- patients presenting with anogenital symptoms, until gonorrhoea has been excluded
- contacts of people with gonorrhoea as outlined under Contact management.
Registered nurses who have completed sexual health competencies and are competent in laboratory procedures and specimen collection are able to perform clinical examinations, collect specimens and undertake point-of-care tests for patients presenting with acute symptoms of urethral or vaginal discharge if they have been delegated by the clinical director of the service (see Delegation of clinical practice).
Registered nurses accredited to supply and administer STI therapies in PFSHSs can supply and administer treatment according to the policy directive RN supply and administration of STI therapies in publicly funded sexual health services.
Clinical examination is offered to all patients presenting with anogenital symptoms. For female patients this includes a bimanual examination.
Males Females Epididymo-orchitis: painful, red swollen testicle or testicles Pelvic inflammatory disease (PID): lower abdominal pain, dyspareunia, intermenstrual bleeding, postcoital bleeding, vaginal discharge Conjunctivitis Conjunctivitis Disseminated disease:
macular rash that may include necrotic pustules
septic arthritis and arthralgia
petechial or pustular skin lesions
septic arthritis and arthralgia
Meningitis or endocarditis (rarely) Meningitis or endocarditis (rarely) Prostatitis (very rarely)
When to test for gonorrhoea
Testing for asymptomatic clients is outlined in HIV and STI testing. Also test:
- females with symptoms of cervicitis, PID and/or pelvic pain or rectal symptoms
- males with symptoms of urethritis or epididymo-orchitis or rectal symptoms
- contacts of any person with an STI.
Consider other testing required to determine aetiology, such as chlamydia, Mycoplasma genitalium and lymphogranuloma venereum (LGV).
If the patient is diagnosed with proctitis, refer to Proctitis for management.
Diagnosis in females
Test Site or specimen Consideration Nucleic acid amplification test (NAAT) Endocervical Clinician-collected as examination; bimanual examination recommended NAAT Self-collected from vagina Only If patient declines examination NAAT First-catch urine Not recommended as it is not as sensitive as endocervical or vaginal swab Culture Endocervical Collect for sensitivities in addition to NAAT
Clinician-collected as examination; bimanual examination recommended
NAAT Pharyngeal Sex workers only NAAT Rectal swab Collect if proctitis is present
Consider testing for LGV and M. genitalium
Diagnosis in males
Test Site or specimen Consideration Gram stain Urethral Gram stain of urethral secretions showing polymorphonuclear leukocytes with intracellular gram-negative diplococci Culture Urethral Collect as first-line investigation in presence of urethral discharge and where gram-negative diplococci have been confirmed on Gram stain. NAAT First-catch urine NAAT Pharyngeal MSM only NAAT Rectal swab Collect if proctitis is present and/or patient is MSM
Consider testing for LGV and M. genitalium
Role of culture
Urethral or endocervical specimens for culture are to be collected by the clinician from patients presenting with urethral or vaginal discharge. If the patient also needs pharyngeal or rectal swabs on the basis of risk assessment, consider adding specimens for gonorrhoea culture from these sites.Before antibiotic treatment, culture must be taken from all patients with positive NAAT results for antibiotic susceptibility testing for surveillance purposes.
Situation Recommendation Patients with uncomplicated urethral, cervical, pharyngeal or rectal infection
People attending as contacts of gonorrhoea patients
Ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly
azithromycin 1 g single dose orally
Past anaphylactic reaction to penicillina or cephalosporin Azithromycin 2 g single dose orally Rectal co-infection with rectal chlamydia Ceftriaxone 500 mg in 2 mL 1% lignocaine intramuscularly
doxycycline 100 mg orally, twice daily for 7 days
Pregnancy Same as principal treatment Gonococcal conjunctivitis Same as principal treatment
Medical officer review required
a Cross-allergy to cephalosporins has been reported among patients with penicillin allergy. Allergic reactions to first-generation cephalosporins occur in less than 2.5% of persons with a history of penicillin allergy and are uncommon with third-generation cephalosporins such as ceftriaxone and cefixime. Use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy such as anaphylaxis, Stevens–Johnson syndrome and toxic epidermal necrolysis. (See https://allergy.org.au/images/stories/hp/info/ASCIA_HPIP_antibiotic_allergy_2014.pdf for details of IgE-mediated allergy.) The incidence of cross-allergy to first-generation cephalosporins is considered negligible. In patients with a clear history of a type 1 penicillin allergy, consult a senior doctor as to the most appropriate treatment.2
For a person with no symptoms presenting as a contact of a gonorrhoea patient, follow STI and BBV tests as outlined in HIV and STI testing.If pharyngeal or rectal swabs are to be collected on the basis of risk assessment, add specimens for gonorrhoea culture. Presumptive treatment for uncomplicated gonorrhoea is recommended as outlined above.
How far back to trace will depend on the patient’s sexual and testing history, but is usually limited to two months.Because most contacts infected with gonorrhoea will be asymptomatic and at high risk of complications, contact tracing and partner notification are a high priority.
Advise no sex (oral, anal or vaginal) for seven days after current partners have been treated. If sexual contact does occur before this, condoms should be used.All patients treated for gonorrhoea should be advised to return to the service if symptoms do not resolve.
Follow up with patient at one to two weeks or at their next visit to discuss treatment compliance, resolution of symptoms and partner notifications. For patients who elected to contact their own partners, confirm they were able to notify partners. If they were unable to do so, offer further assistance.
Testing for chlamydia and gonorrhoea reinfection is recommended at three months.
Test of cure
For pharyngeal, anal or cervical infection, NAAT should be performed two to three weeks after treatment is completed as a test of cure.3If the patient is co-infected with rectal chlamydia, the test of cure should be performed four weeks after treatment completion as this means that (1) the patient only returns to the service once, and (2) it reduces the likelihood of false positive chlamydia results.
All patient consultations including examinations and tests collected are to be documented on the patient’s medical record. If patients are notifying their own partners, document the outcomes of partner notification.
References and further reading
- Australasian Sexual Health Alliance (ASHA). Australian STI management guidelines for use in primary care. Sydney: ASHM; 2018. Available from: http://www.sti.guidelines.org.au/
- Pichichero ME, Casey JR. Safe use of selected cephalosporins in penicillin-allergic patients: a meta-analysis. Otolaryngology and Head and Neck Surgery. 2007;136:340–7. Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17321857
- Sheppeard V. Gonorrhoea—antimicrobial resistance: information for NSW clinicians. Sydney: NSW Ministry of Health; 2018. Available from: http://www.health.nsw.gov.au/Infectious/alerts/Documents/2018/gono-amr-clinician-april2018.pdf