivitis in the first weeks of life can rapidly ulcerate the cornea. Neonates may also develop sepsis, arthritis or meningitis.
History and examination
- Clarify symptoms, onset, all exposed sites, last sexual contact, condom use and partner symptoms.
- Ask about previous STI, antibiotics, allergies, pregnancy, HIV/PrEP, immunosuppression and violence or safeguarding concerns.
- Examine urethra, cervix, vagina, anus, pharynx, eyes, joints, skin and epididymis as indicated.
- In a patient with pelvic pain, assess for PID, pregnancy and surgical abdomen; in a febrile patient inspect joints and skin for dissemination.
Diagnosis
- NAAT on first-void urine or genital swab is highly sensitive; collect rectal and pharyngeal swabs when exposed.
- Culture with antimicrobial susceptibility testing is essential for treatment failure, pharyngeal infection where feasible, disseminated disease, medico-legal cases and resistance surveillance.
- Gram-stained urethral discharge showing intracellular gram-negative diplococci supports diagnosis in symptomatic men but is less sensitive in cervix, pharynx and rectum.
- Test for chlamydia, syphilis and HIV; pregnancy-test patients who could be pregnant.
- Blood cultures and synovial-fluid culture/PCR are required when disseminated infection or septic arthritis is suspected.
Differential diagnosis
Chlamydia, Mycoplasma genitalium, trichomoniasis, candidiasis, bacterial vaginosis, genital herpes, chemical urethritis, urinary tract infection, PID from other organisms, reactive arthritis and septic arthritis.
Management
Uncomplicated infection
Give the current recommended ceftriaxone regimen according to Uganda guidance, weight and site. If chlamydia has not been excluded, add the recommended chlamydia treatment. Check allergy, pregnancy and renal/hepatic considerations.
Pharyngeal infection
Use the guideline-preferred ceftriaxone dose and arrange test-of-cure because eradication is less reliable. Culture and susceptibility testing are particularly valuable when symptoms persist.
PID or epididymo-orchitis
Use a combination regimen covering gonorrhoea, chlamydia and anaerobes according to syndrome-specific national guidance. Treat promptly; admit for severe illness, pregnancy, tubo-ovarian abscess or inability to tolerate oral therapy.
Disseminated disease
Hospitalise for parenteral ceftriaxone, blood/joint cultures, joint drainage where needed and evaluation for endocarditis or meningitis. Continue treatment for the recommended duration after clinical improvement.
Partner management and public health
- Notify and evaluate sexual partners within the guideline-defined exposure window; presumptive treatment is often appropriate.
- Advise no sex until at least seven days after treatment is completed and partners have been treated, following current national guidance.
- Retest around three months because reinfection is common; repeat sooner if symptoms persist.
- Use condoms, reduce overlapping partners and offer HIV prevention (testing, PrEP/PEP assessment) where appropriate.
- Do not share antibiotics or use leftover medication: incomplete exposure drives resistance.
Pregnancy and neonatal prevention
Screen and treat during pregnancy using the recommended ceftriaxone regimen; avoid contraindicated alternatives. Ensure partner treatment and document cure when indicated. At delivery, examine infants carefully and provide national prophylaxis for neonatal ophthalmia. A newborn with purulent conjunctivitis needs urgent ocular swabs, systemic treatment and specialist care—topical drops alone are inadequate.
Treatment failure and antimicrobial resistance
Consider failure when symptoms persist beyond expected recovery, NAAT remains positive at the test-of-cure interval, or reinfection is unlikely. Reassess adherence, new exposure and specimen site; obtain culture and susceptibility testing before retreatment if feasible. Consult STI/microbiology specialists and notify public-health surveillance of suspected resistant strains.
Exam pearls
- Many women and most pharyngeal infections are asymptomatic.
- Take specimens from all exposed anatomic sites.
- Purulent neonatal conjunctivitis is an emergency because corneal destruction can be rapid.
- Disseminated infection classically combines tenosynovitis, migratory arthralgia and pustular skin lesions.
- Always test for chlamydia, HIV and syphilis, and actively manage partners.
References
- SlideShare: Gonorrhea.
- Uganda Clinical Guidelines: Gonorrhoea.
- WHO and current antimicrobial-resistance guidance.
Safety note: Verify the current Uganda ceftriaxone dose, test-of-cure timing and resistance recommendations before prescribing.
