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Key Features

  • Proctitis

    • Most cases are sexually transmitted, especially by anal-receptive intercourse

    • Causes include

      • Neisseria gonorrhoeae

      • Treponema pallidum (syphilis)

      • Chlamydia trachomatis, herpes simplex virus type 2 (HSV-2)

      • Human papillomavirus (HPV)

  • Venereal warts (condylomata acuminata)

    • Caused by HPV

    • Occur in up to 25% of men who have sex with men

  • Proctocolitis

    • Inflammation that extends above the rectum to the sigmoid colon or more proximally

    • Causes include

      • Campylobacter

      • Entamoeba histolytica

      • Shigella

      • Enteroinvasive Escherichia coli

Clinical Findings

  • Proctitis

    • Anorectal discomfort

    • Tenesmus

    • Constipation

    • Discharge

  • Gonorrhea proctitis

    • Itching

    • Burning

    • Tenesmus

    • Mucopurulent discharge

  • Complications of untreated gonorrheal infections

    • Strictures

    • Fissures

    • Fistulas

    • Perirectal abscesses

  • Anal syphilis

    • Asymptomatic

    • Chancre

    • Proctitis

  • In primary syphilis, chancre may mimic a fissure, fistula, or ulcer; proctitis or inguinal lymphadenopathy may be present

  • In secondary syphilis, condylomata lata may be seen, with foul-smelling mucus discharge

  • C trachomatis causes proctitis similar to gonorrhea or lymphogranuloma venereum, proctocolitis with fever and bloody diarrhea, painful perianal ulcerations, anorectal strictures and fistulas, and inguinal adenopathy (buboes)

  • HSV-2 proctitis

    • Severe pain, itching, constipation, tenesmus, urinary retention, and radicular pain

    • Small vesicles or ulcers in the perianal area or anal canal

  • Venereal warts are noted on examination of the perianal skin and within the anal canal; otherwise asymptomatic

  • Higher rate of HPV progression to high-grade dysplasia or anal cancer in HIV-positive persons

Diagnosis

  • Gonorrhea proctitis

    • Rectal swab specimens should be taken during anoscopy for culture

    • Gram staining is unreliable

    • Cultures should also be taken from the urethra and pharynx in men and from the cervix in women

  • Anal syphilis

    • Dark-field microscopy or fluorescent antibody testing of scrapings from the chancre or condylomata

    • Serum VDRL positive in 75% of primary and 99% of secondary syphilis

  • Diagnosis of chlamydial infection is established by serology, culture, or PCR-based testing of rectal discharge or rectal biopsy

  • HSV-2

    • Sigmoidoscopy shows vesicular or ulcerative lesions in the distal rectum

    • Diagnosis by viral culture, polymerase chain reaction, or antigen detection assays of vesicular fluid

Treatment

  • See treatment of specific infections

  • Examine and treat patient's sexual partners

  • Surveillance anoscopy every 3–6 months in HIV-positive persons

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