STI-associated syndromes guide: Proctitis

On this page:

• Public health importance
• Common STI-associated etiology
• Clinical manifestations
• Diagnostic testing
• Empiric treatment and management
• Follow-up
• Reporting and partner notification
• References

Public health importance

Infections of the anus and rectum are often sexually transmitted and are typically associated with receptive anal sex involving direct or indirect contact with rectal mucosal membranes^{Footnote 1}.

Common STI-associated etiology

Proctitis can be a polymicrobial infection. Sexually transmitted infections (STIs) associated with proctitis include Chlamydia trachomatis (CT) (Lymphogranuloma venereum [LGV] and non-LGV genotypes), Neisseria gonorrhoeae (GC), Treponema pallidum and Herpes simplex virus (HSV)^{Footnote 2}.

In one study of gay, bisexual and other men who have sex with men (gbMSM) with proctitis, the following etiological agents were identified^{Footnote 3}:

• GC (20%)
• HSV (13%)
• CT (11%)
• Mixed infections (10%, including 3% with HSV)
• T. pallidum (syphilis) (1%)

Since most provinces and territories are experiencing syphilis outbreaks, consider syphilis in people presenting with proctitis and anogenital ulcer disease (AUD) or rashes.

In persons with advanced human immunodeficiency virus (HIV) infection, consider cryptosporidium and microsporidium in the differential diagnosis^{Footnote 2}.

Enteric infections can also be acquired through oral-anal sexual activities and result in proctocolitis and enteritis^{Footnote 2}. Proctocolitis may be associated with LGV genotypes of C. trachomatis, Entamoeba histolytica, Campylobacter species, Salmonella species and Shigella species. Enteritis may be associated with Giardia lamblia infection. Consult an experienced colleague for the treatment and management of proctocolitis and enteritis as these are beyond the scope of this guide.

Clinical manifestations

Symptoms and signs of proctitis include:

• Anorectal pain
• Continual or recurrent inclination to evacuate the bowels
• Constipation
• Bloody stool
• Mucopurulent rectal discharge

Suspect LGV if inguinal or femoral lymphadenopathy are present or if there is a history of condomless receptive anal sex and acute hemorrhagic proctitis or proctocolitis. Bloody, purulent or mucous discharge from the anus as well as constipation are common with LGV^{Footnote 4Footnote 5Footnote 6Footnote 7}.

In people with HIV, there are additional potential causes of proctitis and infections are often more severe: acute proctitis may present with bloody discharge, painful perianal ulcers or mucosal ulcers^{Footnote 8}.

Abdominal pain, diarrhoea, cramping, bloating, nausea or fever are often associated with enteric pathogens, which can be transmitted through sexual activity involving fecal-oral contact, and with infections higher in the intestinal tract.

Proctitis may also be secondary to inflammatory bowel disease (IBD)^{Footnote 9}.

Diagnostic testing

• Obtain rectal swabs for nucleic acid amplification tests (NAAT) for CT and GC (where available), plus culture for GC (where available).
  • Request that CT-positive rectal specimens from people with symptoms compatible with LGV and from sexual partners of people diagnosed with LGV be forwarded to the provincial or territorial laboratory (if available) or the National Microbiology Laboratory (NML) for LGV genotyping.
• Obtain swabs from lesions or buboes for NAAT for CT and LGV.
• Obtain syphilis serology.
• If clinical presentation or history indicates, collect stool specimen for culture for enteric pathogens and for examination for ova and parasites. Consult local laboratory for the availability of NAAT for protozoa.
• Consider anoscopy for symptomatic individuals who have receptive anal sex.

Empiric treatment and management

The decision to treat empirically or to wait for test results should reflect the:

• Severity of the clinical condition
• Probability of infection
• Person's risk factors for a sexually transmitted or blood-borne infection (STBBI)
• Person's willingness to abstain from sex and to return for test results or follow-up

When treating empirically, the presence of anorectal exudate is an indication to treat for both GC and CT^{Footnote 8Footnote 10}.

Notes:

• Cefixime is considered alternate treatment for gbMSM.
• Data suggest doxycycline is more effective than azithromycin for the treatment of rectal CT^{Footnote 11Footnote 12}.
• LGV genotypes of CT require a longer course of treatment: Doxycycline 100 mg PO BID for 21 days.
• Azithromycin is preferred over doxycycline for the treatment of suspected or confirmed GC, due to significant rates of tetracycline-resistant GC and concerns about multiday treatment compliance^{Footnote 13Footnote 14Footnote 15Footnote 16}.

Treat current sexual partners with the same empiric treatment regimen as the index case.

Refer to etiology-specific guides for the treatment of suspected Syphilis or  Genital herpes infections.