Gonorrhoea
Written 25th April 2020 - Last Update 31st August 2026
Gonorrhoea
Caused by Neisseria gonorrhoeae, a Gram-negative intracellular diplococcus.
Gonorrhoea is most commonly diagnosed in men who have sex with men, among young heterosexual Aboriginal and Torres Strait Islander people living in remote and very remote areas, and travellers returning from high-prevalence areas overseas — with increasing prevalence in the general population, especially women of reproductive age.
Previous infection does not provide immunity to new infection, and reduced susceptibility to first-line treatment is emerging in urban Australia and is being monitored closely.
Clinical presentation
Anal and pharyngeal infections are asymptomatic in most people; vaginal infection is often asymptomatic (in ~80% of cases); penile urethral infection is almost always symptomatic (in 85–90% of cases).
| Symptoms | Complications | |
|---|---|---|
| Genital/local | Penile urethral discharge, dysuria, vaginal discharge, dyspareunia with cervicitis, anorectal symptoms (discharge, irritation, painful defecation, disturbed bowel function) | Epididymo-orchitis (uncommon), prostatitis (very rare), pelvic inflammatory disease (dyspareunia, intermenstrual/post-coital bleeding, discharge), Bartholin gland abscess |
| Eye | Conjunctivitis: purulent, sight-threatening | — |
| Disseminated (rare) | — | Macular rash ± necrotic pustules, septic arthritis, meningitis or endocarditis (rarely) |
Diagnosis
Always collect samples for gonococcal culture before treating, to determine antimicrobial sensitivity and contribute to resistance surveillance — but do not delay treatment while awaiting culture results. Request “gonococcal culture” specifically, not a general “culture”: gonococci need specific culture conditions.
| Site | Test | Notes |
|---|---|---|
| First-pass urine | NAAT | Used when no vaginal swab is possible; less sensitive than a self-collected vaginal swab |
| Penile urethral swab | Culture | Only if discharge/local symptoms present, or before antibiotics |
| Endocervical swab (clinician-collected) | NAAT ± culture | Best test if being examined; add culture if vaginal symptoms present |
| Vaginal swab (self-collected) | NAAT ± culture | Best test if not examined; add culture if vaginal symptoms present |
| Anorectal swab | NAAT ± culture | All men who have sex with men, and anyone with anorectal symptoms |
| Pharyngeal swab | NAAT ± culture | All men who have sex with men, and anyone with multiple partners |
Sample extra-genital sites in men who have sex with men even when they are asymptomatic there. If a patient declines an anal examination, refer for self-collection or to a sexual health service rather than leaving the site untested.
NAATs are highly sensitive and allow self-sampling but are not validated for non-genital sites and can rarely give a false positive; culture is highly specific and allows susceptibility testing but is less sensitive, and needs stringent transport (to the lab within 24 hours).
Treatment
Gonococcal culture should always be collected from all infected sites before antibiotics are given, but treatment itself should not wait for the result.
| Situation | Recommended | Alternative |
|---|---|---|
| Uncomplicated genital and anorectal infection | Ceftriaxone 500mg IMI stat (in 2mL 1% lignocaine) plus azithromycin 1g PO stat | Not recommended (high resistance) except some remote areas/severe allergy — seek specialist advice |
| Uncomplicated pharyngeal infection | Ceftriaxone 500mg IMI stat plus azithromycin 2g PO stat (or 1g followed by a further 1g 6 hours later, to reduce GI side-effects) | As above |
| Adult gonococcal conjunctivitis | Ceftriaxone 1g IMI stat plus azithromycin 1g PO stat | As above |
| Rectal + chlamydia co-infection | Ceftriaxone 500mg IMI stat plus doxycycline 100mg PO BD 7 days (asymptomatic) or 21 days (symptomatic) | — |
| Pregnancy | Same as principal treatment option | — |
| Penicillin-susceptible regional/remote gonorrhoea (confirm with local public health unit) | Amoxicillin 3g PO stat plus probenecid 1g PO stat plus azithromycin 1g PO stat if chlamydia not excluded | Use principal treatment option if acquired beyond the local remote area |
If a patient already received the recommended genital/anorectal treatment and is then found to also have pharyngeal gonorrhoea, they don’t need re-treatment with the higher pharyngeal azithromycin dose, but a test of cure is recommended. If the patient has an IUD in place, leave it and treat as recommended.
Why dual therapy
Dual antibiotic therapy is a deliberate resistance-management strategy, not just redundancy: sharing of resistance genetic material between bacteria, and reduced drug penetration to the pharyngeal mucosa, make the pharynx the most likely site of treatment failure, so the combination creates a pharmacological barrier against more widespread resistance developing.
Ceftriaxone monotherapy should not be used outside specialist centres with culture-based susceptibility monitoring. Ciprofloxacin 500mg PO stat can be used, but only once susceptibility is confirmed on NAAT or culture, and confirming this should not delay treatment.
Other immediate management
- Advise no sexual contact for 7 days after treatment is commenced, or until the course is completed and symptoms have resolved — whichever is later.
- Advise no sex with partners from the last 2 months until they’ve been tested and treated if necessary.
- Recommend partner notification and provide a factsheet.
- Notify the state or territory health department.
- Consider testing for other STIs if not already done at first presentation.
- Consider HIV pre-exposure prophylaxis (PrEP) for anyone diagnosed with gonorrhoea.
Contact tracing
Contact tracing for gonorrhoea is a high priority and should be performed in all patients with confirmed infection, to prevent re-infection and reduce transmission. All partners should be traced back for a minimum of 2 months. The diagnosing doctor is responsible for initiating and documenting this discussion.
Offer testing of exposed anatomical sites to all sexual contacts, and consider presumptive treatment if sexual contact occurred within the last 2 weeks, or where the contact’s circumstances mean later treatment may not happen.
Follow-up
Review at 1 week to confirm treatment adherence and symptom resolution, confirm contact tracing has occurred (or offer more support with it), and use the visit to discuss condoms, contraception, HIV PrEP/PEP, safe injecting practices, consent, cervical screening, and HAV/HBV/HPV vaccination as indicated.
Test of cure: for each infected site (pharyngeal, anal or cervical), TOC by NAAT should be performed 2 weeks after treatment is completed — especially if no gonococcal culture was collected before treatment, if a culture swab showed antimicrobial resistance, or if the patient was treated with a non-standard regimen.
Re-infection is common — retesting at 3 months is recommended to detect it, regardless of test-of-cure status. Consider testing for other STIs (including syphilis and HIV) if not already done, or repeat after the window period. If test of cure or retesting is positive, seek specialist advice.