You are here: Urology Textbook > Penis > Sexually transmitted diseases > Gonorrhea > Testing and treatment

Gonorrhea: Testing and Treatment of Gonococcal Urethritis

• Gonorrhea: Etiology, Signs and Symptoms
• Gonorrhea: Diagnosis and Treatment

Diagnosis of Gonorrhea

Indications for microbiological testing in men:

Urethral discharge, diagnosis of any other STI, sexual partners with STI, and acute epididymitis in a male under 40 years.

Indications for microbiological testing in women:

Vaginal discharge with risk factors for STI (history, age), diagnosis of any other STI, sexual partners of patients with STI, and acute pelvic inflammatory disease.

Swab tests:

The urethral swab is ideally done after a longer pause in micturition. Further pathogen collection from the anus, pharynx, and cervix depends on history and symptoms. The microbiological diagnosis is possible with different techniques:

NAAT:

With the help of a NAAT (Nucleic Acid Amplification Test), gonococci, chlamydia and mycoplasma are detected with high sensitivity and specificity.

Microscopic diagnosis:

Two microscope slides for Gram stain (gonococcus) and Giemsa stain (Chlamydia) are prepared if a microscopic pathogen detection is sought. Over four leukocytes with intracellular gram-negative diplococci can be seen in a high-power field [fig. microscopy of gonorrhea].

Culture and antimicrobial susceptibility testing:

Culture and antimicrobial susceptibility testing of Neisseria gonorrhoeae is possible with Martin-Lewis plates or Thayer-Martin agar.

Test of the sexual partner:

To avoid a ping-pong infection, a detailed history and examination of any sexual partner is necessary.

Urin analysis:

After the urethral swab, urine for culture is collected.

Serological tests:

Other STDs like syphilis, hepatitis, and HIV should be tested.

Notifiable disease:

Gonorrhea is a notifiable disease in some countries, e.g., USA or Canada, but not in others, e.g., the UK, France, or Germany.

Treatment of Gonorrhea

Standard treatment:

The IUSTI guideline recommends a single dose of ceftriaxone 1 g i.m. combined with azithromycin 2 g p.o. in a single dose. Ceftriaxone can also be administered i.v., the recommendation of the RKI is 1–2 g i.v.. The combination with azithromycin is wise because of rising minimum inhibitory concentrations (MICs) in recent years. Azithromycin is also effective against Chlamydia or Ureaplasma. Diagnosis and co-treatment of the sexual partner(s) is very important.

The CDC (2020) recommends lower doses of antibiotics: ceftriaxone 500 mg i.m. in a single dose for persons weighing under 150 kg and 1000 mg i.m. for persons weighing more. A combination with azithromycin or doxycycline in uncomplicated cases is only necessary when chlamydial infection has not been excluded.

Alternative Treatment Options:

Both ceftriaxone and azithromycin show sufficient activity against gonococci alone. If one drug is unavailable or allergies make combined use impossible, single administration of ceftriaxone or azithromycin with subsequent controls is adequate. Further treatment alternatives:

• Cefixim 800 mg p.o. in a single dose or 400 mg p.o. for three days as an alternative to ceftriaxon in combination with Azithromycin. Resistance of Neisseria gonorrhoeae to cefixim is rising.
• Patients with cephalosporine allergy: spectinomycin 2 g i.m. (or gentamicin 240 mg i.m.) once combined with a single dose of azithromycin 2 g p.o.
• Due to rising resistance of Neisseria gonorrhoeae, fluoroquinolone antibiotics should only be used after proven sensitivity in cultural testing.

Follow-up and Test of Cure:

Sexual abstinence is advised beyond antibiotic therapy until TOC is negative. All symptom-free patients should receive a NAAT TOC two weeks after treatment. If positive for gonococci, culture and resistance testing should be awaited before further antibiotic therapy. In patients with persistent symptoms after antibiotic treatment, TOC can be performed one week earlier.

Prevention:

Use of condoms, treatment with intravaginal nonoxynol-9 containing spermicides, antibiotic prophylaxis after sexual intercourse, treatment of newborn eyes with an antibiotic ointment containing silver nitrate, erythromycin, or tetracycline (Credé prophylaxis).

References

CDC Guidelines: gonococcal infections in adolescents and adults. https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm

EAU Guidelines "Urological Infections,” Available: https://uroweb.org/guidelines/urological-infections/.

IUSTI, Unemo et al.: European Guideline on the Diagnosis and Treatment of Gonorrhoea in Adults (2020). https://iusti.org/wp-content/uploads/2020/10/IUSTI-Gonorrhoea-2020.pdf

DSTIG, DGU, and RKI, “Diagnostik und Therapie der Gonorrhoe. AWMF S2k-Leitlinie,” 2018. [Online]. Available: https://www.awmf.org/uploads/tx_szleitlinien/059-004l_S2k_Gonorrhoe-Diagnostik-Therapie_2019-03.pdf.

Robert-Koch-Institut, “Gonorrhoe (Tripper): RKI Ratgeber,” 2023. [Online]. Available: https://www.rki.de/DE/Content/Infekt/EpidBull/Merkblaetter/Ratgeber_Gonorrhoe.html.

  Deutsche Version: Gonorrhoe: Diagnose und Therapie der gonorrhoischen Urethritis.