Mastering Uncomplicated Gonorrhoea Guidelines for PLAB 2 Success

Mastering Uncomplicated Gonorrhoea Guidelines for PLAB 2 Success

Sexual health scenarios are high-yield and frequently tested in the PLAB 2 OSCE examination. These stations require not only accurate clinical knowledge but also sensitivity, strong communication skills, and adherence to crucial UK public health guidance, such as partner notification and safeguarding. Among the most critical infections to master is Uncomplicated Gonorrhoea, due to rising prevalence and the increasing threat of antimicrobial resistance.

As a specialist examiner, I can confirm that candidates are assessed rigorously on their ability to manage this condition according to current UK standards (primarily BASHH guidelines).

1. The Clinical Presentation and Diagnosis (PLAB 2 Approach)

In a PLAB 2 station, you must first ascertain the patient's symptoms and risk factors, ensuring a non-judgemental approach.

Key Diagnostic Steps:

1. History: Elicit symptoms (e.g., urethral or vaginal discharge, dysuria, intermenstrual bleeding, rectal discomfort, pharyngeal symptoms). Remember, most Gonorrhoea infections are asymptomatic (especially pharyngeal and rectal infections).

2. Risk Assessment: Identify potential exposure, number of partners, and previous STI history.

3. Specimen Collection (Essential for OSCE):

   • Men: First-catch urine (FCU) for Nucleic Acid Amplification Test (NAAT). Urethral swabs are often reserved for symptomatic cases.

   • Women: Endocervical or high vaginal swab (HVS) for NAAT. FCU can also be used, but swabs provide better yield.

   • Non-genital Sites: Rectal and pharyngeal swabs for NAAT must be collected based on history (even if asymptomatic) if the site was potentially exposed.

Diagnosis in PLAB 2: You generally diagnose based on a positive NAAT or microscopy (Gram stain showing Gram-negative intracellular diplococci, though NAAT is the standard).

2. The UK Standard Treatment Guidelines (Medical Guidelines Focus)

The treatment of Gonorrhoea must address the potential for resistance, which is why UK guidelines mandate dual therapy, even for uncomplicated cases, to maximise cure rates and reduce resistance development.

A. First-Line Management (Uncomplicated Anogenital & Pharyngeal)

The standard treatment in the UK (BASHH Guidelines) is:

• Ceftriaxone 1 g administered as a single intramuscular (IM) injection (or IV if IM is contraindicated).

Note on Dual Therapy: Historically, Azithromycin was combined with Ceftriaxone. However, due to concerns about macrolide resistance, the BASHH 2019 guideline update advises against routine dual therapy unless local guidelines specify otherwise, or if there is a risk of missed chlamydia coinfection where chlamydia testing is pending or unreliable.

• Crucial Communication Point: If co-infection with Chlamydia is suspected or testing is pending, you must also prescribe Doxycycline 100 mg twice daily for 7 days (as Chlamydia is more common than resistant Gonorrhoea).

B. Handling Treatment Failure and Allergy

1. Penicillin Allergy: If the patient has a significant penicillin allergy, treatment often involves specialized regimens guided by sensitivity testing. Options may include high-dose Gentamicin (IM) or Cefixime, but these should be discussed with a specialist.

2. Resistance: If symptoms persist post-treatment (treatment failure), a Test of Cure (TOC) must be performed, and the sample sent for culture and sensitivity. Resistance to Ceftriaxone is a major public health concern.

3. Safety Netting, Public Health, and Follow-Up

These public health and safety components are paramount in the PLAB 2 examination, testing your fitness to practice in the UK.

The Crux of the OSCE Station

Remember, in the PLAB 2 exam, you must demonstrate competence in three areas:

1. Clinical Knowledge: Correctly identifying the necessary swabs and prescribing the 1g IM Ceftriaxone.

2. Communication: Maintaining confidentiality, using non-judgemental language, and clearly explaining the abstinence period.

3. Public Health Duties: Thoroughly explaining Partner Notification and the importance of the Test of Cure.