Causes
Sexually acquired proctitis occurs mostly among men who have sex with men (MSM) but can occur in any persons who have had receptive anal intercourse.
Sexually acquired proctitis is commonly caused by:
- Chlamydia trachomatis (including lymphogranuloma venereum or LGV)
- Neisseria gonorrhoeae
- Herpes simplex virus types 1 and 2 (HSV-1 and -2)
- Mycoplasma genitalium: Evidence for the association with proctitis is mixed. Therefore testing first line for Mycoplasma genitalium in men with proctitis is not recommended
- HSV, LGV and proctitis associated with combinations of the above pathogens is more common among MSM living with HIV compared with MSM without HIV
- Proctocolitis can also be caused by enteric pathogens such as campylobacter, salmonella and shigella some of which may be transmitted between men during sexual contact via the faecal-oral route
Non-infective causes of proctitis may include:
- inflammatory bowel disease (ulcerative colitis or Crohn's disease)
- radiation therapy
Clinical presentation
Sexually acquired proctitis is commonly asymptomatic.
When symptoms are present they usually include:
- pain with or without discharge
- bleeding
- tenesmus, a sensation of constantly needing to pass stool, may also be present
While painful perianal ulcers can be indicative of HSV, HSV proctitis is often not associated with the presence of visible ulcers
Diagnosis
Proctitis is a clinical syndrome and diagnosis is made where there are suggestive features on history and examination.
Proctoscopy may be a useful adjunct to the clinical examination and may show mucosal inflammation and discharge.
Proctoscopy should not be performed when examination is uncomfortable due to the presence of tender ulcers.
Laboratory testing is always required to determine the infective agent.
| Test | Site/ Specimen | Comments |
|---|---|---|
| NAAT | Anorectal swab |
For N. gonorrhoea, C. trachomatis (order genotype test for LGV); a positive chlamydia result alone will not distinguish between LGV and non-LGV chlamydia. Order HSV PCR even in the absence of any visible external ulceration. Consider syphilis PCR, especially when proctitis is associated with ulceration If symptoms of proctitis persist following treatment, and tests for other STIs are negative, then testing for M. genitalium and macrolide-resistance (PCR) may be indicated. |
| Culture | Anorectal swab | For N. gonorrhoea if rectal discharge is present |
| Serology | Blood | For HIV and syphilis |
| Microscopy | Anorectal swab |
Microscopy may be useful where proctitis is associated with an anal ulcer. Dark ground microscopy may identify spirochaetes (Treponema pallidum). Microscopy has low sensitivity for the detection of both syphilis and gonorrhoea and false positives on dark ground microscopy can also occur due to the presence of non-treponemal spirochaetes present in the normal bowel flora. Gram stain of a rectal swab or discharge may identify gram negative diplococci indicative of gonorrhoea. |
|
Microscopy and culture, including ova PCR for enteric pathogens |
Faecal specimen | If enteric infection is suspected, for example when abdominal pain and diarrhoea are present |
Management
Index patient
| Condition | Recommended | Comments |
|---|---|---|
| Proctitis – likely to be sexually acquired |
Doxycycline 100mg PO, twice daily for 1 week AND Ceftriaxone 500mg IM, stat AND Valaciclovir 500mg PO, twice daily for 7-10 days |
Treatment of suspected proctitis should be empirical and commenced prior to test results being available. If LGV is detected, extend doxycycline to 3 weeks. Treatment should take into account the clinical picture and epidemiology of STIs in the particular patient group. As it can be difficult to distinguish clinically between symptomatic proctitis caused by chlamydia, gonorrhoea, and HSV, it is recommended that treatment of MSM with proctitis should cover all of these. |
| Proctitis – likely from an enteric pathogen | Refer to Enteric infections in MSM treatment guideline | |
| Proctitis – likely to be non-infectious | Refer to gastroenterologist if inflammatory bowel disease is suspected. |
Contact tracing & partner management
Where chlamydia, gonorrhoea, Mycoplasma genitalium or LGV are identified, sexual partners should be notified, tested and treated on detection of the STI pathogen.
Disclaimer
We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines.
The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.