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Strategies to prevent gonorrhoea

reinfection in men
Turner R (2012) Strategies to prevent gonorrhoea reinfection in men.
Nursing Standard. 26, 30, 35-39. Date of acceptance: January 20 2012.

Abstract
Gonorrhoea is a common sexually transmitted infection that is on the
increase in the male population in the UK. Gonorrhoea is becoming
increasingly resistant to antibiotics, making it harder to treat patients
effectively. Sexual health nurses therefore have a vital role to play in
preventing gonorrhoea reinfection. This article examines the ways in
which sexual health nurses can work with male patients to prevent
reinfection and effectively maintain their sexual health.

Author
Rosemarie Turner
Senior staff nurse, Chelsea and Westminster Hospital NHS
Foundation Trust, London.
Correspondence to: rosemarie.turner@chelwest.nhs.uk

Keywords
Gonorrhoea, infection prevention and control, mens health,
sexual health

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NURSING STANDARD / RCN PUBLISHING

p35-39w30.indd 35

The aim of this article is to examine the role of

the sexual health nurse in preventing gonorrhoea
reinfection in men. When men present at a clinic
with their first infection of gonorrhoea, strategies
for prevention of reinfection must be implemented
to maintain health and limit antibiotic resistance.
The Health Protection Agency (HPA) (2011a)
reported that 12,866 men were diagnosed with
gonorrhoea in the UK in 2010, which accounted
for 69% of the gonorrhoea diagnoses overall.
Diagnosis rates among men rose 9% in London
and 7% in England from 2009 to 2010 (HPA
2011b). There is a growing resistance to the
antibiotics used to treat gonorrhoea in 2000
the HPA set up the Gonococcal Resistance to
Antimicrobials Surveillance Programme (GRASP),
a national surveillance programme that monitors
the trends in the susceptibility of gonococcal
isolates to antibiotics (HPA 2011c).
Gonorrhoea is a common sexually transmitted
disease affecting men and women. It most
commonly affects the genitourinary tract and
occasionally the pharyngeal and rectal mucosa.
Gonorrhoea is transmitted by direct inoculation
of infected secretions via the mucous membranes
during vaginal, oral or anal sex. It is diagnosed using
a nucleic acid amplification test which identifies
the deoxyribonucleic acid (DNA) of the bacteria,
Neisseria gonorrhoeae. In men a throat or rectal
swab or a urine sample is taken for testing depending
on the sexual practices in which they are engaging.
Heterosexual men will usually only require a urine
sample; men who have sex with men will be offered
a urine sample and a rectal swab; throat swabs
are only usually offered to men who have sex with
men, as gonorrhoea rates are higher in this group.
In women a vaginal, rectal or throat swab is taken
for testing (HPA 2011a). Up to 80% of men with
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Art & science sexual health

gonorrhoea may be symptomatic, while up to
50% of women may have no symptoms (British
Association for Sexual Health and HIV 2011).
Gonorrhoea is not the most common sexually
transmitted infection; incidence of gonorrhoea is
lower than Chlamydia, genital herpes and genital
warts. However, it is extremely important to address
gonorrhoea infection due to the growing resistance
to antibiotics. Men have a high incidence of
gonorrhoea infection, with men who have sex with
men having the highest incidence of gonorrhoea.

Problems associated with gonorrhoea

The HPA (2011b) found that London genitourinary
clinics reported the highest rate of gonorrhoea
infections in England in 2010. At the inner London
sexual health clinic where the author works, there
were 241 diagnoses of gonorrhoea in men between
January and December 2010; this accounted
for 86% of gonorrhoea diagnoses in all patients
attending the clinic.
Gonorrhoea infection has the following
negative implications:
The
 patients health is at risk.
The
 health of all of the patients current and
recent sexual partners is at risk.
Babies

born to infected women are at risk of
gonorrhoeal conjunctivitis.
Gonorrhoea

strains resistant to antibiotic
treatment are becoming increasingly common,
which is not occurring with other sexually
transmitted infections.
The
 financial burden on the NHS for
gonorrhoea treatment is increasing.
Men infected with gonorrhoea are likely to
experience pain caused by urethritis, dysuria, a
green/yellow urethral discharge and long-term
health problems. Michaud et al (2007) found that
men who have a history of gonorrhoea infection
have a twofold increased risk of developing
bladder cancer later in life. This is because
urethritis can recur after treatment and is linked
to bladder cancer. Also, there is a risk that the
pain can become chronic as a result of recurrent
inflammation of the urethra. The patients current
and recent sexual partners are also at risk of
health problems. Infected women may experience
abdominal pain, green or yellow vaginal discharge
and itching, and burning or pain around the
vaginal and urethral orifice. Brocklehurst (2002)
noted that an infant may be infected during
childbirth while passing through the birth canal of
an infected mother. This may result in gonococcal
ophthalmia neonatorum, a profuse purulent
conjunctival discharge that can lead to blindness,
or a systemic infection.
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p35-39w30.indd 36

All sexual partners since the patients last

sexual health check or in the previous six months
must be contacted and treated. Delpech et al
(2009) reported that men who are infected with
gonorrhoea are more likely to have had two or
more sexual partners. If infected, these partners
may then pass the infection on to future partners
or may reinfect treated partners.
The more often patients reattend at clinics for
treatment, the greater the risk of the infection
becoming resistant to treatment. The HPA (2011c)
found in 2007 that penicillin and tetracycline
treatments were no longer effective treatments
for gonorrhoea. In 2008, England and Wales
had an endemic gonorrhoea that was resistant
to ciprofloxacin (HPA 2011c). Palmer et al
(2005) observed that gonorrhoea infection was
increasingly resistant to ciprofloxacin and that
the majority of the resistant strains occurred in
heterosexual men. These findings were supported
by Whiley et al (2007), who reported that
gonorrhoea has become increasingly resistant to
penicillins, tetracyclines, macrolides and quinolone
antibiotic groups. Therefore, since 2008 the HPA
has recommended the use of third-generation
cephalosporins as first-line treatment despite some
strains already being resistant to these antibiotics.
In response to all these findings, the British
Association for Sexual Health and HIV (2011)
advised that the only antibiotics recommended
for first-line treatment were cephalosporins. An
intramuscular injection of 500mg ceftriaxone
and 1g oral azithromycin should be offered to all
patients. Patients are also advised to refrain from
sexual contact for one week after treatment and
one week after partners have been treated.
Repeated treatment, time spent with healthcare
professionals and research into finding new
types of treatments for gonorrhoea are all
costly for the NHS. Helping patients to remain
free from infection will improve patients health
status, reduce the need for antibiotics and decrease
the burden on the NHS to fund research into
alternative treatments.

Annual cost of treating gonorrhoea in men

Patients spend no more than two hours in the
sexual health clinic. During this time they will see
a doctor, a nurse and a health adviser. They will be
given treatment on the same day if their diagnosis
is confirmed. Following diagnosis, they will return
to the clinic for repeat testing and a follow-up
appointment with the health adviser. In total, the
cost of treating 241 patients (the number of men
attending the authors clinic with gonorrhoea in
2010) over one year was 22,191.28. This cost is

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itemised in Table 1 and assumes that the patient

sees a doctor in the second year of their rotations,
a health adviser (band 6) and a band 5 staff nurse.
This does not take into account the ongoing
cost of treating health problems related
to untreated gonorrhoea in men such as
epididymo-orchitis and prostatitis. If these
problems occur before gonorrhoea is treated they
may become chronic (British Association for
Sexual Health and HIV 2011).

The nurses role in preventing reinfection

The literature highlights two ways of tackling the
problem of gonorrhoea reinfection:
The
 implementation of partner notification
programmes.
Schemes

to educate patients in risk reduction.
Partner notification programmes mean that sexual
partners of patients diagnosed with a sexual
infection are contacted and treated to prevent
infection spreading (Wilson et al 2009). Faldon
(2004) explained that partner notification may
break the chain of infection and it can be carried
out either directly by the patient or by the clinic on
the patients behalf. David et al (1997) researched
partner notification and demonstrated that they
were able to trace 1.7 contacts per patient, which
suggests that this method is a feasible option. This
intervention would be an effective way of preventing
reinfection where patients have regular partners.
At the clinic, patients are provided with paper
contact slips to give to their partners. These slips
contain the patients clinic number and can either
state the infection diagnosed or simply sexual
health infection if the patient does not wish to
disclose the specifics of the infection. By having the
patients clinic number, partners can be provided
with the correct treatment, but cannot be told
what the infection is without the patients consent.
Partners cannot be told what infection they have
been in contact with as this would break patient
confidentiality; if the partner does not want
treatment without knowing what infection they
may have, they are advised to wait for their test
results. An alternative option is for the clinic to
contact the partner/s on behalf of the patient. This
can be carried out anonymously if the patient does
not wish to be identified.
Both methods of partner notification can be
daunting for patients and their partners. Patients
may be concerned about informing partners and
experience emotions of embarrassment or shame,
while partners may be concerned about taking
treatment if they are not informed what infection
they may have been exposed to. No formal audits
were carried out at the clinic, and therefore it

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is not known how effective these methods of

partner notification are. The number of contact
slips brought to clinic is monitored, which gives
an indication of how many partners are
contacted; however, as not all patients choose
this method of partner notification, exact
numbers are not known. It would be useful to
implement a formal audit process to examine
which methods of partner notification are the most
effective. This is planned to be implemented in
summer 2012.
Partner notification is common practice in
many sexual health settings. It allows the patient to
consider the moral implications of not informing
their sexual partners of infection. It is also an
effective way of locating partners and informing
them if the patient chooses not to contact them, as
healthcare professionals in the clinic can contact
them directly. The drawbacks to this method are
that a patient may not be entirely honest regarding
who or how many sexual partners he has had, or
that he may not have a partners contact details.
There may be several reasons for this, such as
embarrassment at the number of partners or fear of
the ramifications of having sexual partners outside
of a long-term relationship. Nurses involved in
the patients care must ensure that any personal
values or convictions they hold relating to sexual
health are not made known. Their individual views
may exacerbate the patients anxiety, therefore
maintaining a professional manner while adhering
to facts and helpful advice is essential at all times to
reduce patients potential embarrassment.
At present, health advisers usually carry out
partner notification because their role is to support

TABLE 1
Cost of treating one episode of gonorrhoea infection in men
Aspect of care

Cost

60 minutes with doctor

12

30 minutes with health adviser (band 6)

7.68

30 minutes with nurse (band 5)

6.37

500mg ceftriaxone

0.39

1g azithromycin

2.56

Gonorrhoea culture plate (to test for antibiotic sensitivities)

4.73

Urine sample for gonorrhoea/Chlamydia trachomatis nucleic

acid amplification testing

22.15

Second 30 minute appointment with health adviser (band 6)

7.68

Second 30 minute appointment with nurse (band 5)

6.37

Urine sample for gonorrhoea/Chlamydia trachomatis nucleic

acid amplification testing

22.15

Total cost per patient

92.08

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Art & science sexual health

and inform patients following diagnosis. Nurses
have a direct role in partner notification when
they administer medication, as they then have the
opportunity to discuss with patients their feelings
about informing sexual partners and explaining
what treatment their partners may need. Nurses can
explain that treatment will not be effective unless
their partners are also treated and that medication
will have to be re-administered if the patient is
exposed to infection again. Overall, however, it
seems that health advisers are in the best position
to discuss partner notification with patients as this
conversation can be introduced while giving support
to patients regarding their diagnosis.
As well as informing partners about potential
infections, it is also important to consider why a
patient with an infection may behave in a manner
that will put him at risk of reinfection. Mehta
et al (2003) found that reinfected patients tend to
have different risk behaviours to those who are
not reinfected; for example, those who become
reinfected may have multiple partners and engage
in high risk sexual practices such as unprotected
sexual contact with multiple unknown partners.
In these cases, tracing partners may only succeed
in preventing temporary reinfection until the
patient finds new sexual partners who may also
be infected with gonorrhoea or another sexually
transmitted infection. Patients may not know who
their partners are or how to contact them (Risley
et al 2007). In this situation it would therefore
be impossible for the patient or staff at the clinic
to inform partners. Therefore, while partner
notification programmes may be successful
in some cases, other methods need to be used
alongside these programmes.
An example of this is behavioural management,
whereby patients are given back responsibility for
preventing reinfection. Trelle et al (2007) found
that patients were less likely to become reinfected
when they had a shared responsibility in managing
their health. One method of involving the patient
is to provide him with a contact card to give to
partners so they can seek appropriate treatment.
Bignell et al (2006) explained that when patients
understand the infection, its inherent risks and
how to prevent contracting it again, reinfection
is less likely to occur. Warner et al (2004) found
that patients and partners were more likely to
use condoms when they were properly informed
about gonorrhoea. This would explain why Shain
et al (1999) found that risk reduction teaching
resulted in fewer infective episodes. These studies
support the importance of education in reducing
gonorrhoea reinfection in men.
In the authors workplace, the time available
for discussion with patients can be limited.
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p35-39w30.indd 38

While partner notification is recognised as an

important part of treatment, the primary focus
is on administering treatment because patients
may only be in the clinic for up to two hours
and may leave before seeing all members of
staff. Therefore administering an injection of
ceftriaxone is prioritised over sending the patient
to the health adviser for partner notification.
An audit is being conducted to examine how
waiting times can be reduced, which it is hoped
will result in more time becoming available to
spend on partner notification and risk reduction
training. If the nurse administering the treatment
was appropriately trained to carry out partner
notification and risk reduction interventions,
the patient would have to see fewer people and
may therefore be more likely to engage in partner
notification. At the authors London clinic, patients
are offered verbal and written information.
There is also a telephone translation service to
ensure that patients whose first language is not
English understand the information given while
maintaining patient confidentiality.
Risk reduction appears to be an effective
strategy to prevent reinfection. The aim is to
teach patients how they became infected with
gonorrhoea, the risks of the infection and, most
importantly, how and why to avoid reinfection.
It is likely that male patients will want to avoid
infection in future as the symptoms, such as the
green/yellow discharge, are clearly visible. Nurses
have an opportunity to examine a patients
behaviour as they may have evidence of recent
sexual history and whether or not condoms are
used. Nurses can provide condoms, and many
sexual health nurses are trained in demonstrating
correct condom technique and advising on
different types of condom. As condoms are the
only reliable method of preventing sexually
transmitted infections, it is important the patient
understands how to wear them correctly.
If it becomes apparent that the patient is
engaging in unsafe sexual practices because of
psychological or mental health problems, then this
must be addressed by referral to an appropriate
professional. For example, if a patient explains
that unsafe sexual contact was due to being under
the influence of alcohol or drugs, the patient may
need to see a health adviser. The health adviser
can discuss with the patient the recommended
safe level of alcohol intake and how to stay safe
by involving partners in conversations regarding
condom use. Similarly, if the patient believes he
has a sex addiction he may require a psychosexual
referral to a psychologist. Risk reduction training
may have a positive outcome for the patient by
empowering him to take control of his actions, but

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it may be difficult for a nurse to achieve this in the

limited time available. It can be the role of the nurse
to approach this subject with the patient so that the
patient gives it consideration. Once this has been
done, the nurse can refer the patient on to a health
adviser or psychologist to continue the process.
A campaign to improve knowledge regarding
gonorrhoea among male patients by providing
a noticeboard of posters and information is also
recommended. National campaigns targeted at men
may benefit patients; advertising in mens magazines
and newspapers would provide information to
those who may not attend sexual health clinics.
However, patients may not read the leaflets or the
posters provided in the clinic if they do not see them
or fear being seen reading them by other patients.
Therefore, for these patients it may be useful to use
the motivational interviewing technique, in which
patients are supported by a trained member of staff
to go through a process of behaviour change (Klein
et al 2004). Through motivational interviewing,

patients are engaged with one staff member through

weekly meetings to discuss their progress and
develop ways in which to continue or introduce
positive behaviour. It may therefore be useful for
nursing staff to attend motivational interviewing
teaching sessions.

Conclusion
There are several ways in which nurses can prevent
reinfection of gonorrhoea in men. Treatment of
the patient and his sexual partner/s is only an
interim measure and should be used alongside other
methods to achieve long-term sexual health. It is
the role of the sexual health nurse to enable patients
to have a fulfilling, healthy and safe sex life. Nurses
can help prevent gonorrhoea reinfection by treating
patients promptly; ensuring they understand what
they are being treated for and why; explaining the
risks of recurrent infection; and by empowering
them to take control of their actions NS

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