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Essentials of Diagnosis

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  • • A thorough sexual history, including information about the practice of rectal sex (receptive or insertive) or oral-anal sex, with or without condoms.
  • • Screening for rectal pathogens based on sexual risk history.
  • • Anoscopy in patients with symptoms of anorectal pain, tenesmus, or discharge.
  • • Collection of specimens for gonorrhea, chlamydia, and serologic tests for syphilis and HIV, and stool specimens for culture and ova and parasite examinations in patients with symptoms of proctocolitis.

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General Considerations

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Proctitis is an inflammatory condition of the rectum that usually occurs secondary to infection introduced during sexual activity. A more extensive condition—proctocolitis—may occur after oral ingestion of a pathogen that produces colorectal inflammation. Both conditions are noted more frequently in men who have sex with men (MSM). Proctitis is commonly caused by gonorrhea, chlamydia, and herpes simplex virus (HSV) infections, and proctocolitis by enteric bacteria or parasites.

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The incidence of acute, sexually transmitted proctitis and proctocolitis, which decreased dramatically during the 1980s and early 1990s, began increasing again in the mid-1990s. As a consequence of successful antiretroviral therapy for HIV infection and AIDS, declining concern about HIV and AIDS, and renewed physical health, many HIV-infected men in the United States have increasingly been engaging in sexual risk behaviors associated with the spread of STDs. Consistent condom use between HIV-infected sex partners in some cities has also declined, resulting in substantial increases in rates of syphilis and rectal STDs.

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Pathogenesis

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Sexually transmitted intestinal infections may be transmitted by direct rectal inoculation or indirectly in the course of oral-anal contact. Conventional sexually transmitted diseases (STDs) most often cause rectal infections through direct inoculation by anal intercourse, although perineal contamination by cervicovaginal secretions among women has been described. Chlamydia trachomatis and Neisseria gonorrhoeae infect columnar epithelium and infect the anorectal mucosa via oral-genital and rectal insertive intercourse. HSV, human papillomavirus, and Treponema pallidum infect stratified squamous epithelium and can be transmitted similarly to the anorectal region. Although not considered “classical” STDs, enteric pathogens, parasites, and hepatitis A and B can be transmitted during direct oral-anal contact, (anilingus) or during oral-genital contact after rectal intercourse. Exposure to as few as 10–100 organisms of Shigella, Entamoeba histolytica cysts, or Giardia lamblia cysts may precipitate infection.

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Risk Factors

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Multiple partners, anonymous partners, and individual sexual practices that increase the risk of acquiring specific diseases are associated with increased risk of acquiring any STD. Individuals who engage in receptive anal intercourse or anilingus are at high risk for acquiring sexually transmitted proctitis and enteritis.

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Anal intercourse continues as a prevalent sexual practice in both homosexual and heterosexual populations. Studies report that up to 43% of adult women have participated in anal intercourse. Teen definitions of sexual activity may not include oral or anal sex, and the prevalence of anal sex among teens ...

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