Proctitis is inflammation of the rectal mucosa. Clinical manifestations often include anorectal pain, itching, discharge, ulcers, diarrhea, bleeding, or lower abdominal cramping. Anoscopic examination may reveal mucosal inflammation, erythema, bleeding, ulcerations, and/or discharge. Proctitis may develop from prior radiation treatments, autoimmune disorders, vasculitis, ischemia, and infectious diseases (enteric pathogens and sexually transmitted infections (Table 85-2).
TABLE 85-2Anorectal Sexually Transmitted Infections ||Download (.pdf) TABLE 85-2 Anorectal Sexually Transmitted Infections
|Bacteria ||Viruses |
|Neisseria gonorrhoeae* ||Herpes simplex type 2* |
|Chlamydia trachomatis* ||Human immunodeficiency virus |
|Treponema pallidum* ||Human papillomavirus |
If the patient has an anorectal infection caused by one of the sexually transmitted infection organisms, assume that another may be present. Screen for other sexually transmitted infections; obtain appropriate blood tests, specimens from anoscopy for Gram stain, and viral and bacterial cultures; and start empiric therapy. For detailed discussion of sexually transmitted infections, see chapters 149, "Sexually Transmitted Infections" and 252, "Skin Disorders: Groin and Skinfolds."
Condylomata acuminata, commonly known as anal warts, are often caused by human papillomavirus types 6 and 11.10 Lesions begin as discrete, soft, fleshy growths on the perianal skin and the squamous epithelium of the anal canal. They may vary from dot-like to larger papilliform, cauliflower-like lesions. With time, pain, itching, bleeding, and anal discharge become part of the symptom complex. Perianal involvement is often associated with vulvovaginal and penile lesions. Optimal treatment is referral to an appropriate specialist for laser ablation, cryotherapy, electrocautery, immunotherapy, or surgical excision. Anorectal carcinoma and cervical and orogenital cancer are associated with human papillomavirus types 16 and 18.
Surprisingly most women and about 50% of men with anorectal gonorrhea are asymptomatic.10 Classically, patients experience tenesmus with profuse yellow, bloody discharge, which usually begins about 1 week after exposure. Patients in the acute phase generally have mild burning and/or pruritus with some purulent seepage. Anoscopic examination during this phase of the disease reveals marked hyperemia and edema of the rectal mucosa and diffuse inflammation with purulent discharge from the anal crypts. Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt. Diagnosis is made by Gram stain, cultures, and nucleic acid amplification tests. Dissemination involving the heart, liver, CNS, and joints should be considered. Treatment is with ceftriaxone, 250 mg IM, and azithromycin, 1 gram PO once, or doxycycline, 100 milligrams PO twice a day for 7 days.
Chlamydia trachomatis causes both urogenital and anorectal infections. The lymphogranulomatous variety, serovars L1, L2, and L3, occurs mainly in the tropics. Infection can involve the rectum by perirectal lymphatic invasion from vaginal seeding or from direct anorectal mucosal infections. The nonlymphogranulomatous variety, serovars D to K, may infect the rectal mucosa, although it does not cause the extensive rectal scarring and stricturing that its lymph gland–invading cousin from the tropics does. A patient with chlamydial proctitis may be asymptomatic or may present with anal pruritus, pain, bleeding, tenesmus, and purulent discharge. The more severe form of proctitis occurring with this infection is usually due to the lymphogranulomatous type of chlamydia. Signs include fever, flulike symptoms, and prominent unilateral lymph node enlargement. Perirectal abscesses and chronic fistulas may develop. Red, friable mucosa and acutely painful anal ulcerations may be seen on anoscopy. Testing is not commonly available, and treatment is based on clinical findings. Treatment for nonlymphogranulomatous chlamydial proctitis includes azithromycin, 1 gram PO once, or doxycycline, 100 milligrams PO twice a day for 7 days. Treatment for lymphogranulomatous chlamydial infections includes doxycycline, 100 milligrams PO twice a day for 21 days, or erythromycin, 500 milligrams PO four times a day for 21 days.
The causative agent of syphilis is the spirochete Treponema pallidum. Chancres that form a few weeks after infection are the characteristic lesion of primary syphilis and usually manifest themselves at the anal verge or in the anal canal. Rectal mucosal involvement is uncommon, and at times, the chancre may be absent. Syphilitic chancres may be misdiagnosed as a simple fissure because anal chancres are often very painful. A symmetric lesion on the opposite side of the anal margin and inguinal adenopathy may be present. Condyloma lata are large, raised, flat, grey or white lesions. They appear in the perianal region as a manifestation of the secondary stage of syphilis. The rapid plasma reagin and the Venereal Disease Research Laboratory tests are commonly used for screening, with confirmation with a T. pallidum–specific immunoassay. Current treatments include benzathine penicillin G (Bicillin L-A), 2.4 million units IM for one dose, or doxycycline, 100 milligrams PO twice a day, or tetracycline, 500 milligrams PO four times a day for 14 days.
Anorectal herpes is more commonly caused by the type 2 herpes simplex virus. Symptoms occur within a few weeks after exposure and consist of itching and soreness in the perianal area, progressing to severe anorectal pain. Early lesions are small, discrete vesicles on an erythematous base. Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers on the perianal skin, the anoderm, and rectal mucosa. The pain and tenesmus from these lesions may be so intense that the patient develops severe constipation and difficulty urinating. The patient may develop a flulike illness with inguinal adenopathy noted on examination during the initial course of the illness. Symptoms persist for 1 to 2 weeks and are frequently recurrent, although less pronounced, during the ensuing year. Topical analgesia may be needed for adequate examination. Viral cultures, polymerase chain reaction, and immunofluorescent testing are helpful for diagnosis. Treatment consists of adequate pain medication, stool softeners, and acyclovir, 400 milligrams PO five times a day for 10 days for the initial episode, and 400 milligrams PO three times a day for 5 days for recurrent episodes. Suppression consists of acyclovir 400 milligrams PO twice a day. Consider herpes simplex virus, syphilis, human immunodeficiency virus, chancroid, and donovanosis when anal ulcers are present.
ANORECTAL ACQUIRED IMMUNODEFICIENCY SYNDROME–RELATED INFECTIONS
Patients rendered immunodeficient by human immunodeficiency virus are subject to a variety of opportunistic infections that affect the intestinal, anorectal, and other body systems (Table 85-3). Severe rectal pain, diarrhea, and hematochezia are common presenting symptoms. Anoscopy confirms anal canal ulcers and acute proctitis. Obtain serology for syphilis, and start antibiotic therapy.
TABLE 85-3Anorectal Acquired Immunodeficiency Syndrome–Related Infections ||Download (.pdf) TABLE 85-3 Anorectal Acquired Immunodeficiency Syndrome–Related Infections
|Herpes simplex virus types 1 and 2 ||Campylobacter |
|Mycobacterium avium-intracellulare ||Entamoeba |
|Cytomegalovirus ||Cryptosporidium |
|Salmonella enterocolitis ||Isospora |
|Shigella ||Giardia |
Stool softeners, sitz baths, careful anal hygiene, and pain medications will provide some relief. Enteric pathogens may require antibiotics such as trimethoprim and sulfamethoxazole (Isospora), metronidazole (Entamoeba, Giardia), azithromycin (Campylobacter), acyclovir (herpes), or fluoroquinolones (Salmonella, Shigella). Provide empiric therapy against gonorrhea, nonlymphogranulomatous chlamydia, and incubating syphilis for human immunodeficiency virus–associated acute proctitis. Refer for appropriate follow-up, further evaluation, and definitive treatment.