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Guidelines for Managing Sexually Transmitted Infections - WA
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2.4.3. Investigations

A definitive diagnosis of gonorrhoea is established by detecting N. gonorrhoeae in a clinical specimen by culture or by NAAT. Culture swabs are recommended whenever possible so that antimicrobial susceptibilities can be obtained. Serious resistance to gonorrhoea is emerging with few treatment options in the future being available, and antimicrobial surveillance is a vital public health measure.

A presumptive diagnosis of gonorrhoea is achieved by:

  • demonstrating at least two GNID in a smear made from a male urethral swab. Absence of neutrophils or gonococci on Gram stain does not exclude gonorrhoea.
  • demonstrating GNID in a smear from a patient with clinical features compatible with gonococcal infection.


If there is a discharge, take a urethral swab of the discharge for smear and transport in agar for culture. Collect first void urine (FVU) for NAAT. If the patient is unable to pass urine, another dry urethral swab of the discharge should be collected for NAAT.

  • If there is no discharge (a rare situation in male urethral gonorrhoea), collect FVU for NAAT.
  • Detecting GNID in a urethral smear is a reliable indicator of gonorrhoea, but the absence of diplococci does not exclude the diagnosis. For these reasons, always collect samples for culture and NAAT.
  • For men who have anally receptive sex with men, but are asymptomatic, take a blind anal swab (or instruct the patient how to collect a blind anal swab himself. Please refer to the STI Self Testing Card for instructions.) However, if the patient presents with anal symptoms, take a swab for microscopy and culture under direct vision of the rectal mucosa via a proctoscope.
  • Throat swabs for culture and for NAAT are recommended for men who have oral sex with men.


If cervical pus is present or the cervix is inflamed, take an endocervical swab for smear and culture, and an endocervical swab or cytobrush for NAAT.
If there is no discharge, take an endocervical swab or cytobrush for NAAT only. If a woman declines a vaginal examination and an endocervical swab cannot be taken, sampling from the genital tract by a self-obtained low vaginal swab (SOLVS) should be taken in addition to FVU for NAAT. Sampling of both the genital tract and urine increases the detection of gonorrhoea.

  • Endocervical swabs are essential for culture and high vaginal swabs are not adequate for culture. If the patient has had a hysterectomy, urine for NAAT must be collected.
  • Throat swabs for culture and sensitivity and for NAAT are recommended for women who have had oral sex.
  • Anal swabs for culture and sensitivity and for NAAT are recommended for women who have had anal sex.

Specimen collection and handling

  • It is important to collect suitable specimens before treatment because the diagnosis of gonorrhoea relies heavily on detecting the organism by culture or NAAT. Serology is not useful for gonorrhoea testing.
  • When delays of greater than 24 hours occur in getting the specimen to a laboratory (eg in rural and remote areas) NAAT is the preferred test. However, where there is pus, a culture should still be sent.

Special considerations

  • Allow slides to air-dry before sealing and labelling.
  • Clearly label all specimens with the patient's name, date of birth or medical record number, and the site, date and time of collection.
  • Specimens for culture should reach the laboratory as quickly as possible and preferably within 24 hours of collection.
  • If swabs for culture are unlikely to be processed in the laboratory within 24 hours of collection, they should still be sent, although the yield will be diminished.
  • Never put specimens for gonorrhoea culture in the refrigerator. Keep them in an insulated container between 10 °C and 25 °C.

See Section 1.3 for further information on methods of testing, including use of GeneXpert point-of-care test in health services where this is available.

A specific test for antibodies to syphilis. This test remains positive for life after syphilis has been contracted, whether treated or not.

A specific blood test for syphilis. This test remains positive for life after syphilis has been contracted, whether treated or not.

A test that measures antibodies to a protein called cardiolipin, which are formed during infection by Treponema pallidum. It can be quantified and hence can be used to monitor progress of infection or treatment.

A specific blood test for syphilis. This test remains positive for life after syphilis has been contracted, whether treated or not.

A test that measures antibodies to a protein called cardiolipin, which are formed during infection by Treponema pallidum. It can be quantified and hence can be used to monitor progress of infection or treatment.

That section of the Department of Health (Western Australia) with responsibility for communicable diseases including STIs/HIV.

The stage in HIV infection when the immune system is severely depleted and opportunistic infections and cancers develop.

A generic name for tests, most commonly the polymerase chain reaction (PCR), to detect the genetic material of an organism (eg Neisseria gonorrhoeae, Chlamydia trachomatis) in specimens of body fluids or tissues, rather than growing the organism itself. The tests work by amplifying the small amount of the organism’s genetic material in the specimen over a million-fold so that it can be more easily detected, making NAAT a very sensitive method.

A virus which attacks specific cells of the immune system giving rise to immune deficiency.

A condition characterised by lower abdominal pain caused by inflammation of the upper genital tract organs and their adnexae secondary to infection, that mimics a range of abdominal emergencies such as acute appendicitis or ectopic pregnancy and which can have serious outcomes, including peritonitis and infertility.

The Western Australian Centre for Pathology and Medical Research.

See Nucleic Acid Amplification Test (NAAT).
An examination technique that uses both hands, one for feeling the cervix through the vagina, and the other for feeling the body of the uterus through the lower abdominal wall. This provides considerable information about the state of the uterus, adnexae and the pelvic cavity.

A common reaction to treatment in patients with primary and secondary syphilis. It is a mild reaction with fever, headache, malaise, rigors and joint pains and lasts for several hours.

See Nucleic Acid Amplification Test (NAAT).
A test that measures antibodies to a protein called cardiolipin, which are formed during infection by Treponema pallidum. It can be quantified and hence can be used to monitor progress of infection or treatment.
An Aboriginal or Torres Strait Islander person who has undertaken a training program at a recognised training institution to act as a health worker for Aboriginal or Torres Strait Islander people. The precise role of Aboriginal health workers is still evolving and varies considerably both within WA and between the states.
A test for an antigen or antibody that uses a colour reaction produced by an enzyme to indicate a positive result.
A flagellated protozoan that causes inflammation of the vagina.

Mutual monogamy with a non-infected partner, avoiding multiple sexual partners or anonymous and other casual sex, and consistent and correct use of condoms with all partners not known to be free of infection.

Reference: Chin, J. (ed.) 2000, Control of Communicable Diseases Manual, 17th edn, American Public Health Association, Washington.

Enlargement of the liver and spleen.

Inadvertent piercing of the skin with a hyperdermic needle or other sharp instrument.

A chronic inflammatory disorder of unknown aetiology with recurrent ulceration of the oral and pharyngeal mucous membranes and the genital skin.

A pregnancy occurring outside the uterus, ie in the fallopian tube.

The delivery of an infant before the normal term of pregnancy.

A rare reaction to procaine penicillin, characterised by a sensation of impending doom with hallucinations.

Wart-like lesions seen in second stage syphilis, often in the perianal region and other warm moist areas.

First amount of urine passed (not a midstream sample nor first sample of the day).

The state of an immune system that has been suppressed and as a result does not produce antibodies. Such suppression may be medication-induced (eg corticosteroids), or by disease (eg HIV).

A patient's agreement to a medical procedure (including physical examination), obtained after telling the patient what will be done and why. Patients are entitled to know what risks, if any, are involved in medical procedures offered to them. No medical procedures can proceed without the patient's informed consent.

The process of identifying contacts of the index case so that they can also be given appropriate testing, counselling and treatment.

An inflammation of the conjunctiva or lining of the eye usually accompanied by purulent discharge.

Oral, vaginal, anal or some other form of sexual contact with the index case during the period when there was risk of transmission of infection.

An enzyme produced by some bacteria, that is capable of antagonizing the antibacterial action of penicillin and certain other antibiotics.

Inflammation around the liver, usually in the region of the portal vein and bile ducts.

The period after infection, before sufficient antibodies have developed to be detected by tests. Test results will be negative, although the person is infected and infectious.

Inflammation of the epididymis of the testicle.

The removal of the uterus by surgical operation.

A test for antibodies to various antigens. Particularly used to confirm a positive EIA test for HIV.

A potentially fatal allergic reaction to foreign protein or other substances.

Interviewing a patient to give advice and support. For patients with STIs, counselling involves education about risk behaviour, disease and treatment, and helping patients to cope with the psychosocial implications of their infection.

Diplococcus is the form of the organism causing gonorrhoea. It is a kidney shaped bacterium that occurs in pairs. This organism stains red with the Gram stain and hence is referred to as Gram-negative.
One of the variety of white cells circulating in the blood stream, an increase of which occurs mostly in response to bacteria.

A short tubular instrument used for examining the rectum.

The direct examination of the anorectal mucosa with the aid of a proctoscope.

Inflammation of the prostate gland.

Inflammation of the fallopian tubes.

Vaginal epithelial cells covered in bacteria and seen on a Gram stain of a high vaginal swab.

A common dye stain used in microbiology for classifying bacteria.

The original person identified with an infection. The index case may or may not have infected other persons but represents a starting point for the process of contact tracing (sometimes referred to as ”index patient”).

Inflammation of the meninges or the lining of the brain.

Inflammation of the urethra that may or may not be accompanied by a discharge.

A wire brush on a short stick for taking specimens from the cervix.

Inflammation of the rectum.

The process of testing individuals or individuals within communities who are not known to have an infection for the purpose of identifying otherwise unknown cases.

A skin rash of varying type due to allergy. The rash is usually itchy.

A rigidity of the muscles of the abdominal wall on physical examination; a sign of underlying peritonitis.

Inflammation of the testicle.

Sexual activity that minimises the risk of transmitting infection: no exchange of bodily fluids; no penetrative sex without the use of a condom.

Tests on the patient's serum (blood tests) to detect antibodies or antigens (eg hepatitis B surface antigen) to infectious agents.
A metal or disposable plastic instrument used to enable a visual examination of the vagina, ectocervix and cervical os.

A group of symptoms that patients describe, combined with the signs that providers observe during examination.

The ulcer of primary syphilis.

A person who has had sex with, shared injecting equipment with or has had some other high-risk exposure to the index case.

Pain on passing urine.

Granulomatous lumps that can occur in almost any organ; a manifestation of tertiary syphilis.

An infant from birth to the age of four weeks (28 days).

A thin latex rubber sheath worn over the penis for disease prevention or contraception.

Extension of columnar epithelium onto the vaginal surface of the cervix.

Amies transport medium: a semisolid solution of buffers and nutrients designed to preserve the viability of bacteria during transport to the testing laboratory.

The extent to which an antibody-containing substance can be diluted before losing its power of reacting with the appropriate antigen. Expressed as titres of 1:2, 1:4, 1:8, 1:16, and so on.

The term “NAAT” has been used throughout the Guidelines as a generic term, which includes “PCR” and “LCR”. See Nucleic Acid Amplification Test (NAAT).

Immunoglobulin of class G antibodies produced in response to an antigen. This immunoglobulin is longer lasting than IgM.

Immunoglobulin of class M antibodies. This antibody is produced on first exposure and the levels fall more rapidly than do those of lgG.

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Last Updated - 20/10/2015
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