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REMEDY : BNSSG referral pathways & Joint Formulary

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Checked: 23-06-2022 by 3 Vicky Ryan Next Review: 21-06-2024


**Update from Unity - June 2023**

Please be aware that we have seen a rise in cases of gonorrhoea and syphilis. Please follow the guidance on Remedy or, if unable to treat in primary care, refer cases of gonorrhoea and syphilis to Unity Sexual Health for treatment and partner notification. For clinical advice or referral for treatment please see Unity Sexual Health’s clinical referral information. The office is open Monday/Tuesday/Thursday: 9-5pm, Wednesday: 9-1pm & 3-7pm and Friday: 9-1pm. If the patient is clinically well (the majority of cases), they may wait over the weekend before accessing treatment as long as they abstain from sexual intercourse.


Early diagnosis and treatment is imperative to reduce ongoing transmission. It can be treated with intramuscular penicillin or an alternative antimicrobial. Syphilis is caused by the bacterium Treponema pallidum pallidum. Transmission occurs during sexual contact with a highly infectious lesion and is reduced but not eliminated by condom use. Syphilis may present at different stages:

Primary syphilis

This usually presents with a chancre (indurated ulcer) on the genitals, rectum or oropharynx around three weeks after sexual contact (range 9-90 days). Ulcers may be painless or painful, single or multiple and may look similar to genital herpes. Chancres often go unnoticed and heal spontaneously, usually within six weeks.

Secondary syphilis

Following untreated primary syphilis most cases will develop secondary syphilis 4-10 weeks later. Manifestations of secondary syphilis include: 

  • Rash – maculopapular, often subtle, occasionally involving palms and soles
  • Constitutional symptoms
  • Lymphadenopathy
  • Patchy alopecia
  • Mucous patches (buccal, lingual and genital)
  • Condylomata lata (highly infectious, mainly affecting perineum and anus)
  • Hepatitis
  • Splenomegaly
  • Glomerulonephritis
  • Neurological complications including acute meningitis, cranial nerve palsies
  • Anterior uveitis, optic neuropathy, interstitial keratitis and retinal involvement

Symptomatic late syphilis

One-third of those with untreated syphilis will develop symptomatic late syphilis with complications including stroke, cognitive decline, tabes dorsalis, aortitis, and destructive granulomas.


Since the start of 2020, there has been a notable increase in the number of cases of syphilis in heterosexual men and women presenting to Unity Sexual Health. This infection has previously been more associated with sex between men.

There has been an increase in cases being seen, in all age groups

Common presentations include:

  • ulcer (can be vaginal, penile, anal or oral),
  • rash (can effect palms, soles),
  • lymphadenopathy,
  • hearing loss,
  • vision changes or
  • eye problems.

The following link provides photographs of common presentations:

Syphilis | DermNet (

Syphilis testing should be included in all routine STI testing, alongside an HIV test.

Please note, serology may be negative early in the course of infection.

Syphilis infection in pregnancy

Syphilis passed from mother to child during pregnancy can cause permanent skin, bone, renal, and neurological problems. This risk can be minimised with early diagnosis and treatment.


If you suspect syphilis please advise your patient to avoid any sexual contact and refer them to your local Sexual Health Clinic as soon as possible.

For clinical advice or referral for treatment please see Unity Sexual Health’s clinical referral information.

Where patient-led notification is not preferred or is unfeasible, patients should be referred to the Health Advisers on 0117 3426944 or Consent should be gained from the patient.


Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.