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For further information, see CMDT Part 15-41: Anorectal Infections

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)

  • Condylomata acuminata (warts)

    • 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

    • Inguinal lymphadenopathy may be present

  • 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

    • Develops 4–21 days after exposure

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

  • Condylomata acuminata are noted on examination of the perianal skin and within the anal canal and present with

    • Itching

    • Bleeding

    • Pain

    • Or may be asymptomatic

  • In HIV-positive persons, higher rates of HPV progression to high-grade dysplasia or anal cancer


  • Gonorrhea proctitis

    • Nucleic acid amplification testing

      • Has excellent sensitivity and specificity

      • Preferred in most clinical settings

    • Rectal swab specimens should be taken during anoscopy

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

    • Culture and sensitivity testing may be required in patients with suspected infection recurrence

  • Anal syphilis

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

    • Serum VDRL or RPR test is positive in 75% of primary and 99% of secondary syphilis

  • Diagnosis of chlamydial infection is established by 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, PCR, or antigen detection assays of vesicular fluid

  • Condylomata acuminata diagnosed with biopsy from large or suspicious lesion


  • 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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