Ano-rectal Syndromes

Proctitis |

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 or syphilis
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
Herpes	Swab of ulcer	NAAT
Gonorrhoea	Ano-rectal swab	If NAAT test result is positive, collect swab for culture before treatment, to assess antibiotic sensitivity. This should not delay treatment
Chlamydia	Ano-rectal swab	NAAT, LGV testing if reactive.
NAAT – Nucelic acid amplification test LGV – Lymphogranuloma venereum

Specimen collection

These should always be clinician collected as the patient should be examined. Ideally this should be done via proctoscope. If patients are reluctant to undergo anorectal examination the importance and benefits of physical examination should be explained with respect to achieving an accurate diagnosis and appropriate management plan.

Special considerations

Ano-rectal chlamydia that presents with proctitis should raise the suspicion of LGV, which requires a longer course of treatment

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 with anal swab for treponemal PCR and syphilis serology. Due to the window period, syphilis serology may not detect primary syphilis that presents with proctitis.

If the patient is a known contact of M. genitalium, or if no other infectious cause for proctitis is found, consider testing for M. genitalium by ano-rectal swab for NAAT

Rectal infections are commonly accompanied by concomitant infection at other anatomical sites.

If the patient is a man who has sex with men (MSM), consider additional testing.

Management

Syndromic Treatment of nonspecific proctitis
• doxycycline 100mg PO bd for 21 days, • PLUS ceftriaxone 500mg in 2mL of 1% lignocaine, IMI stat • PLUS Valaciclovir 500mg PO, BD for 5 - 10 days.

Treatment advice

If specific STI test are negative, corresponding treatment for the pathogen can be ceased.

Testing for LGV may not be available in some locations, or turnaround time for results may be lengthy. Single doses of azithromycin are unreliable for treating LGV.

Limited evidence comparing other antiviral agents (aciclovir) 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.

If all tests are negative, all medications are ceased and if symptoms persists then seek specialist advice.

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.

Last Updated: Wednesday, 11 July 2018