Men infected with N. gonorrhoeae typically experience symptoms such as urethral discharge or painful urination (dysuria) within 2-5 days after exposure. Fewer than 10 per cent of men have asymptomatic gonorrhoea.2 
Around half of infected women are asymptomatic. If symptoms do occur in women, such as dysuria, increased or altered vaginal discharge or abdominal pain, this is usually within 10 days. Women may experience pain on intercourse if the infection spreads from the cervix. 
Pharyngeal infection is asymptomatic in more than 90 per cent of cases but it may cause tonsillitis or pharyngitis. 
NICE advises that gonorrhoea should only be treated in primary care if specialist services cannot be accessed within a reasonable time. Antimicrobial resistance (AMR) among STIs has increased significantly in recent years, with gonorrhoea becoming a specific global concern.1,19 
Global data from the Gonococcal AMR Surveillance Programme (GASP) has found high rates of quinolone resistance, increasing azithromycin resistance and emerging resistance of extended-spectrum cephalosporins, reserved for last-line treatment. With AMR already shown to penicillins, sulphonamides, tetracyclines, quinolones and macrolides, N. gonorrhoeae has become a multidrug-resistant organism.1 
The UK adopted the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) protocol in 2000 to test for and monitor AMR in N. gonorrhoea and potential treatment failures. GRASP data has been used to revise national treatment guidelines in 2005, 2011 and 2019.19 
For uncomplicated gonorrhoea, the NICE CKS first-line recommendation for primary care treatment is for ceftriaxone 1g as a single intramuscular (IM) dose. This is also the recommendation for pregnant women. The BNF says oral ciprofloxacin could be considered instead if the organism is known to be susceptible.2,20 
Alternative approaches if ceftriaxone is contraindicated are:2 

• cefixime 400 mg (oral, single dose) + azithromycin (oral) or
• gentamicin 240mg (IM, single dose) + azithromycin 2g (oral) or
• spectinomycin 2g (IM, single dose) + azithromycin 2g (oral). 

If an injection is not possible, then azithromycin 2g (oral, single dose) can be tried on its own, but with the caveat of high levels of azithromycin AMR.