Canadian Guidelines on Sexually Transmitted Infections

Supplementary statement for recommendations related to the diagnosis, management, and follow-up of Sexually Transmitted Proctitis: March 2014

Key Issue

The Gonococcal Infections chapter has been revised in response to emerging antimicrobial resistance. As a result, the 2010 print and online versions of the Sexually Transmitted Intestinal and Enteric Infections chapter of the Canadian Guidelines on Sexually Transmitted Infections also require updates.

This statement is intended to inform clinicians of key changes in the management of sexually transmitted proctitis until such time as the full chapter revision is available.

The following recommendations apply only to men and women presenting with symptoms suggestive of sexually transmitted proctitis and not children. Clinicians should refer to the full chapter for special considerations in children presenting with symptoms of proctitis.

Sexually transmitted enteric infections can occur in men and women who engage in oral-anal sexual activities causing proctocolitis and enteritis. Clinicians should refer to Table 1 in the full chapter for a summary of the most common pathogens associated with sexually transmitted intestinal and enteric infections, as discussion of these pathogens is beyond the scope of this statement.

Diagnosis

  • Infections of the anus and rectum are often sexually transmitted and typically occur in men and women who engage in unprotected receptive anal intercourse. For a summary of the most common sexually transmitted pathogens associated with proctitis, refer to Table 1 of the full chapter.
  • If a symptomatic patient reports any anorectal sexual activities, anoscopic evaluation should be a routine part of the physical examination.
  • Anoscopic examination and specimen collection for patients presenting with proctitis:
    • Obtain rectal swabs for culture preferably under direct vision through an anoscope, for appropriate diagnostic testing for N. gonorrhoeae, C. trachomatis. Consideration should be given to collection of samples for N. gonorrhoeae using both culture and NAAT in symptomatic patients.
    • Validated NAATs can be used to detect rectal infections. Although no products are currently licensed in Canada; individual laboratories may offer NAATs after in-house laboratory validation, including confirmation of positives with culture or a second NAAT.
    • If lesions are present, refer to the full chapter for additional specimen collection recommendations.

Treatment

  • In patients with suspected or confirmed or gonococcal proctitis, treatment should include combination therapy in response to increasing antimicrobial resistance.
    • Combination therapy using medications with two different mechanisms of action is thought to improve treatment efficacy as well as to potentially delay the emergence of cephalosporin-resistant gonorrhea.
    • This combination therapy also includes effective treatment for concomitant chlamydia infection, which occurs frequently.
  • Refer to Table 7 in the Gonococcal Infections chapter for treatment recommendations for non-MSM and women, and to Table 8 for MSM. Refer to the Follow-up section for test of cure recommendations.
  • In patients with signs or symptoms consistent with LGV, HSV and/or Syphilis, clinicians should refer to the Treatment sections of the corresponding chapter(s).

Follow-up

  • All patients treated for proctitis should undergo evaluation for response to treatment. For those treated for LGV, HSV and/or Syphilis, refer to the recommended Follow-up sections of the corresponding chapter(s).
  • Those who have a confirmed gonococcal infection should be reported to local public health and be followed up as per the recommendations in the Partner notification and Follow-up sections of the Gonococcal Infections chapter.
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