Ano-rectal Syndromes
Overview
Anal discharge and/or pain are typical symptoms of proctitis.
Possible causes
- Herpes simplex viruses (HSV Types 1 and 2)
- Chlamydia trachomatis (particularly lymphogranuloma venereum (LGV) strains)
- Neisseria gonorrhoea are the most common causes of proctitis.
- Other organisms include: Treponema pallidum (syphilis), and Mycoplasma genitalium.
- Proctitis may be non-infectious. Assess STI risk and investigate for non-infectious causes in those without risk or whose investigations are negative. Investigations for non-infectious proctitis may include sigmoidoscopy/colonoscopy.
Clinical presentation
| Symptoms | Considerations |
|---|---|
| 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
| Infection | Site/Specimen | Test |
|---|---|---|
|
Swab of ulcer |
NAAT |
|
|
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. |
|
|
Ano-rectal swab |
NAAT, LGV testing if reactive. |
|
|
NAAT – Nucelic acid amplification test |
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Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
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 | ||
|---|---|---|
| Situation | Recommended | Alternative |
| 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. |
Seek specialist advice. |
| Herpes* |
Initial episode: |
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
- Contact tracing for gonorrhoea, lymphogranuloma venereum (LGV) and chlamydia is a high priority and should be performed in all patients with confirmed infection.
- Contact tracing for herpes is not recommended.
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.