Clinical features, diagnosis incl specimen collection

Signs and symptoms in men:

• mucopurulent/purulent urethral discharge
• dysuria
• anal discharge
• perianal/anal pain or discomfort
• epididymal tenderness/swelling
• balanitis

Signs and symptoms in women:

• often no signs or symptoms are present
• increased/altered vaginal discharge
• pelvic/lower abdominal tenderness/pain
• dysuria
• mucopurulent endocervical discharge
• easily induced endocervical bleeding
• intermenstrual bleeding/ menorrhagia (rarely)

Complications:

• epididymitis
• prostatitis
• endometritis
• pelvic inflammatory disease (PID)
• haematogenous dissemination leading to skin lesions, arthralgia, arthritis, and tenosynovitis

1. Microscopy

Gram negative intracellular diplococci

(NB Microscopy provides a provisional diagnosis – always make this clear. Final diagnosis is the result of the PCR and/or culture).

If microscopy not available on site, dry the slide on a hotplate/airdry and transport as per guideline for gram-stain and microscopy at local lab.

2. NAAT

Nucleic acid amplification testing (NAAT) is a new technique which facilitates less invasive testing and examination.

NAAT testing is emerging as the primary method of excluding gonorrhoea from ano-genital and pharyngeal sites (although not yet licensed for use in rectum and pharynx).

A positive result from a GC NAAT should always, with patient consent, have a culture swab by repeat sampling prior to treatment and sending the specimen to the appropriate bacteriology lab for direct plating. This allows antibiotic susceptibility testing and resistant strains can be identified.

There is a small risk of false positives with NAAT testing so counselling/partner notification should take this into account, especially if the clinical likelihood is low.

3. Culture

When doing a culture for GC, a NAAT test (if available in your health board) should be performed at the same time. Culture is used for:

• Clinical locations where NAAT testing is unavailable
• Any genital or rectal discharge
• Suspected PID / cervicitis
• Contacts of gonorrhoea – prior to epidemiological treatment
• Pharyngeal specimens (pending further validation)
• Rectal samples in men who have sex with men (MSM)
• Any NAAT-positive case with no previous culture performed (state on request that NAAT positive)

The following table shows which tests should be taken:

* Take test if client is:

• symptomatic from this site or
• GC NAAT positive at this site or
• gonorrhoea contact at this site or
• post sexual assault and penetration has occurred in these sites

Urine

10mls first void urine (NB technique should be carefully explained to patient, to ensure that the correct sample is obtained) in a plain universal container. The patient must not have urinated for at least one hour (or two hrs for some kits).  NB Do not insert urinalysis dipsticks in the sample, as it may introduce contamination and adversely affect the amplification process.

Cervix

Remove visible mucopus first, then firmly rotate in cervical os and over squamo-columnar junction. Try and avoid bleeding which can reduce sensitivity.

Vulvovaginal swab

This may be self taken by patient (self obtained vulvo-vaginal swab - SOLVS) or by the clinician.

Insert the dry swab approx 5 cm into the vagina and gently rotate the swab for 10 to 30 seconds according to local manufacturer's instructions. Bleeding may reduce sensitivity.

Pharyngeal swab

Rub the swab over the posterior pharynx and tonsillar crypts.

Rectal swab

• Proctoscopy: The swab should be rubbed against the rectal wall.
• Blind: The swab should be inserted 3cm into the anus and rotated for 10 to 30 seconds.

There have been incidences of the swab which comes with the kit breaking in the rectum. Clinicians may prefer, therefore, to use a separate swab with no breaking point on it.

In certain circumstances, a self collected rectal swab is acceptable.