Gonorrhoea

Incubation period: 2-7 days
Often indistinguishable from chlamydial infection
Most often presents with urethritis or cervicitis. The distal rectal mucosa may also be affected. Haematogenous spread is possible.
♂:
- Serous or purulent discharge
- Burning on emptying the bladder
- The urethral opening may be reddened
- Balanitis, sometimes paraphimosis
- Pain in the perineum and lower abdomen
⧬
- In 80% asymptomatic
- Serous or purulent discharge
- Burning and pain on urination
- Local redness and swelling, erosions and ulcerations
- Peritoneal pain (pelvic inflammatory disease)
- Blood flow disturbance
- Swelling of the adnexa
Extragenital manifestation
- Pharyngitis (almost all cases of pharyngeal gonorrhoea are asymptomatic)
- Proctitis (often asymptomatic in both sexes)
- Sepsis
- ↓ AZ, febrile episodes

Urethritis: In all patients with urethritis, the diagnostic steps listed in Table 1 should be taken. If symptoms persist, the steps in Table 2 are taken.
Pharyngeal or anal symptoms: For pharyngitis and anal complaints, see Table 3.

Table 1. Diagnostic steps in all urethritis patients	Sample collection	Processing	To detect
Step 1)	Men: Swab from the urethra with the eSwab using a thin swab (Figure 1): Urethral discharge; spontaneous or swab urethra or Urethral swab; cotton swab 2cm into urethra and gently twist Women: If culture desired, arrange for smear of endocervix in gynaecology department.	Step 1a: Smear on slide dab/smear for Gram stain	Gram-negative diplococci (Neisseria gonorrhoeae), Other bacteria, Leukocytes
Step 1b): Then immediately add the smear to the medium	Neisseria gonorrhoeae culture (incl. resistance)
Step 2)	Men: first stream urine (min. 2 hrs. after last micturition) Alternatively, if micturition is not possible: In case of urethral swab of step 1, additionally require PCR Women: Vaginal swab	Care	Neisseria gonorrhoeae - PCR, Chlamydia trachomatis - PCR
Step 3)	Blood collection	Care	Luesserology, HIV test

Table 2. Diagnostic steps for persistence of symptoms after therapy (after consultation with a squad doctor) Step

Sample collection

Processing

For detection

Urethral swab

Put the swab into the medium

Mycoplasma genitalium - PCR,

Trichomonas vaginalis - PCR

The therapy recommendation is basically based on the pathogen detection.

Therapy at the initial visit to the polyclinic is based on the result of the direct preparation (Table 1.)

Table 1. Therapy recommendation according to the result of the direct preparation test result	Interpretation	Procedure / Therapy
Direct preparation unremarkable	Unclear urethritis	No therapy, Only protected intercourse, Control in 1 week
In direct preparation gram-negative diplococci (mainly intracellular) and leucocytes (> 5/facial field)	Gonorrhoea	Ceftriaxone i.m. 1.0g single dose
In direct preparation leukocytes (> 5/facial field) and possibly bacteria	Non-gonorrhoeal urethritis	Doxycycline p.o. 100 mg 2x/d for 7 days Alternatively: Second line: Azithromycin 500mg "single dose", then 250mg 1xtgl. for 4 days (IUSTI 2016)

Further recommendations

Patients with documented urethritis should be tested for other STIs, including syphilis and HIV
Clinical follow-up after 1 week (e.g. on the occasion of discussion of test results)
Microbiological follow-up indicated in case of therapy with second-line therapy or persistent urethritis after pathogen-targeted therapy.
Prohibition of unprotected sexual intercourse for 7 days after single-dose therapy or until completion of 7-day therapy.
Sexual partners of patients with gonorrhoea in the last 60 days should be tested for N. gonorrhoea by PCR and culture because of the high rate of infection and treated on the same day, i.e. even before the test result is available.

Thayer JD, Jr JEM. A Selective Medium for the Cultivation of N. gonorrhoeae and N. meningitidis. Public Health Reports (1896-1970) 1964;79:49.
Lewis DA, Ison CA, Forster GE, Goh BT. Tetracycline-Resistant Neisseria gonorrhoeae. Sexually Transmitted Diseases 1996;23:378-83.
Sherrard J, Barlow D. Gonorrhoea in men: clinical and diagnostic aspects. Sexually Transmitted Infections 1996;72:422-6.
Yealy DM, Greene TJ, Hobbs GD. Underrecognition of CervicalNeisseria gonorrhoeaeandChlamydia trachomatisInfections in the Emergency Department. Academic Emergency Medicine 1997;4:962-7.
Palladino S, Pearman JW, Kay ID, et al. Diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae genitourinary infections in males by the Amplicor PCR assay of urine. Diagnostic Microbiology and Infectious Disease 1999;33:141-6.
Whiley DM, Garland SM, Harnett G, et al. Exploring 'best practice' for nucleic acid detection of Neisseria gonorrhoeae. Sexual Health 2008;5:17.
Lebwohl, Mark. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. Elsevier, 2014. Print.
British Association for Sexual Health and HIV national guideline for the management of infection with Neisseria gonorrhoeae (2019)
Horner P. et al. 2016 European guideline on the management of non-gonococcal urethritis. International Journal of STD & AIDS 2016; 27: 928–937

Differential diagnoses