Anorectal Infections

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

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

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

See treatment of specific infections

Examine and treat patient's sexual partners

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