QuestionSBA
QuestionChoice
Penile discharge is common in trichomoniasis. However, it is caused by a protozoan rather than a bacterium
33001
d
Trichomoniasis
QuestionChoice
Chlamydia is likely to present with similar symptoms to gonorrhoea however is a rod-shaped gram-negative bacteria
32999
b
Chlamydia
QuestionChoice
Syphilis does not usually present in this way. Instead, there will most often be an initial chancre, a small painless ulcer, found on the glans of the penis
33000
c
Syphilis
QuestionChoice
Zoon's balanitis is an inflammation around the head of the penis and the foreskin. It leads to well-defined, itchy, red patches. Histology shows increased plasma cells on skin samples
33002
e
Zoon's balanitis
QuestionChoice
Urethral discharge is a common symptom in males with gonorrhoea. Gonorrhoea is a gram-negative diplococcus
32998
a
Gonorrhoea
Concept
Chapter
# Summary
  
  
Gonorrhoea is a sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae. Key symptoms include genital discharge, dysuria, and sometimes, tenderness of inguinal nodes in men and abnormal bleeding in women. Diagnosis is primarily made through nucleic acid amplification tests (NAAT) and culture, and confirmed by the presence of monomorphic Gram-negative diplococci within polymorphonuclear leukocytes. The recommended first-line treatment is Ceftriaxone, with a test of cure needed to evaluate disease clearance and treatment effectiveness. Untreated, gonorrhoea can lead to complications such as pelvic inflammatory disease, epididymitis, systemic infection, and increased risk of HIV/AIDS.
  
  
# Definition
  
  
Gonorrhoea is a sexually transmitted infection (STI) caused by the gram-negative diplococcus, Neisseria gonorrhoeae.
  
  
# Epidemiology
  
  
Gonorrhoea is the most common bacterial sexually transmitted infection worldwide. It is most prevalent among young adults, specifically those aged 15–24 years.
  
  
# Aetiology
  
  
The aetiology of gonorrhoea is exclusively the bacterium Neisseria gonorrhoeae, which is a gram-negative diplococcus.
  
Risk factors for gonorrhoea infection include:
  
- Young adults
- New sexual contacts
- Inconsistent barrier contraception
- Men who have sex with men
- Previous STI
- Deprivation
  
  
# Signs and Symptoms
  
  
Clinical manifestations of gonorrhoea can vary between genders:
  
  
- Symptoms in men: often asymptomatic, discharge, dysuria, tender inguinal nodes
- Symptoms in women: discharge, dysuria, abnormal bleeding
  
  
Upon examination in women, discharge from the cervical os, Skene's gland or Bartholin's gland may be observed. Gonorrhoea may also present with extragenital complications including pharyngitis, conjunctivitis, rectal pain and discharge, septic arthritis and disseminated infection.
  
  
# Differential Diagnosis
  
  
Conditions to consider in differential diagnosis include:
  
  
- **Chlamydia trachomatis infection**: Presents with similar symptoms such as discharge and dysuria, often co-infected with gonorrhoea.
- **Trichomonas vaginalis infection**: May present with pruritus, dysuria, and malodorous discharge.
- **Bacterial vaginosis**: Characterised by a fishy-smelling discharge, increased vaginal pH and positive 'whiff' test.
- **Candidiasis**: Symptoms include pruritus, burning sensation and thick, white, 'cottage cheese' like discharge.
  
  
# Investigations
  
  
Diagnostic modalities for gonorrhoea include:
  
  
- Self-taken vulvovaginal swab in women or self-obtained first pass urine in men; self-obtained rectal swab; or clinician-obtained endocervical or penile swab
- Microscopy revealing monomorphic Gram-negative diplococci within polymorphonuclear leukocytes
- Nucleic acid amplification tests (NAAT)
- Culture & sensitivities
  
  
# Management
  
All patients should be referred to a genito-urinary medicine clinic or local specialist services for treatment, partner notification and screening for other STI's.
  
- People who are systemically unwell should be admitted, and those with complications should be referred to the appropriate specialty.
- The mainstay of treatment for gonorrhoea is antibiotics. Ideally antibiotics should be prescribed after culture results but sometimes this is not practicable. 
- Current guidelines recommend Ceftriaxone as the first-line treatment. This is given as a single intramuscular injection. 
- Alternative treatments include intramuscular gentamicin or oral cefixime, both with azithromycin orally. 
- Ciprofloxacin should only be considered when sensitivities are known and there are no suitable alternative antibiotics.
  
For pregnant or breastfeeding women, a single dose of intramuscular ceftriaxone or oral azithromycin should be used.
  
For all patients following treatment, a test of cure is essential to monitor disease clearance and assess the effectiveness of the chosen antibiotic regimen.
  
  
# Complications
  
  
If untreated, gonorrhoea can lead to serious complications, including:
  
  
- Infertility in women due to pelvic inflammatory disease (PID), which may result in scarring of the tubes and an increased risk of pregnancy complications
- Infertility in men due to epididymitis caused by the spread of gonorrhoea to the epididymis
- Disseminated infection that may affect joints and other areas of the body, leading to fever, rash, skin sores, joint pain, swelling and stiffness
- Increased susceptibility to human immunodeficiency virus (HIV) infection, potentially leading to AIDS, and enhanced transmission of both diseases to partners
  
  
# NICE guidelines
  
[Click here to see information on NICE about gonorrhoea](https://cks.nice.org.uk/topics/gonorrhoea/)
  
# References 
  
[Click here for BASHH guidelines on Neisseria gonorrhoeae](https://www.bashhguidelines.org/media/1238/gc-2018.pdf)
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Neisseria Gonorrhoea infection
Topic
27
Genitourinary medicine
Condition
739
Gonorrhoea
UkmlaTopic
24
Sexual health
6600
Urethral discharge is a common symptom in males with gonorrhoea
A 19-year-old man visits his GP due to urethral discharge and dysuria. This has been ongoing for the last week. He states that he had unprotected vaginal sex with two female partners and unprotected insertive anal sex with one male partner with over the last month.

His GP arranges for microscopy of the discharge. This showed gram-negative diplococci.

What is the diagnosis?
a