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Gonorrhoea

Demonstration of gonococcal nucleic acid in first void urine is suitable for screening.
Culture is the basic diagnostic method and it also provides determination of antimicrobial sensitivity. It is obtained in clinical suspicion of gonorrhoea or always if the nucleic acid detection test is positive.
A combination of ceftriaxone and azithromycin is the drug of choice if the sensitivity of the gonococcal strain is not known.
Decreased sensitivity to ceftriaxone has been reported in some parts of the world.
Gonorrhoea should not be treated with oral antimicrobials if the strain is not known to be sensitive to ciprofloxacin.

Caused by Neisseria gonorrhoeae (gonococcus), which is a gram-negative diplococcus.
The incidence of gonorrhoea varies considerably between countries, as does resistance to drugs.
- In 2020, the WHO estimated 82 million new gonorrhoea infections worldwide http://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis).
- In Finland, the incidence of gonorrhea has increased. In 2020, almost 500 infections were detected (population 5.5 millions).
  - More than half of the infections are acquired in Finland.
  - Infections occur also in young adults' age group.
  - The incidence of concomitant chlamydial and gonorrhoeal infections has increased.
  - More than half of the infections in men are acquired in sex between men.
Quinolone resistant strains are more and more common, and quinolones are no more recommended for the treatment of gonorrhoea.
In parts of the world there have been reports on strains that are resistant to ceftriaxone.

The incubation time in men is 2-5 days after exposure, in women somewhat longer.
Infections with mild or totally absent symptoms have become more common.
In men the symptoms are urethritis and a yellowish urethral discharge; women have vaginal discharge, pain on urinating and lower abdominal pain.
Proctitis and pharyngitis often are symptomless or the symptoms are mild.

In women the most serious complication is pelvic inflammatory disease (PID Pelvic Inflammatory Disease (Pid)). In men gonorrhoea may sometimes cause epididymitis Testis Pain.

Gonococcal nucleic acid detection test in the screening of gonorrhoea
- First-void urine sample or a sample taken with a swab is examined by nucleic acid probing Laboratory Testing for Chlamydia Trachomatis and Neisseria Gonorrhoeae.
- The swab sample is taken according to the location of transmission, also from the pharynx or anus if needed.
- The same sample can be used to test for both gonorrhoea and chlamydial infection.
Antimicrobial sensitivity can only be determined by bacterial culture. The culture should be performed in addition to the nucleic acid detection test if the patient's history suggests gonorrhoea (partner has gonorrhoea) and/or there are clear symptoms suggesting the infection.
- The sample may be obtained with a dacron swab from the urethra, cervix, pharynx and rectum. It is placed into a special transport tube (storage at +4°C, if necessary).

If the gonococcal nucleic acid detection test is positive, a culture sample has to be obtained in order to determine antimicrobial sensitivity before any antimicrobial treatment is started.
Ceftriaxone Antibiotics for Gonorrhoea1 g as a single dose i.m. (strains sensitive to ceftriaxone)
If the antimicrobial sensitivity is not known: ceftriaxone 1 g i.m. + azithromycin 2 g p.o.
In patients allergic to cephalosporins, gentamicin 240 mg i.m. + azithromycin 2 g p.o. may be used.
Complicated infection: ceftriaxone 1 g once daily i.m. for 3 to 5 days
The patient should abstain from sex for a period of one week and thereafter use a condom until a negative follow-up examination result has been obtained.

Special attention should be paid to tracing contacts in the community. This should preferably be centralized in STD outpatient clinics or to other experts.
A control sample after treatment is important for verifying cure.
Nucleic acid detection test 3 weeks after treatment
The infection is reported to the health authorities according to the local regulations.

Unemo M, Ross J, Serwin AB ym. 2020 European guideline for the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS 2020;(Oct 29):956462420949126. [PubMed]