Ano-rectal Syndromes

Proctitis |

Overview

Anal discharge and/or pain are typical symptoms of proctitis.

Possible causes

Clinical presentation

SymptomsConsiderations
Anal discharge
Mucopurulent or light blood staining. May be subtle.
Anal pain
Often accompanied by spasm. May preclude proctoscopy.
Perianal ulcers and systemic features
If present suggest herpes.
Altered bowel habit Constipation predominates in proctitis. Alternating constipation and diarrhoea occurs in proctocolitis.
Tenesmus Sensation of needing to pass stools indicates inflammation of anal canal.

Diagnosis

InfectionSite/SpecimenTest

Herpes

Swab of ulcer

NAAT

Gonorrhoea

Ano-rectal swab

NAAT. If NAAT test result is positive, swab for culture, before treatment. Cultures are the preferred test samples for non-genital sites.

Chlamydia

Ano-rectal swab

NAAT, LGV testing if reactive.

NAAT – Nucelic acid amplification test
LGV – Lymphogranuloma venereum

 

Specimen collection 

Clinician collected |
Self-collection

Special considerations

  • Symptomatic ano-rectal chlamydia infection is more likely to be caused by lymphogranuloma venereum (LGV) by strains.
  • STIs are a neglected cause of proctitis. All patients with proctitis should be assessed for risk of STIs and tested if indicated.
  • If syphilis is suspected, consider testing.
  • If M. genitalium is suspected, collect ano-rectal swab for NAAT.
  • Rectal infections are commonly accompanied by concomitant infection at other sites, therefore collect specimens from other sites.
  • If patient is a man who has sex with men (MSM), consider additional testing.

Management

Principal Treatment Options
SituationRecommendedAlternative
Lymphogranuloma venereum (LGV)/Chlamydia

Doxycycline 100mg PO, BD for 21 days.

Alternative regimens are not recommended due to lack of efficacy data. If alternative regimen required, seek specialist advice.

Gonorrhoea

Ceftriaxone 500mg in 2mL of 1% lignocaine, IMI stat.
PLUS 
Azithromycin 1g PO, stat. 

Seek specialist advice.

Herpes*

Initial episode: 
Valaciclovir 500mg PO, BD for 5 days.

Recurrence: 
Episodic therapy: Valaciclovir 500mg PO, BD for 3 days.
Suppressive therapy: Valaciclovir 500mg PO, daily for 6 months.

Initial episode:
Aciclovir 400mg PO, TDS for 5 days.

Recurrence:
Episodic therapy: Famciclovir 1g PO, BD for 1 day.
Suppressive therapy: Famciclovir 250mg PO, BD for 6 months.

Treatment advice

  • Distinguishing between the causative agents of proctitis clinically can be difficult. As patients can be or (quickly become) unwell, immediate treatment of LGV/chlamydia, gonorrhoea and herpes is recommended. Do not wait for test results.
  • Testing for LGV may not be available in some locations, or turn around time for results may be lengthy. Single doses of azithromycin are unreliable for treating LGV.
  • If chlamydia testing is negative, doxycycline should be ceased.
  • For rectal coinfection with gonorrhoea and chlamydia, treatment should be given for both infections i.e.: Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine PLUS Azithromycin 1g PO, stat PLUS Doxycycline 100mg PO, BD 21 days.
  • Limited evidence comparing other antiviral agents (aciclovir and famciclovir) with valaciclovir indicate that they are therapeutically equivalent for treating herpes. The ability for the patient to adhere to the recommended dosing frequency should be considered when selecting the appropriate treatment. Initial episodes of herpes may require a longer duration of treatment.

Other immediate management

  • Advise no sexual contact for 7 days after treatment is administered
  • Advise no sex with partners from the last 6 months until the partners have been tested and treated if necessary
  • Contact tracing.

Contact Tracing

See Australasian Contact Tracing Manual for more information.

Follow up

If confirmed STI, follow up provides an opportunity to:

  • Confirm patient adherence to treatment and assess for symptom resolution.
  • Confirm contact tracing procedures have been undertaken or offer more contact tracing support.
  • Provide further sexual health education and prevention counselling.

For test of cure (TOC) and retesting advice see:

Auditable outcomes

  • 100% of patients diagnosed with proctitis are treated with an appropriate antibiotic regimen.
  • 100% of patients with proctitis have been investigated with appropriate tests to exclude STIs.
Last Updated: Tuesday, 22 March 2016