STI-associated syndromes guide: Proctitis
This guide provides an overview of the management and empiric treatment of sexually transmitted infection (STI) - associated proctitis, which is an inflammation of the rectal mucosa, not extending beyond 10–12 cm of the anal verge.
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 membranesFootnote 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 identifiedFootnote 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 diagnosisFootnote 2.
Enteric infections can also be acquired through oral-anal sexual activities and result in proctocolitis and enteritisFootnote 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 LGVFootnote 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 ulcersFootnote 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 CTFootnote 8Footnote 10.
Empiric treatment for proctitis |
---|
Ceftriaxone 250 mg IM in a single dose [A-l] or Cefixime 800 mg PO in a single dose [A-l] |
Notes:
- Cefixime is considered alternate treatment for gbMSM.
- Data suggest doxycycline is more effective than azithromycin for the treatment of rectal CTFootnote 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 complianceFootnote 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.
Follow-up
Evaluate response to treatment in all individuals treated for proctitis. Consider referring individuals with persistent or recurrent proctitis to an experienced colleague, a gastroenterologist or an infectious disease specialist for further investigation.
The need for test of cure (TOC) depends on which pathogen is confirmed by laboratory testing. Refer to the etiology-specific guide.
Reporting and partner notification
When treatment is indicated for an STI: notify, evaluate, test and treat (as appropriate) sexual partners. Refer to the etiology-specific guide(s) for guidance on reporting and partner notification.
References
- Footnote 1
-
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002;51(RR-6):1-78.
- Footnote 2
-
Rompalo AM. Diagnosis and treatment of sexually acquired proctitis and proctocolitis: an update. Clin Infect Dis 1999;28(Supplement_1):S84-S90.
- Footnote 3
-
Albrecht MA, Hirsch MS, McGovern B. Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection. Uptodate http://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-genital-herpes-simplex-virus-infection 2014:1-68.
- Footnote 4
-
Nieuwenhuis RF, Ossewaarde JM, Götz HM, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clin Infect Dis 2004;39(7):996-1003.
- Footnote 5
-
Kropp RY, Wong T, Canadian LGV Working Group. Emergence of lymphogranuloma venereum in Canada. CMAJ 2005: 172(13):1674-1676.
- Footnote 6
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Weir E. Lymphogranuloma venereum in the differential diagnosis of proctitis. CMAJ 2005 Jan 18;172(2):185.
- Footnote 7
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Goen JL, Schwartz RA, De Wolf K. Mucocutaneous manifestations of chancroid, lymphogranuloma venereum and granuloma inguinale. Am Fam Physician. 1994;49(2):415-425.
- Footnote 8
-
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015 Jun 5;64(RR-03):1-137.
- Footnote 9
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Høie S, Knudsen LS, Gerstoft J. Lymphogranuloma venereum proctitis: a differential diagnose to inflammatory bowel disease. Scand J Gastroenterol 2011;46(4):503-510.
- Footnote 10
-
Swygard H, Seña AC, Cohen MS. Treatment of uncomplicated Neisseria gonorrhoeae infections. UpToDate 2019.
- Footnote 11
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Kong FY, Tabrizi SN, Law M, et al. Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. Clin Infect Dis. 2014;59(2):193-205
- Footnote 12
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Hathorn E, Opie C, Goold P. What is the appropriate treatment for the management of rectal Chlamydia trachomatis in men and women? Sex Transm Infect 2012; 88(5):352-354.
- Footnote 13
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Lyss SB, Kamb ML, Peterman TA, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhoeae in sexually transmitted disease clinics in the United States. Ann Intern Med 2003; 139(3):178-185.
- Footnote 14
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Tapsall JW. What management is there for gonorrhea in the postquinolone era? Sex Transm Dis 2006;33(1):8-10.
- Footnote 15
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Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010 Dec 17;59(RR-12):1-110.
- Footnote 16
-
World Health Organization. Guidelines for the Management of Sexually Transmitted Infections. 2003.
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