Proctitis, Proctocolitis, and Enteritis

Sexually transmitted gastrointestinal syndromes include proctitis, proctocolitis, and enteritis. Evaluation for these syndromes should include appropriate diagnostic procedures (e.g., anoscopy or sigmoidoscopy, stool examination, and culture).

Proctitis is inflammation of the rectum (i.e., the distal 10–12 cm) that can be associated with anorectal pain, tenesmus, or rectal discharge. N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV are the most common sexually transmitted pathogens involved. In persons with HIV infection, herpes proctitis can be especially severe. Proctitis occurs predominantly among persons who participate in receptive anal intercourse.

Proctocolitis is associated with symptoms of proctitis, diarrhea or abdominal cramps, and inflammation of the colonic mucosa extending to 12 cm above the anus. Fecal leukocytes might be detected on stool examination, depending on the pathogen. Pathogenic organisms include Campylobacter sp., Shigella sp., Entamoeba histolytica, and LGV serovars of C. trachomatis. CMV or other opportunistic agents can be involved in immunosuppressed HIV-infected patients. Proctocolitis can be acquired through receptive anal intercourse or by oral-anal contact, depending on the pathogen.

Enteritis usually results in diarrhea and abdominal cramping without signs of proctitis or proctocolitis; it occurs among persons whose sexual practices include oral-anal contact. In otherwise healthy persons, Giardia lamblia is most frequently implicated. When outbreaks of gastrointestinal illness occur among social or sexual networks of MSM, clinicians should consider sexual transmission as a mode of spread and provide counseling accordingly. Among persons with HIV infection, enteritis can be caused by pathogens that may not be sexually transmitted, including CMV, Mycobacterium aviumintracellulare, Salmonella sp., Campylobacter sp., Shigella sp., Cryptosporidium, Microsporidium, and Isospora. Multiple stool examinations might be necessary to detect Giardia, and special stool preparations are required to diagnose cryptosporidiosis and microsporidiosis. In addition, enteritis can be directly caused by HIV infection. Diagnostic and treatment recommendations for all enteric infections are beyond the scope of these guidelines.

Diagnostic Considerations for Acute Proctitis

Persons who present with symptoms of acute proctitis should be examined by anoscopy. A Gram-stained smear of any anorectal exudate from anoscopic or anal examination should be examined for polymorphonuclear leukocytes. All persons should be evaluated for HSV (by PCR or culture), N. gonorrhoeae (NAAT or culture), C. trachomatis (NAAT), and T. pallidum (Darkfield if available and serologic testing) (see pathogen-specific sections). If the C. trachomatis test is positive on a rectal swab, a molecular test PCR for LGV should be performed, if available, to confirm an LGV diagnosis (see LGV) (394).

Treatment for Acute Proctitis

Acute proctitis of recent onset among persons who have recently practiced receptive anal intercourse is usually sexually acquired (845,846). Presumptive therapy should be initiated while awaiting results of laboratory tests for persons with anorectal exudate detected on examination or polymorphonuclear leukocytes detected on a Gram-stained smear of anorectal exudate or secretions; such therapy also should be initiated when anoscopy or Gram stain is unavailable and the clinical presentation is consistent with acute proctitis in persons reporting receptive anal intercourse.

Recommended Regimen

  • Ceftriaxone 250 mg IM in a single dose
    PLUS
  • Doxycycline 100 mg orally twice a day for 7 days

Bloody discharge, perianal ulcers, or mucosal ulcers among MSM with acute proctitis and either a positive rectal chlamydia NAAT or HIV infection should be offered presumptive treatment for LGV with doxycycline 100 mg twice daily orally for a total of 3 weeks (847,848) (see LGV). If painful perianal ulcers are present or mucosal ulcers are detected on anoscopy, presumptive therapy should also include a regimen for genital herpes (see Genital HSV Infections).

Other Management Considerations

To minimize transmission and reinfection, men treated for acute proctitis should be instructed to abstain from sexual intercourse until they and their partner(s) have been adequately treated (i.e., until completion of a 7-day regimen and symptoms resolved). All persons with acute proctitis should be tested for HIV and syphilis.

Follow-Up

Follow-up should be based on specific etiology and severity of clinical symptoms. For proctitis associated with gonorrhea or chlamydia, retesting for the respective pathogen should be performed 3 months after treatment.

Management of Sex Partners

Partners who have had sexual contact with persons treated for GC, CT, or LGV within the 60 days before the onset of the persons symptoms should be evaluated, tested, and presumptively treated for the respective pathogen. Partners of persons with sexually transmitted enteric infections should be evaluated for any diseases diagnosed in the person with acute proctitis. Sex partners should abstain from sexual intercourse until they and their partner with acute proctitis are adequately treated.

Allergy, Intolerance, and Adverse Reactions

Allergic reactions with third-generation cephalosporins (e.g., ceftriaxone) are uncommon in persons with a history of penicillin allergy (428,430,464). In those persons with a history of an IgE mediated penicillin allergy (e.g., those who have had anaphylaxis, Stevens Johnson syndrome, or toxic epidermal necrolysis), the use of ceftriaxone is contraindicated (428,431).

HIV Infection

Persons with HIV infection and acute proctitis may present with bloody discharge, painful perianal ulcers, or mucosal ulcers. Presumptive treatment should include a regimen for genital herpes and LGV.

 

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