Gonorrhoea

Overview

Gonorrhoea is a sexually transmitted infection (STI) caused by Neisseria gonorrhoeae, an obligate human pathogen. The sites of infection include urethra, endocervix, pharynx, rectum, and conjunctiva.

Gonorrhoea is treatable and curable with antibiotics. However, N. gonorrhoea has developed resistance to antibiotics, posing a challenge in its treatment. Rational use of antibiotics is critical to decrease this threat.

Disease epidemiology

In 2020, World Health Organization estimated 82.4 million new infections with N. gonorrhoeae among adults aged 15 to 49 years. Prevalence of gonorrhoea is highest among vulnerable populations such as men who have sex with men (MSM), sex workers, transgender women and adolescents and young people in high burden countries. Over the last decade, the incidence of gonorrheal STIs has increased due to the rising number of antibiotic-resistant strains.

In Singapore, gonorrhoea had the lowest incidence among the three legally notifiable STIs in 2019 and 2020. It was more commonly reported in men. No gonococcal ophthalmia neonatorum cases were reported in 2019 and 2020. Regarding gonorrhoea susceptibility, the percentage of gonorrhoea cultures with decreased susceptibility to ceftriaxone decreased from 9.19% in 2019 to 7.33% in 2020. There was one resistant case detected in 2019 and no cases detected in 2020. The percentage of gonorrhoea cultures resistant to ciprofloxacin remained consistent at 81.1% in 2019 and 81.9% in 2020.

Pathogen(s)

Neisseria gonorrhoeae.

Transmission

Gonorrhoea is usually transmitted through vaginal, anal, or oral intercourse with an infected individual. Ejaculation does not have to occur for gonorrhoea to be transmitted or acquired. 

An infected mother can also transmit gonorrhoea to her baby during vaginal delivery.

Incubation period:  Average 3 to 5 days, sometimes longer.

Infectious period: Up to 7 days post-treatment.

Clinical features

Gonorrhoea is characterised clinically by a profuse purulent discharge from the affected genital site (more than 80% in male urethritis, up to 50% in female cervicitis), often accompanied by local pain or discomfort. However, asymptomatic infection may occur in 10% of urethral infection, more than 50% of cervical infections, and more than 90% of pharyngeal infection and rectal infections.

Men and women may experience different symptoms.

In men, common symptoms include:

• Pain or burning sensation when urinating

• A white, yellow, or greenish discharge from the penis

• Painful or swollen testes

Most women with gonorrhoea do not have symptoms. If symptoms occur, they can include:

• Pain or burning when urinating

• Vaginal discharge

• Vaginal bleeding between periods or during sexual intercourse

Infants born to mothers with gonorrhoea may develop an eye infection. This causes redness, pain, soreness, ulcers, and tearing. This is preventable with eye medications for newborns.

Contiguous spread of the infection may lead to epididymo-orchitis, prostatitis, endometritis and salpingo-oophoritis. Haematogenous spread results in disseminated gonococcal infection (DGI).

Risk factors

Risk factors include:

• Unprotected sex with an infected person

• Having multiple sex partners

• Inconsistent condom use if the relationship is not monogamous

• Persons who exchange sex for money or drugs

• History or current presence of other STIs

Diagnosis

A presumptive diagnosis of gonorrhoea is made on finding Gram-negative intracellular diplococci in a smear of the discharge. Confirmatory diagnosis is made by identification of the organism on culture media (e.g. modified Thayer-Martin agar).

Tests for diagnosis include:

• Nucleic acid-based amplification testing (NAATs) (PCR) can be used as diagnostic/screening tests on non-invasively collected specimens (urine and self-taken vagina/pharyngeal/rectal swabs)

• Polymerase chain reaction (PCR) can be used to detect urethral and cervical, pharyngeal, and rectal gonorrhoea

• Because non-culture tests cannot provide anti-microbial susceptibility results in cases of persistent gonococcal infection after treatment or potential resistant infections, clinicians should perform both culture and antimicrobial susceptibility testing

Gonococcal complement fixation test (GC-CFT) should not be used for diagnosing gonorrhoea.

Treatment and management

Recommended regimens for uncomplicated gonococcal infection of the cervix, urethra, or rectum:

• Ceftriaxone 500mg IM in a single dose, plus Doxycycline 100mg orally 2 times a day, for 7 days

Recommended regimens for uncomplicated gonococcai Infection of the pharynx:

• Ceftriaxone 500mg IM in a single dose, plus Doxycycline 100mg orally 2 times a day, for 7 days

Pregnancy considerations:

• Cephalosporins in the recommended dosages are safe and effective in pregnancy

• Spectinomycin can be administered to women who are unable to tolerate Cephalosporins

• Simultaneous treatment for chlamydial infection with Azithromycin 1g orally in a single is advocated

Follow-up:

• Test-of-cure and assessment for post-gonococcal urethritis (PGU) is performed after 14 days

• Test-of-cure culture tests are recommended in all cases at all sites, especially for pharyngeal gonorrhoea

• In cases of possible antibiotic resistance, cultures should be performed with additional antimicrobial sensitivity

• Patients with gonococcal ophthalmia should have cultures done daily on therapy; repeat on day 5 and I14 after therapy completion date

• Serologic tests for syphilis and HIV should be performed; if negative they should be repeated 3 months after the last at-risk exposure

Refer to the Department of Sexually Transmitted Infections Control (DSC)'s website for more information on alternative regimens and other treatment options.

Precaution, prevention, and control

Annual screening for N. gonorrhoeae infection is recommended for all individuals who are sexually active:

• Individuals with multiple sex partners, change in sex partner, or engaging in unprotected sex should consider regular screening

• More frequent screening than annual might be indicated for certain individuals based on their risk behaviours

Prevention of gonorrhoea:

• Inform current or recent sexual partners if a diagnosis of gonorrhoea has been confirmed

• Avoid sexual intercourse until at least 7 days after treatment is completed

• Not having sex

• Consistent and correct use of condoms when engaging in sexual activity.

• Limit the number of sexual partners

• Get tested for STIs regularly

Management of sexual contacts:

Sexual contacts of the patients in the preceding 60 days should be traced, screened, and treated on epidemiologic grounds. If the last sexual exposure was more than 60 days, the patient’s most recent partner should be treated.

Notification

Gonorrhoea is a notifiable disease.

Who should notify:

• Medical practitioners

• Laboratories

When to notify:

• On clinical suspicion or laboratory confirmation

How to notify:

• Please refer to the Infectious Disease Notifications for more information.

Notification timeline:

• Within 72 hours from time of diagnosis

Resources

Refer to resources for the communicable disease surveillance in Singapore.

Refer to DSC’s website for more information about gonorrhoea.

References

• Centers for Disease Control and Prevention. STI treatment guidelines: Gonococcal infections. 2021.

• Department of Sexually Transmitted Infections Control (DSC). STI management guidelines 7^th edition. 2021.

• World Health Organization. Gonorrhoea (Neisseria gonorrhoeae infection). 2023.