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Gonorrhoea

Gonorrhoea infections have more than doubled in the UK in the past decade, with 85 223 cases reported in 2023 (UKHSA GRASP report 2024). It is the second most common STI in the UK, and disproportionately affects younger people aged 15–24y, men who have sex with men, people of Black Caribbean ethnicity and those living in areas of deprivation (BASHH Gonorrhoea guideline 2025).

Antimicrobial resistance is a significant global concern, but, thankfully, rates of multidrug resistance remain low in the UK, with only 6 cases detected since 2015. However, reduced susceptibility to first-line antibiotics is increasing, and resistance to penicillins, tetracyclines and ciprofloxacin is more common (UKHSA GRASP report 2024).

The British Association for Sexual Health and HIV (BASHH) updated its guidance on gonorrhoea in 2025. There were changes to the guidance on antibiotic choice, with ciprofloxacin no longer recommended as first-line treatment, and updated recommendations on testing for pharyngeal gonorrhoea in all cases and contacts of urogenital gonorrhoea.

This article was updated in June 2025.

Should we be screening for gonorrhoea?

UKHSA guidance recommends (gov.uk - detection of gonorrhoea in England accessed 2025, last updated 2021):

Testing for gonorrhoea:

If it is clinically indicated, i.e. if a patient:

Is symptomatic (see table below).
Reports a positive sexual contact.
Has a high-risk sexual history.

Screening for gonorrhoea:

Only in a population/setting with a gonorrhoea prevalence of ≥1% as, below this prevalence, the majority of positive results are likely to be false positive.
Routine screening in pregnancy is not offered in the UK (BMJ 2025;389:e084789).
The UKHSA recommends asymptomatic screening for those in a “high prevalence population” such as attendees at sexual health clinics (gov.uk - detection of gonorrhoea in England).

Management of gonorrhoea

In 2025, BASHH updated its guidelines on the management of gonorrhoea; the table below includes tips which may be helpful for us in primary care (BASHH guideline for the management of infection with Neisseria gonorrhoeae, 2025).

Characteristics	Neisseria gonorrhoeae is a gram-negative diplococcus which is transmitted sexually. Main sites of infection are: Urethra. Endocervix. Pharynx. Conjunctiva. Rectum. Secondary infection can occur systemically or transluminally.
Symptoms	May be asymptomatic (especially pharynx/rectum). May co-exist with other infections (e.g. chlamydia) which may be symptomatic. Rectal infection may present with anal discharge or pain (note: there may not be a history of anal sex). Pharyngeal infection may present with sore throat.
	MEN Urethral discharge >90%. Dysuria >50%. Less commonly: testicular pain.	WOMEN 50% endocervical infection asymptomatic OR Abnormal vaginal discharge. Lower abdominal pain (50% of cases). Dysuria. Rarely, intermenstrual or heavy menstrual bleeding.
Complications	Rare but serious. PID (up to 14% of women with gonorrhoea (BMJ 2025;389:e084789). Epididymo-orchitis. Prostatitis. Abscesses. Arthritis or tenosynovitis. Disseminated spread. Neonatal infection. HIV infection: current infection with gonorrhoea increases the risk of catching HIV by around 2.5% (BMJ 2025;389:e084789).
Diagnosis	If we suspect gonorrhoea clinically or a patient tests positive on a NAAT test, we should ideally refer to GUM for confirmation and management. Infection can be missed if a test is done too soon. Tests can take up to 14d after contact with an infected individual to become positive. Repeat testing should be offered after this period if empirical treatment has not already been given. Tests: NAAT and bacterial culture: see boxes below.
NAAT test	NAAT testing has >95% sensitivity in both symptomatic and asymptomatic infection. Better than culture, especially for oropharyngeal and rectal sites. A positive NAAT test requires testing for culture to confirm and check sensitivities BEFORE treatment. Self-taken NAAT has the same accuracy as a clinician-taken sample, which may help to widen access to testing for asymptomatic individuals, but it is not advised in symptomatic cases due to the wider microbiology samples also needed in this group (BMJ 2025;389:e084789).
	MEN First pass urine is recommended. Or can swab urethra (equally sensitive). Trans men: Test first pass urine if neopenis (surgically-created penis). Offer vaginal swabs (if has vagina and at risk or symptomatic.	WOMEN Vulvovaginal swab performs better than endocervical. Can be patient- or clinician-taken. Do not routinely test urine in women – significantly lower sensitivity for endocervical infection. Urine testing may be appropriate after hysterectomy in some cases. Trans women: Swab neovagina (surgically-created vagina). Test first pass urine.
	When investigating possible gonorrhoea, swab rectum and pharynx if history indicates (offer to all sex workers and men who have sex with men). Pharyngeal swabs should also be taken in anyone with a diagnosis of genital gonorrhoea and all confirmed contacts.
Microscopy and bacterial culture	Less sensitive – particularly in primary care as prompt laboratory processing is required to give acceptable results. Allows confirmatory identification and antimicrobial susceptibility (important due to increasing resistance).
	MEN Microscopy has sensitivity of 90–95% if urethral discharge present (but not if asymptomatic). Microscopy should be done on all men with rectal symptoms.	WOMEN Microscopy has poor sensitivity. Take endocervical and urethral swab for maximum sensitivity. Poor at picking up asymptomatic rectal infection.
Management: REMEMBER – ideally refer to GUM for this!	General advice: Screen for all other STIs. Confirm diagnosis with culture and sensitivities. Give patient information and safe sex advice. Recommend abstinence until 7 days after they and their partner(s) have completed treatment. Initiate partner notification. Treatment failures require reporting to UKHSA. Offer review after treatment to ensure resolution of symptoms.
	First-line antibiotic regimen for uncomplicated anogenital and pharyngeal infection: Ceftriaxone 1g IM as a single dose.. Test of cure is not routinely required, but should be done in the following situations: Pharyngeal infection. Pregnancy. Antimicrobial sensitivity is unknown. Non-first-line antibiotics were used. Persistent symptoms or signs. For alternative regimens or complicated gonorrhoea, see the BASHH guideline or (preferably!) refer to GUM.
	Note: ceftriaxone may be mixed with 1% lidocaine hydrochloride injection to reduce pain at intramuscular injection site (BNF, accessed August 2025).

New antimicrobial options

A BMJ editorial highlights 2 new antibiotics currently in phase 3 clinical trials. The oral topoisomerase inhibitors zoliflodacin and gepotidacin are potentially useful against gonorrohoea, although concerns have been raised about effectiveness against extra-genital infection (BMJ 2025;389:r1001).

Management of contacts of gonorrhoea

Test all contacts for infection using the methods outlined above. Pharyngeal swabs should be offered to all. Tests may not become positive until >14d after exposure.

Routine empirical treatment is not needed for all contacts, but may be offered to some individuals (BASHH guideline for the management of infection with Neisseria gonorrhoeae 2025):

If presenting >14d after exposure: treat only if test positive.
If presenting ≤14d of exposure, consider empirical treatment for:
- Pregnant people and their contacts.
- Those with limited access to return for follow-up testing: geographically remote, homeless, with other barriers to accessing healthcare such as substance misuse, mental health problems, financial or family constraints, including domestic abuse.
- Sex workers.

For all others presenting within 14d, including those who are asymptomatic, consider not treating empirically but testing 2 weeks after exposure and only treating if positive.

The use of DoxyPEP STI prophylaxis does not protect against gonorrhoea infection, and people using these regimens should follow the same guidance as all other contacts.

Immunisation programme

There is no licensed vaccine against Neisseria gonorrhoeae.

However, Neisseria meningitidis is closely related to Neisseria gonorrhoeae, and the 4CMenB vaccine (currently in use in the UK childhood vaccination programme as Bexsero) has shown real-world effectiveness against gonorrhoea, reducing infection risk by around 40%.

The JCVI has recommended an off-licence use of the 4CMenB vaccine for at-risk groups through sexual health services (gov.uk - JCVI advice on the use of meningococcal B vaccination for the prevention of gonorrhoea).

Eligible groups

From The Green Book, accessed June 2025:

Gay, bisexual and other men-who-have-sex-with-men (GBMSM) with a history of any bacterial STI in the past 12m.
- In those with a current gonorrhoea infection, the vaccine should be given at the same time as treatment of active infection, to avoid delay in offering protection.
GBMSM with ≥5 sexual partners in the past 3m.
People for whom risk assessment by a sexual health professional indicates similar risk: sex workers practising condomless sex, trans women and gender-diverse people who were assigned male at birth were highlighted in the JCVI guidance.

Schedule

2 doses at least 4 weeks apart, with no maximum time interval between doses.

Gonorrhoea

Numbers of diagnoses of gonorrhoea are increasing, and antibiotic-resistant strains are emerging.

Primary care practitioners should refer all cases of suspected gonorrhoea to the sexual health services for management.

Population screening is not recommended in low-prevalence areas.

Gonorrhoea may be asymptomatic, or cause genitourinary symptoms or abnormal vaginal bleeding in women.

There is an opportunistic immunisation programme with the 4CMenB vaccine in place through sexual health services for GBMSM at highest risk.

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