Gonococcus

Gonorrhoea is a sexually transmitted disease caused by a gram-negative diplococcus Neisseria gonorrhoeae (1)

• it is an uncomplicated infection of the lower genital tract
  • undetected or inadequately treated disease may result in complicated infection of the upper genital tract (uncommon in UK) - e.g. prostatitis or epididymitis in men and salpingitis or pelvic inflammatory disease in women (2)
• primary sites of infection include - urethra, endocervix, rectum, pharynx and conjunctiva (1)
• the disease is transmitted by direct inoculation of infected secretions from one mucous membrane to another - genital-genital, genital-anorectal, oro-genital or oro-anal contact (3)
  • most common form of transmission is from sexual contact
  • non-sexual transmission can occur when an infected mother passes the infection to a newborn child, usually resulting in gonococcal conjunctivitis

Clinical features of the disease vary between genders.

• about 50% of females are asymptomatic, whereas asymptomatic infection rarely occurs in males
• due to this asymptomatic nature, complicated gonococcal infection is more common in women than in men (2)
• common symptoms in women may include increased or altered vaginal discharge and lower abdominal pain. It can also be a rare cause of heavy menstrual, postcoital or intermenstrual bleeding due to cervicitis or endometritis (4)

Gonorrhoea is known to facilitate the acquisition and transmission of HIV (2):

• current infection with gonorrhoea increases the risk of HIV acquisition by 2.81 times in women and 2.38 times in men who have sex with men (5)

If untreated, gonorrhoeal infections may spread to the epididymis and/or testes causing epididymo-orchitis, or to the endometrium, fallopian tubes and/or ovaries, causing pelvic inflammatory disease (PID) (5):

• PID occurs in up to 14% of women with untreated gonorrhoea and leads to subfertility, ectopic pregnancy, and chronic pelvic pain, with risk increasing with each recurrent infection

Key points (6):

• antibiotic resistance is now very high
• use IM ceftriaxone if susceptibility not known prior to treatment
• use ciprofloxacin only if susceptibility is known prior to treatment and the isolate is sensitive to ciprofloxacin at all sites of infection
• refer to GUM
• test of cure is essential

Gonorrhoea vaccine programme:

• MenB is a vaccine that has been shown to prevent gonorrhoea
  • in November 2023, the Joint Scientific Committee on Vaccination and Immunisation (JCVI) recommended the use of MenB to prevent gonorrhoea in people who are more likely to get an STI (especially gay, bisexual, and other men who have sex with men)
  • from 1st August 2025, MenB will be available on the NHS in England, Scotland, and Wales as part of a gonorrhoea vaccination programme

References:

1. Bignell C, Fitzgerald M; Guideline Development Group.UK national guideline for the management of gonorrhoea in adults, 2011. Int J STD AIDS. 2011;22(10):541-7.
2. Health Protection Agency (HPA) 2010. Guidance for gonorrhoea testing in England and Wales.
3. Bignell C; IUSTI/WHO. 2009 European (IUSTI/WHO) guideline on the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS. 2009;20(7):453-7.
4. FSRH and BASHH Guidance (February 2012) Management of Vaginal Discharge in Non-Genitourinary Medicine Settings.
5. Ross S, Pinto-Sander N, Iwuji C. Diagnosis and management of gonorrhoea. BMJ 2025; 389 :e084789.
6. Public Health England (June 2021). Managing common infections: guidance for primary care.