XDR gonorrhoea (resistant to ceftriaxone + azithromycin) identified in the UK drives the BASHH 2019 guideline: standard treatment is now ceftriaxone 1 g IM monotherapy (not dual therapy), with culture + sensitivity testing mandatory for ALL cases. Ciprofloxacin resistance exceeds 50% in UK E. coli — oral antibiotics are not appropriate for gonorrhoea. Any suspected gonorrhoea should be managed at GUM (IM ceftriaxone + cultures). Epididymo-orchitis vs torsion: Doppler USS is required — clinical features alone are insufficiently reliable. Torsion: sudden onset, absent cremasteric reflex, high-riding testis. Epididymo-orchitis: gradual onset, tender posterolateral epididymis, fever, discharge. If torsion cannot be excluded → immediate surgical exploration.

Mycoplasma genitalium: now 15–25% of NGU, with azithromycin resistance approximately 40% in UK strains. BASHH 2023 changed first-line NGU from azithromycin 1 g stat to doxycycline 100 mg BD × 7 days — covers both Chlamydia and M. genitalium without resistance selection. Persistent NGU after doxycycline → GUM for M. genitalium NAAT → moxifloxacin 400 mg OD × 10 days if confirmed. Never escalate to azithromycin for persistent NGU — selects for macrolide resistance.

First-void urine (FVU) for Chlamydia NAAT: the urethra contains the highest chlamydial density in the first 10–20 ml. MSU flushes away periurethral cells, reducing sensitivity by 15–25%. Instruction: do not urinate for 2 hours before, then collect only the very first 10–20 ml. 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).

PHE data: approximately 40–50% of gonorrhoea diagnoses in MSM are at pharyngeal or rectal sites, nearly always asymptomatic — urethral-only testing misses the majority. BASHH recommends annual STI screening for all sexually active MSM and 3-monthly for multiple partners. PrEP (tenofovir/emtricitabine daily or on-demand) reduces HIV acquisition by >99% — available on NHS via GUM clinics or iwantprepnow.co.uk. GPs identifying high-risk patients should actively direct to GUM for PrEP. PEP must be started within 72 hours of high-risk exposure — efficacy negligible after 96h. Refer to GUM or A&E immediately.

TOC (test of cure) after gonorrhoea treatment: mandatory per BASHH. NAAT + culture at 1–2 weeks post-treatment — culture specifically required because NAAT cannot detect antibiotic resistance. Treatment failure detection requires TOC culture sensitivity. This is the fundamental reason gonorrhoea belongs in GUM. Partner notification periods: Chlamydia = last 4 weeks; GC = last 3 months; syphilis = up to 2 years (secondary). SXT app (sxt.org.uk) enables anonymous partner notification by text/email — no direct contact details needed.

Betamethasone 0.05% cream for phimosis: apply BD to tight inner prepuce × 4–6 weeks with gentle daily stretching — 75–80% success rate, avoiding circumcision in the majority. BXO (lichen sclerosus of prepuce): white scarred foreskin → circumcision + histology mandatory (SCC risk). Acute bacterial prostatitis: ciprofloxacin 500 mg BD × 28 days — full course mandatory (poor prostate antibiotic penetration; shorter courses cause relapse). Never massage prostate vigorously in acute prostatitis (bacteraemia risk). Chronic CPPS: tamsulosin 0.4 mg OD + pelvic floor physiotherapy + CBT.

The 28-day prostatitis antibiotic course is frequently shortened in primary care — antibiotic penetration into the prostate is poor (blood-prostate barrier). Ciprofloxacin has the best prostate penetration of available oral antibiotics (lipophilic). Shorter courses (7–14 days) cause incomplete bacterial eradication and transition to chronic bacterial prostatitis. Full 28-day course is mandatory for confirmed acute bacterial prostatitis.

Syphilis rates in the UK are at their highest since 1948 — maintain high index of suspicion. 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.

Same-day Doppler USS for new scrotal pain during UTI/STI treatment is a patient safety standard. Testicular torsion salvage: 100% at <6h, <10% at >24h. Clinical features (Prehn's sign, cremasteric reflex, testis lie) are insufficiently reliable to exclude torsion — USS is required. Document cremasteric reflex at every scrotal pain assessment. If Doppler not immediately available → emergency surgical exploration.