Proctitis is inflammation of the rectal mucosa. Proctitis may
develop from prior radiation treatments, autoimmune disorders, vasculitis, ischemia, and
infectious diseases (enteric pathogens as well as those sexually
STDs of the anorectum can be seen among patients who practice
anal sex. Infection is transmitted when condoms are not used (Table 88-2). The exceptions are infection
with lymphogranuloma venereum, in which infection extends directly
to the rectum from the vagina, and contamination of the anus by
gonococcal-laden discharge from the urethra or cervix.
As a rule, if the patient has an anorectal infection caused by
one of the STD organisms, assume that another STD may be present.
Obtain appropriate blood tests, and consider anoscopy to obtain
specimens for Gram stain and viral and bacterial cultures.
Depending on the etiology, symptoms often include anorectal pain,
itching, anorectal discharge, diarrhea, bleeding, or lower abdominal
cramping. Anoscopic examination may reveal mucosal inflammation,
erythema, bleeding, ulcerations, and/or discharge.
Condylomata acuminata, commonly known as anal warts,
are caused by a human papillomavirus, and most are sexually transmitted.
Lesions begin as discrete, soft, fleshy growths on the perianal
skin and the squamous epithelium of the anal canal. They may vary
from dot-like to larger papilliform, cauliflower-like lesions. With time,
pain, itching, bleeding, and anal discharge become part of the symptom
complex. Perianal involvement is often associated with vulvovaginal
and penile lesions. Evaluation of a patient with condyloma acuminata
should include screening for human immunodeficiency virus (HIV), Chlamydia, syphilis,
gonorrhea, herpes, hepatitis, cytomegalovirus, and Giardia. Topical
podophyllum and chemotherapy have been used in the past, but the
recurrence rate is significant. Optimal treatment is referral to
an appropriate specialist for laser ablation, cryotherapy, electrocautery,
immunotherapy, or surgical excision. Reoccurrence is common. Squamous
cell carcinoma has been associated with condyloma acuminata.
Symptoms of gonococcal proctitis vary, ranging from none to the
more common symptoms of severe rectal pain with profuse yellow,
bloody discharge. The symptoms usually start about 1 week after
exposure. Patients in the acute phase generally have mild burning
and/or pruritus with some purulent seepage. Anoscopic examination
during this phase of the disease reveals marked hyperemia and edema
of the rectal mucosa and diffuse inflammation with purulent discharge
from the anal crypts. Unlike nonvenereal cryptitis, infection is
not confined to the posterior crypt. Diagnosis is made by Gram stain
and cultures. Dissemination involving the heart, liver, central
nervous system, and joints should be considered. Treatment is with
ceftriaxone, 125 milligrams IM, plus azithromycin, 2 grams PO single
dose, or doxycycline, 100 milligrams PO twice a day for 7 days,
depending on local resistance patterns.
C. trachomatis causes both urogenital and anorectal
infections. The lymphogranulomatous (LGV) variety occurs mainly
in tropical and subtropical climates. Infection can involve the
rectum by perirectal lymphatic invasion from vaginal seeding or
from direct anorectal mucosal infections. The non-LGV chlamydial
organisms may infect the rectal mucosa, although they do not cause
the extensive rectal scarring and stricturing that its lymph gland–invading
cousin from the tropics does. A patient with chlamydial proctitis
may be asymptomatic or may present with nonspecific symptoms, including
anal pruritus, pain, and purulent discharge. Tenesmus and bleeding
may also be present.
The more severe form of proctitis occurring with this infection
is usually due to the LGV type of chlamydia. Acutely painful anal
ulcerations associated with prominent unilateral lymph node enlargement
can be noted. Fever and constitutional flulike symptoms may be seen.
In addition to rectal scarring, which is a late sequela, infection
of the perirectal tissue results in perirectal abscesses and chronic
Red, friable mucosa may be seen on anoscopy. The LGV forms may
be distinguished from the non-LGV forms by the LGV complement fixation test.
Immunofluorescent antibody testing is the diagnostic test of choice, although
serology and nucleic acid amplification tests, such as polymerase chain
reactions, are utilized as well. Treatments for the non-LGV chlamydial
proctitis are azithromycin, 2 grams PO single dose, or doxycycline, 100
milligrams PO twice a day for 7 days. Treatment
for LGV chlamydial infections is doxycycline, 100 milligrams PO
twice a day for 21 days.
The causative agent of syphilis is the spirochete Treponema
pallidum. Chancres that form a few weeks after infection
are the characteristic lesion of primary syphilis and usually manifest
themselves at the anal verge or in the anal canal. Rarely will a
chancre involve the rectal mucosa, although proctitis due to syphilis
can occur in the absence of a chancre. Syphilitic chancres may be
misdiagnosed as a simple fissure, and anal chancres are often very
painful. A symmetric lesion on the opposite side of the anal margin
is a distinguishing feature, and inguinal adenopathy is often present. Condylomata
lata, which are flatter and firmer than condylomata acuminata, appear
in the perianal region as a manifestation of the secondary stage
of syphilis. The fluorescent treponemal antibody test becomes positive
in approximately 1 month, and the rapid plasma reagin and the Venereal
Disease Research Laboratory tests are also commonly used to diagnose
syphilis. AIDS patients may remain nonreactive, and central nervous
system infections are not uncommon. Treatment is benzathine penicillin-G
(Bicillin L-A), 2.4 million units IM for one dose, or doxycycline,
100 milligrams PO twice a day for 14 days. Azithromycin resistance
Anorectal herpes is almost always caused by the type 2 herpes simplex
virus. Symptoms occur within a few weeks after exposure and consist
of itching and soreness in the perianal area, progressing to severe anorectal
pain. Early lesions are small, discrete vesicles on an erythematous
base. Vesicles then enlarge, coalesce, and rupture, forming exquisitely
tender ulcers on the perianal skin, the anoderm, and rectal mucosa.
The pain and tenesmus from these lesions may be so intense that
the patient is reluctant to have a bowel movement, resulting in
constipation and possibly fecal impaction. The patient may develop
a flulike illness with inguinal adenopathy noted on examination
during the initial course of the illness. Symptoms persist for 1
to 2 weeks and are frequently recurrent, though less pronounced,
during the ensuing year. Topical analgesia may be needed for adequate
examination. Viral cultures and immunofluorescent testing are helpful
for diagnosis. Treatment consisting of adequate pain medication,
stool softeners, and acyclovir, 400 milligrams PO for 10 days for
the initial episode, and 800 milligrams PO three times a day for
2 days for recurrent episodes.
Patients rendered immunodeficient by HIV are subject to a variety
of opportunistic infections that affect the intestinal, anorectal,
and other body systems (Table 88-3). Severe
rectal pain, diarrhea, and hematochezia are common presenting symptoms.
Perform anoscopy to confirm acute proctitis and identify the causative
Table 88-3 Anorectal
Acquired Immunodeficiency Syndrome–Related Infections |Favorite Table|Download (.pdf)
Table 88-3 Anorectal
Acquired Immunodeficiency Syndrome–Related Infections
|Herpes simplex types 1 and 2|
Obtain serology for syphilis.
Antibiotic therapy should not be delayed pending the results
Stool softeners, sitz baths, careful anal hygiene, and pain medications
will provide some relief. Enteric pathogens may require antibiotics
such as trimethoprim and sulfamethoxazole (Isospora),
metronidazole (Entamoeba, Giardia),
azithromycin (Campylobacter), acyclovir (herpes),
or fluoroquinolones (Salmonella, Shigella).
Empiric therapy aimed at eradicating gonorrhea, non-LGV chlamydia, and
incubating syphilis should be initiated for any patient presenting with
symptoms and physical signs suggestive of acute proctitis. This therapy
should be administered to all patients with acute proctitis even if
there are concomitant lesions suggestive of other organisms. Referral for
appropriate follow-up and for further evaluation and definitive
treatment is needed.