Approach:
Should begin with a thorough examination of the external anus, evaluating for any lesions, fissures, or hemorrhoids.
If any abnormalities are discovered, or if the patient is complaining of rectal pain, bleeding, or purulent or bloody discharge, anoscopy and digital rectal exam is recommended.
Lidocaine ointment and may be used to facilitate examination if the patient is experiencing a great deal of pain
Infectious Etiologies:
Infectious proctitis:
Most often caused by gonorrhea
Symptoms are rectal pain, bleeding, +- purulent discharge, and can be associated with urgency or feelings of constipation. The external anal exam is normal, but the digital exam is noteworthy for diffuse tenderness.
STI testing is done through anal swabs for chlamydia and gonorrhea. If a visible lesion is present, swabbing the lesion for HSV PCR is indicated.
Diffuse ulcerations, systemic symptoms (fevers, chills), and lymphadenopathy should raise your suspicion for lymphogranuloma venereum (LGV), which is caused by Chlamydia trachomatis serovars L1, L2, and L3, have been reported in MSM.
If any ulcerations are present, it should raise suspicion for syphilis, HSV, or LGV.
An anal pap test may also be taken as MSM are at an increased risk of HPV related disorders, including anal warts/anal cancer
LGV:
Infection caused by specifically Gonorrhea L1, L2, and L3. In the Western world, it is most commonly found in HIV positive men who have sex with men.
Its pathogenesis is as follows:
Stage 1: 3-21 days after exposure: a painless blister or sore develops at the site of infection; most commonly the rectum, genitals, or mouth. This is commonly unnoticed. This develops into groups of blisters and can become more diffuse, spreading throughout the body. In rectal infection, proctitis can develop.
Stage 2: At 10-30 days, inflamed and swollen lymph glands appear in the groin, armpit, or neck. Anal infection can cause painful ulcerations, discharge, and bleeding. Systemic symptoms of fever or rash may develop.
Stage 3: if untreated, LGV can become more severe, causing general swelling of the lymph glands, swelling of the genitals, and severe ulcerations of the genitals, causing lasting damage, fibrosis, strictures, fistulas, and deformity.
Testing: Testing for chlamydia in the ER will rule out LGV. Further speciated chlamydial testing generally takes weeks to perform, and are not of particular use.
Treatment:
For all MSM patients with proctitis, treatment should be initiated for gonorrhea and chlamydial infections, with Ceftriaxone 500 mg IM and doxycycline 100 mg orally BID for 7 days.
For patients with ulcers, HSV treatments hould be initiated with valacyclovir 1g orally twice a day for 7-10 days.
For patients in whom you suspect LGV, doxycycline therapy should be extended to 3 weeks.
Anal warts:
MSM are at a higher risk of anal warts secondary to HPV, as seen below.
Treatment:
Prescriptions of Podofilox or imiquimod, which are patient applied creams in the case of immune modulators, can be given to the patient. Follow up with colorectal surgery should be given.