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Last year saw the highest ever number of gonorrhoea notifications in WA, following a decline in notifications in 2020 and 2021due to COVID-19-related travel restrictions limiting importation of overseas strains.
Opportunistic testing is important for prompt diagnosis and treatment because 80% of people with uncomplicated gonococcal cervicitis, most people with gonococcal pharyngitis or proctitis, and 10-15% of people with gonococcal urethritis have no symptoms.
Routine sexually transmissible infection (STI) testing every three months is recommended for people who may be at higher risk, such as men who have sex with men. Ask the patient about sexual practices to ensure correct specimen collection sites.
How to test for gonorrhoea
Consider routinely offering throat and rectal swabs in addition to a first void urine (FVU) for people with a penis and self-obtained lower vaginal swab (SOLVS) for people with a cervix, as well as blood-borne virus (HCV, HBV, HIV) and syphilis serology.
Consider gonococcal urethritis in sexually active patients presenting with dysuria or symptoms of a urinary tract infection. Make sure to collect a FVU for gonorrhoea and chlamydia PCR, in addition to a mid-stream sample for culture. This enables diagnosis of both conditions.
People with urethral or cervical discharge should have a swab of the discharge collected for culture and antimicrobial resistance (AMR) testing, in addition to a PCR test. Culture enables identification of AMR strains – especially ceftriaxone resistance – which is important because they are highly prevalent in many south-east Asian countries frequented by Australians.
Treatment options for gonorrhoea
Empirical treatment of sexually active people who present with a urethral or vaginal discharge is important to prevent complications in the patient. It can also limit community transmission by reducing the duration of infectivity.
Ceftriaxone 500mg in 2mL 1% lignocaine as an intramuscular injection, given with oral azithromycin – 2g for pharyngeal, and 1g for rectal infections – or 100mg doxycycline daily for 1 week remains the mainstay of gonorrhoea treatment.
As with all STIs, partners should be informed promptly so they can be tested and offered empirical treatment while awaiting pathology testing. This will interrupt ongoing transmission back to the index case and others in the community.
Opportunistic testing
Routinely and opportunistically offering STI testing helps patients feel comfortable and willing to discuss their sexual health.
Examples of conversation starters could include:
Young people: “STIs are very common among people of your age, and most STIs do not show any symptoms. We encourage all sexually active young people to get tested regularly.”
Aboriginal people (MBS item 715): “As part of your health check we also ask about your sexual health. Are you happy if I ask some questions today? You might feel a bit embarrassed, but I ask everyone the same questions and it helps me to know what to test you for depending on your risks. Do you have any questions before we start?”
Reproductive health consultations: “While you’re here for advice about contraception/cervical screening it’s a good time to talk about other areas of sexual health, like having a sexual health check-up…”
Antenatal and pre-pregnancy consultations: “STIs are common among people of reproductive age and most STIs do not show any symptoms, but they can cause serious illness in mothers and babies, including stillbirth.
“We encourage everyone who is pregnant or contemplating pregnancy to have a sexual health check-up. We also encourage pregnant people to have syphilis testing at their first pregnancy checkup and at 28 and 36 weeks, so that if they have an STI it can be treated early before it affects mum’s or baby’s health.”
Specimen collection
Most patients can collect their own FVU, SOLVS and rectal swab for opportunistic STI testing. Throat swabs are best collected by a clinician.
Key messages
- Opportunistic and routine STI testing every three to 12 months depending on risk is important because most STIs do not show any symptoms
- Consider gonococcal urethritis in sexually active patients presenting with dysuria or symptoms of a urinary tract infection. Collect first void urine for gonorrhoea and chlamydia PCR, and a mid-stream sample for culture
- Ceftriaxone 500mg in 2mL 1% lignocaine as an intramuscular injection, given with oral azithromycin – 2g for pharyngeal, and 1g for rectal infections – or 100mg doxycycline daily for 1 week remains the mainstay of gonorrhoea treatment.
Specimen collection for sexually transmissible infection tests
Preparing swabs for patient self-collection
- Show the swab to the patient.
- Label all tubes and urine jar with the patient’s details to avoid handling the tube after the patient returns the specimen.
- Moisten the tip of the swab with saline or sterile water.
- Put all equipment in the specimen bag and hand to the patient.
- Review the collection process with the patient and remind them to put the swab inside the tube, seal the tube and put the sealed tube inside the specimen bag.
Clinician collected specimens
- If patients have any symptoms, a physical examination and clinician collected swab samples are recommended.
- Throat swabs are difficult for patients to collect, therefore clinician collected throat swabs are recommended for symptomatic and asymptomatic patients.
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