Red Flags — Disseminated Gonorrhoea, Malignancy & Retention
Take a focused sexual and clinical history and obtain appropriate specimens before treatment whenever possible. Do not delay treatment in severe urethritis, suspected disseminated gonococcal infection, severe epididymo-orchitis or systemic illness — arrange sexual-health or hospital management. This guide is intended primarily for patients aged 16 and over; under-16s need safeguarding assessment, careful consideration of consent and advice from paediatric sexual-health or specialist services (BASHH children and young people guideline).
Discharge + fever/systemic illness + migratory polyarthralgia, tenosynovitis, pustular skin lesions, arthritis or meningitic features Suspected disseminated gonococcal infection (DGI) → same-day hospital/GUM assessment; 999 if clinically unstable or unsafe to transfer. Obtain blood cultures and relevant disseminated-site specimens, but do not delay specialist treatment.
Penile mass or ulcer — NICE NG12 (updated April 2026) Consider a suspected cancer pathway referral for penile cancer if there is a penile mass or ulcerated lesion when an STI has been excluded, a persistent penile lesion after STI treatment has been completed, or unexplained or persistent symptoms affecting the foreskin or glans. → Suspected cancer: urology
Purulent discharge + suspected cephalosporin resistance (sex abroad, e.g. Asia-Pacific, or a contact of a resistant case) Possible extensively drug-resistant gonorrhoea. Same-day GUM so that cultures are taken before treatment and the regimen is guided by susceptibility.
Discharge + acute unilateral scrotal pain and swelling Epididymo-orchitis vs testicular torsion. If torsion is possible (sudden severe pain, especially under 25s, high-riding testis, absent cremasteric reflex) → immediate emergency urology referral — do not wait for a scan. Epididymo-orchitis with STI risk → same-day GUM or emergency assessment; STI tests and urine culture; treatment must cover gonorrhoea and chlamydia per the current BASHH epididymo-orchitis pathway (check local guidance — fluoroquinolone use is restricted).
Severe genital or perineal pain, swelling, erythema, fever or systemic illness Possible Fournier's gangrene → 999 — immediate emergency hospital assessment, whether or not the patient takes an SGLT2 inhibitor.
Painless penile/oral ulcer + inguinal lymphadenopathy + sexual risk history Primary syphilis chancre. Syphilis serology (treponemal antibody, with RPR if reactive) and GUM same day for dark-ground/PCR testing of the ulcer.
How to use this step
Most men with discharge have an uncomplicated STI; these red flags pick out the few who need same-day hospital, same-day GUM or a suspected cancer pathway. Ask specifically about fever, joint or skin symptoms, scrotal pain, difficulty passing urine and any lump or ulcer on the penis.
Sexual assault
If the history suggests assault, offer referral to a sexual assault referral centre (SARC) — forensic samples, HIV post-exposure prophylaxis and emergency support are time-critical.
Cases of ceftriaxone-resistant gonorrhoea, several linked to travel, have been reported in England, which is why BASHH (gonorrhoea guideline 2025) keeps ceftriaxone 1 g IM as sole first-line therapy and asks for a gonococcal culture before treatment wherever possible, so that susceptibility can be tested. Ciprofloxacin is used only when the isolate is known to be susceptible. This is the practical reason suspected gonorrhoea is managed in GUM rather than with oral antibiotics in general practice. Epididymo-orchitis vs torsion: epididymo-orchitis is usually more gradual, with a tender, swollen epididymis behind the testis, often with discharge or dysuria; torsion is sudden and severe, often with nausea. No single clinical sign reliably excludes torsion and imaging must not delay surgical exploration, so any real doubt means emergency referral. Penile cancer is uncommon and usually affects older men, but a lesion that persists after STI treatment is exactly the scenario NG12 targets.
2
Diagnose
Classification — Causes of Penile Discharge
Urethral — STI
Gonorrhoea (profuse purulent, usually 2–7 days post-exposure) · NGU: Chlamydia, Mycoplasma genitalium (15–25% of NGU; macrolide resistance common in UK strains), Trichomonas, adenovirus and HSV (the latter two often with meatitis or conjunctivitis)
Non-STI urethral
Post-catheter/instrumentation urethritis · Chemical (soaps, lubricants) · Reactive arthritis (urethritis + arthritis + conjunctivitis) · Prostatitis (perineal pain + systemic features) · UTI (uncommon young men — investigate structural cause)
Preputial / glans
Candidal balanitis (white cheesy under foreskin, itch, erythema — glucose/HbA1c if severe, persistent or recurrent) · Bacterial/anaerobic balanitis (phimosis, foul-smelling) · Zoon's plasma cell balanitis (bright red glazed patches — biopsy required) · Contact dermatitis. Candida may be opportunistic — a positive subpreputial culture does not establish causation; recurrent/persistent balanitis → consider irritant/contact dermatitis, lichen sclerosus, psoriasis, Zoon balanitis, penile intraepithelial neoplasia, diabetes, immunosuppression or STI.
Timing: discharge within a week of a new partner favours gonorrhoea; 1–3 weeks favours chlamydia/NGU. Character: copious yellow-green pus favours gonorrhoea; scant clear or mucoid discharge, often only first thing in the morning, favours NGU. Site: discharge from under the foreskin rather than the meatus points to balanoposthitis. Associated: conjunctivitis and joint pain suggest reactive arthritis; perineal pain and fever suggest prostatitis.
What is not discharge
Pre-ejaculate, post-micturition dribble and spermatorrhoea can be mistaken for discharge. A clear, non-staining fluid only with arousal needs reassurance, not antibiotics.
Mycoplasma genitalium accounts for roughly 15–25% of NGU and is common in persistent and recurrent urethritis. BASHH NGU guidance (2015; updated 2026) replaced azithromycin 1 g stat with doxycycline 100 mg BD × 7 days as first line, because single-dose azithromycin was driving macrolide resistance in M. genitalium. Doxycycline treats chlamydia reliably but cures only a minority of M. genitalium infections, so persistent NGU after doxycycline → GUM for M. genitalium NAAT with resistance testing; GUM then chooses between an extended azithromycin course (macrolide-susceptible) and moxifloxacin (macrolide-resistant) per the BASHH M. genitalium guideline. Do not screen asymptomatic patients for M. genitalium routinely; moxifloxacin carries MHRA safety restrictions. Avoid repeated empirical azithromycin or doxycycline courses in primary care.
3
Diagnose
Sexual History, Examination & Investigations
Sexual history (BASHH minimum)
Partners (number + gender, last 3 months) · Activity (oral/vaginal/anal, insertive/receptive) · Condom use · Last sexual contact · Previous STIs · HIV status (offered all) · Hep B/C · Chemsex enquiry (crystal meth, GHB/GBL, mephedrone — high STI transmission, PrEP/harm reduction needed) · Recent antibiotics · PrEP use · Previous partner notification
Consultation set-up
Offer a chaperone for the genital examination; explain confidentiality (including for under-16s, applying Fraser guidance) and ask about safeguarding concerns — sexual assault, coercion, exploitation, trafficking, age-disparate relationships or other abuse — and explain the limits of confidentiality.
FVU 10–20 ml (first-void urine — NOT MSU) for chlamydia + gonorrhoea NAAT · Urethral swab for gonococcal culture (susceptibility) before antibiotics if gonorrhoea is suspected — usually taken in GUM, or send promptly if taken in the surgery · Pharyngeal ± rectal NAAT according to exposure (pharynx in everyone with urogenital gonorrhoea and all contacts) · M. genitalium NAAT with macrolide-resistance testing where NGU is confirmed (usually via GUM) · Syphilis serology treponemal antibody screen + RPR · HIV 4th gen · Hep B/C if risk · Glucose/HbA1c if balanitis is severe, persistent or recurrent · Subpreputial swab only if balanoposthitis is significant, recurrent or bacterial infection is suspected
First-void urine (FVU) is the standard NAAT specimen in men: the first 10–20 ml carries the urethral cells, whereas a midstream sample dilutes them and lowers sensitivity. Instruction: ideally avoid passing urine for an hour or two beforehand, then collect only the very first part of the stream. Write 'FIRST VOID URINE — CHLAMYDIA NAAT' on the request form. Chemsex: crystal meth + GHB/GBL + mephedrone during sex (predominantly MSM) — associated with MDR gonorrhoea, HIV, HCV. Non-judgmental enquiry: 'Some people use substances to enhance sex — does that apply to you?' Positive → GUM (multi-site testing, PrEP assessment, HCV screen, harm reduction: never mix GHB with alcohol, carry naloxone, 56 Dean Street/GMFA).
4
Diagnose
Investigation Framework
GP-feasible STI screen
FVU (or validated self-collected specimen) for chlamydia + gonorrhoea NAAT; gonococcal culture with susceptibility if gonorrhoea is suspected. Pharyngeal/rectal NAAT according to exposure. Syphilis serology + HIV. Hep B/C if risk. Glucose/HbA1c if balanitis is severe, persistent or recurrent.
GUM advantages
Multi-site testing for MSM (pharyngeal + rectal NAAT — extragenital infection is often asymptomatic) · IM ceftriaxone · POCT same-day results · Partner notification officers · PrEP/PEP access · Chemsex support
GP management appropriate
Candidal balanitis (no STI features). Chemical/irritant urethritis. Confirmed uncomplicated Chlamydia: doxycycline + partner notification (local sexual health services can take over partner notification if the practice cannot).
Results you may meet
Chlamydia positive: treat (check pregnancy, breastfeeding, allergy and interactions — doxycycline is generally avoided in pregnancy, which needs an alternative regimen, sexual-health advice and test of cure); document partner-notification advice and offer GUM referral for confidential contact tracing; offer retesting after treatment, particularly if at increased risk (reinfection is common). Gonorrhoea positive on NAAT: same-day GUM (or locally agreed pathway) for culture and ceftriaxone — do not substitute oral treatment routinely. Both negative with ongoing symptoms: GUM for objective confirmation of urethritis (microscopy or a validated laboratory method) — do not diagnose NGU on discharge appearance alone; confirmed NGU → M. genitalium NAAT with resistance testing.
GUM referral mandatory
Confirmed or probable GC · MSM (multi-site testing) · Persistent NGU after doxycycline · Complications (epididymo-orchitis) · Syphilis · HIV reactive · Chemsex
Extragenital gonorrhoea and chlamydia are often asymptomatic, so test the pharynx and rectum according to exposure; pharyngeal testing is also advised for everyone with urogenital gonorrhoea and all contacts (BASHH 2025). MSM are advised to have at least an annual HIV/STI screen, and every 3 months if having condomless sex with new or casual partners. PrEP (tenofovir/emtricitabine, daily or event-based) is highly effective at preventing HIV and is available free through NHS sexual health clinics — GPs identifying higher-risk patients should direct them there. HIV post-exposure prophylaxis should be started as soon as possible, ideally within 24 hours and not beyond 72 hours (BHIVA/BASHH PEP guideline 2021) — refer to GUM or the emergency department immediately.
Confirmed or probable GC (or locally agreed specialist pathway; ceftriaxone may be given in general practice only under local governance) · MSM (multi-site testing) · XDR gonorrhoea · Reactive syphilis serology or syphilitic ulcer (urgent GUM) · Reactive HIV test (same-day specialist pathway — do not communicate a diagnosis without confirmatory testing) · Chemsex · Sexual assault / PEP within 72h
GUM (1–5 days)
Penile discharge with possible STI, clinically stable (same-day if severe or complicated) · Persistent/recurrent NGU (objective confirmation of urethritis + M. genitalium testing) · Epididymo-orchitis + STI screen · Partner notification support
Suspected cancer: urology
NICE NG12 (updated April 2026): penile mass or ulcerated lesion with STI excluded; persistent penile lesion after completed STI treatment; or unexplained or persistent symptoms affecting the foreskin or glans → consider a suspected cancer pathway referral (NG12). Do not delay with prolonged empirical treatment — describe/photograph the lesion, arrange STI testing promptly and refer without avoidable delay.
Urology (urgent)
Blood-stained discharge without a clear infective cause (persistent discharge from under the foreskin can also be a penile-cancer presentation — consider the NG12 route) · progressive stricture symptoms (poor stream, spraying, incomplete emptying)
Persistent red/glazed patches of the glans not responding to treatment (possible Zoon balanitis or penile intraepithelial neoplasia — biopsy may be required) · Recurrent balanitis or phimosis — assess diabetes/dermatosis, then GUM, dermatology or urology depending on findings
GP management
Candidal balanitis: clotrimazole 1% cream BD for 7–14 days, or fluconazole 150 mg single oral dose for more severe symptoms (BASHH balanoposthitis guideline 2026). Confirmed Chlamydia (uncomplicated): doxycycline 100 mg BD × 7 days + partner notification.
Test of cure (TOC) after gonorrhoea: the BASHH 2025 guideline no longer requires routine TOC for anogenital infection treated with ceftriaxone 1 g when the isolate is ceftriaxone-susceptible, because treatment failure has not been reported in that situation. TOC remains recommended for persistent symptoms or signs, pharyngeal infection, unknown susceptibility, treatment with a regimen other than ceftriaxone, and pregnancy. Where performed: culture if symptomatic, at least 72 hours after treatment; NAAT if asymptomatic, at least 2 weeks after treatment, with culture if NAAT positive. Culture is what reveals resistance, which is the fundamental reason gonorrhoea belongs in GUM. Partner notification look-back periods depend on the infection and symptoms (for example 4 weeks before symptom onset for men with symptomatic NGU or chlamydia, with longer periods for asymptomatic infection and for syphilis) — GUM health advisers set these case by case. SXT app (sxt.org.uk) enables anonymous partner notification by text/email — no direct contact details needed.
6
Treat
Treatment by Diagnosis
Gonorrhoea
Ceftriaxone 1 g IM stat (via GUM or locally agreed pathway)
Recommended regimen for uncomplicated anogenital and pharyngeal infection in adults (BASHH 2025); culture with susceptibility before treatment where feasible; do not substitute oral treatment routinely. Discuss urgently with GUM/microbiology if suspected resistance, treatment failure, ocular infection, DGI or acquisition in a high-resistance setting. TOC not routine for susceptible anogenital infection with resolved symptoms; required for persistent symptoms, pharyngeal infection, unknown susceptibility, a non-ceftriaxone regimen or pregnancy. Partner notification per GUM. Abstain until partners treated and 7 days after treatment.
NGU first-line
Doxycycline 100 mg BD × 7 days
Severe confirmed or probable NGU: treat immediately (BASHH NGU 2026). Mild symptoms: consider awaiting NAAT/microscopy if reliable follow-up is available. Treats chlamydia reliably; cures only a minority of M. genitalium. NOT azithromycin 1 g stat (drives macrolide resistance). Partner-notification look-back per GUM (typically 4 weeks before symptom onset for symptomatic NGU). Abstinence until both treated. Doxycycline is generally avoided in pregnancy.
NGU recurrent/persistent
Refer to GUM: M. genitalium NAAT with macrolide-resistance testing, then regimen per BASHH M. genitalium guideline
Confirm urethritis objectively before further antibiotics. Treatment is resistance-guided and normally GUM-directed (macrolide resistance is common; doxycycline alone has low eradication efficacy). Do not screen asymptomatic patients routinely. Avoid blind repeated courses in primary care; moxifloxacin and other fluoroquinolones carry MHRA restrictions (January 2024).
Candidal balanitis
Clotrimazole 1% cream BD for 7–14 days, or fluconazole 150 mg oral single dose if more severe
BASHH balanoposthitis 2026. Add 1% hydrocortisone with the imidazole if very inflamed. Consider nystatin if imidazole allergy or suspected resistance. Glucose/HbA1c if severe, persistent or recurrent. SGLT2i: shared decision, not automatic withdrawal. Routine treatment of asymptomatic partners is not required; symptomatic partners should be assessed and treated according to their diagnosis. Fluconazole caution: pregnancy (avoid without specialist advice), significant liver disease, QT-prolonging drugs, warfarin and other interactions, repeated/high-dose use — check the SPC.
Bacterial balanitis
Water/saline cleansing; systemic antibiotics only when clinically indicated
Clean gently with water or saline; avoid soaps and irritants. If significant purulence, oedema, foul smell, recurrence or suspected bacterial balanitis: subpreputial swab where feasible; exclude STI and dermatosis. Suspected anaerobic balanoposthitis (a clinical diagnosis): metronidazole 400–500 mg BD × 7 days is a BASHH option; otherwise antibiotics guided by culture and local antimicrobial advice. Persistent or recurrent disease → GUM, dermatology or urology; assess for phimosis or underlying dermatosis (BASHH balanoposthitis 2026).
Before prescribing
Pregnancy, breastfeeding, age, interactions
Check pregnancy status where relevant. Doxycycline is generally avoided in pregnancy; fluconazole should not be used in pregnancy without specialist advice; avoid fluoroquinolones in pregnancy unless specialist-directed. Refer pregnant patients with gonorrhoea, syphilis, suspected PID, complicated STI or persistent symptoms to GUM/obstetrics. Check breastfeeding, allergy, renal function and drug interactions (SPC). Under-16s: use the BASHH children and young people guideline, not adult regimens, with safeguarding assessment.
Treatment is organism-specific because the causes of balanoposthitis differ: candida, anaerobes, streptococci and non-infective dermatoses (lichen sclerosus, psoriasis, eczema, Zoon balanitis) all look similar. A swab, STI tests and a glucose/HbA1c check prevent blind treatment. Lichen sclerosus (white, scarred, sometimes tight foreskin) is treated first with an ultrapotent topical steroid such as clobetasol propionate 0.05% ointment once daily, reducing over up to 3 months (BASHH balanoposthitis 2026); circumcision is for disease that does not respond or for phimosis, and long-term review is needed because of a small risk of penile cancer. Acute bacterial prostatitis is covered by NICE NG110 (2018): an oral antibiotic for 14 days then review (see step 7). Never massage the prostate in acute prostatitis (bacteraemia risk).
7
Treat
Balanitis, Phimosis & Prostatitis
Recurrent candidal balanitis + diabetes / SGLT2i
Optimise HbA1c. SGLT2 inhibitors cause glycosuria and increase genital candida; most episodes respond to standard treatment and genital hygiene. Recurrence alone should not automatically lead to stopping the SGLT2 inhibitor — use shared decision-making, weighing glycaemic control, recurrence, cardiovascular/renal benefits and alternatives. Rare but serious: Fournier's gangrene (necrotising fasciitis of the perineum) — severe genital or perineal pain, swelling, erythema, fever or systemic illness needs immediate emergency hospital assessment (999), whether or not the patient takes an SGLT2 inhibitor (MHRA Drug Safety Update, February 2019).
Phimosis — non-surgical
A trial of a potent topical steroid to the tight prepuce with gentle stretching often avoids surgery; urology for circumcision if it fails. Lichen sclerosus (BXO): ultrapotent topical steroid first (clobetasol propionate 0.05% ointment); circumcision if unresponsive; histology if any area looks atypical.
Reactive arthritis
Test and treat any underlying STI (doxycycline treats chlamydia, not established arthritis). Symptomatic treatment, e.g. NSAIDs (dose per NICE/SPC). Rheumatology if arthritis is severe, persistent or functionally limiting. Often HLA-B27 positive (not diagnostic). Full STI screen + GUM. Red eye with pain or photophobia may be uveitis rather than conjunctivitis — same-day eye assessment.
Prostatitis — acute bacterial
NICE NG110 (2018): send an MSU for culture before antibiotics where feasible, but start treatment promptly without awaiting the result — ciprofloxacin 500 mg BD (or ofloxacin) for 14 days then review, continuing for a further 14 days if symptoms persist; trimethoprim 200 mg BD for 14 days if a fluoroquinolone is not appropriate. Fluoroquinolones now carry MHRA restrictions (January 2024) — prescribe systemic fluoroquinolones only when other commonly recommended antibiotics are inappropriate; counsel about potentially disabling, long-lasting tendon, neurological, musculoskeletal and psychiatric effects, and to stop and seek advice if these develop. Same-day hospital assessment if systemically unwell or in retention (999 if clinically unstable); same-day hospital assessment if not starting to improve within 48 hours (resistant infection, retention or prostatic abscess). Chronic/CPPS: avoid fluoroquinolones; alpha-blocker, pelvic floor physiotherapy and psychological support; urology if persistent.
Antibiotic penetration into the prostate is limited, which is why acute prostatitis needs a longer course than cystitis. NICE NG110 (2018) sets 14 days followed by review rather than a fixed 28 days: stop if symptoms have fully resolved, or give a further 14 days if they persist, to reduce the risk of chronic bacterial prostatitis while avoiding unnecessary fluoroquinolone exposure. In a young man with dysuria and discharge, remember that urethritis from an STI is far more likely than prostatitis — test for chlamydia and gonorrhoea first.
8
Lifestyle
Prevention, Safer Sex & Wellbeing
Condom use Consistent use substantially reduces gonorrhoea and chlamydia transmission. Correct technique: leave space at tip, fully unroll, water-based lubricant. Also partially protects against HPV, herpes, syphilis.
STI screening Since June 2021 the National Chlamydia Screening Programme (UKHSA) proactively offers opportunistic screening in GP and pharmacy settings to young women and other people with a womb under 25; men can still test through sexual health services (including online kits) whenever at risk or symptomatic. MSM: at least annually, 3-monthly if condomless sex with new or casual partners.
HPV vaccination Gardasil 9 protects against HPV 6/11/16/18 and 5 other high-risk types. School programme with catch-up for eligible young people to age 25; MSM up to age 45 via sexual health services (UKHSA Green Book, chapter 18a). Reduces genital warts and HPV-related penile, anal and oropharyngeal cancer.
PrEP Anyone at higher HIV risk (e.g. MSM with condomless sex, partners of people with detectable HIV, recent rectal STI): GUM for PrEP assessment. Highly effective when taken as prescribed; free through NHS sexual health clinics.
Foreskin hygiene Daily retraction + warm water only (no soap under prepuce). Dry thoroughly. Emollient (Doublebase) instead of soap for recurrent balanitis. Cotton underwear.
Psychological support Shame and stigma are common after STI. "This is very common and treatable." PHQ-9 for depression. Psychosexual counselling for sexual dysfunction secondary to infection anxiety.
Partner notification Document partner-notification advice and offer GUM referral for confidential contact tracing, testing and treatment. SXT app (sxt.org.uk) for anonymous notification by text/email. GUM contact tracing if patient unable. Look-back periods vary by infection and symptoms — GUM health advisers set them.
Hepatitis B vaccination Offer to MSM, people with multiple partners and other at-risk groups through sexual health services (UKHSA Green Book, chapter 18). Hepatitis A vaccination for eligible groups, particularly MSM.
Chemsex harm reduction Never mix GHB/GBL with alcohol (fatal respiratory depression). Never take alone. Carry naloxone. Antidote (antidote.org.uk), 56 Dean Street, GMFA for specialist support.
Maintain a high index of suspicion for syphilis. Primary syphilis can present as a painless penile, oral, or perianal ulcer. Any indurated painless ulcer in a sexually active adult = syphilis serology urgently. Secondary syphilis (infectious rash, condylomata lata, lymphadenopathy) can mimic many conditions. Antidote (antidote.org.uk) is a specialist LGBTQ+ drug and alcohol service providing chemsex support — GPs should actively signpost rather than leaving patients without specialist support. In the SCA, a non-judgemental, routine framing works well: "I ask everyone with these symptoms some personal questions about sex so that I test for the right things — is that OK?"
9
Safety
Follow-Up & Safety-Netting
After NGU treatment
Review 1–2 weeks: symptoms resolved? Persistent → GUM for objective confirmation of urethritis and M. genitalium NAAT before further antibiotics. Ensure partner treated. Document STI, treatment, partner notification advice.
After gonorrhoea (GUM-managed)
TOC when indicated: culture at least 72 hours after treatment if symptomatic; NAAT at least 2 weeks after treatment if asymptomatic. Repeat HIV and syphilis tests after the window period if the exposure was recent. MSM: 3-monthly STI screen if multiple partners.
New fever + arthralgia + skin rash (DGI) · Urinary retention · Sudden severe testicular pain · Severe genital or perineal pain, swelling or redness with fever (possible Fournier's gangrene) · Rapid expansion of penile lesion
Same-day GUM / urology
Symptoms not improving at 48h on correct antibiotics → culture + sensitivity (acute prostatitis not improving at 48h → same-day hospital assessment) · New scrotal pain developing (sudden severe pain = possible torsion → emergency urology, without waiting for a scan) · Partner confirmed drug-resistant infection
New scrotal pain in a man already being treated for urethritis is usually epididymo-orchitis, but torsion can coexist and testicular salvage falls sharply after about 6 hours from onset. Clinical signs (Prehn's sign, cremasteric reflex, testicular lie) cannot reliably exclude torsion, and a normal Doppler scan does not exclude it either — so when torsion is possible the correct step is emergency surgical referral, not an outpatient scan. Document the cremasteric reflex and testicular lie at every scrotal assessment. SCA safety-net wording: "If you get sudden severe pain in the testicle, or a fever with joint pains or a rash, go to A&E straight away. If the discharge hasn't settled a week after finishing treatment, come back or contact the clinic — you may need a different test."
Educational use only. Based on BASHH UK National Guideline for the management of Neisseria gonorrhoeae (2025), BASHH NGU guideline (2026), BASHH Mycoplasma genitalium guideline (2025), BASHH chlamydia guideline (2026), BASHH Summary Guidance on Testing for STIs (2023), BASHH guideline on STIs in children and young people (2021), BASHH balanoposthitis guideline (2026), BHIVA/BASHH HIV PEP guideline (2021), NICE NG12 Suspected cancer (updated April 2026), NICE NG110 Prostatitis (acute) (2018), MHRA Drug Safety Updates (fluoroquinolones January 2024; SGLT2 inhibitors February 2019), UKHSA Green Book chapters 18 and 18a and product SPCs, and local antimicrobial guidelines — local formulary and referral arrangements take precedence. Always adapt to individual patient context. This guide supports, but does not replace, clinical assessment. It is intended primarily for adults aged 16 years and over presenting in primary care with penile discharge or balanoposthitis. Use current BASHH, NICE, UKHSA, MHRA and local guidance, particularly for gonorrhoea, persistent NGU, pregnancy, children and young people, suspected syphilis/HIV, epididymo-orchitis and antimicrobial-resistant infection. Refer to GUM whenever specialist microscopy, extragenital testing, partner notification, resistance testing or complex treatment is required. Key sources: BASHH guidelines · NICE NG110 · NICE NG12 · MHRA Drug Safety Update · local antimicrobial guidelines.