Table 2. Sexually transmitted proctitis: symptoms, diagnostic pearls, and treatment.
| Pathogen | Symptoms | Findings | Diagnosis pathology |
Treatment | Other |
|---|---|---|---|---|---|
| Neisseria gonorrhea | Itching, painful defecation, tenesmus, thick yellow mucopurulent discharge, urethritis | Pus when push on crypts | Intracellular gram-negative diplococci Thayer–Martin plate |
Ceftriaxone 250 intramuscular × 1 + (treat for Chlamydia also) azithromycin 1 g orally or doxycycline 100 mg orally × 7 d |
Most common cause in HIV-infected patients Reportable Most patients are asymptomatic |
| Chlamydia trachomatis |
Proctitis, rectal pain, tenesmus, fever |
Erythematous rectal mucosa | Cell culture Direct immunofluorescent |
Doxycycline 100 mg twice daily × 7 d Azithromycin 1 g x 1 d |
Most common strains D and K |
| Lymphogranuloma venereum Chlamydia trachomatis |
As above (Chlamydia trachomatis, but worse), perianal ulcers (foul smelling), severe proctitis including mucoid and hemorrhagic discharge, unilateral inguinal lymphadenopathy (bubo) | Endoscopic inflammation and ulceration. Late stages may show fistulae and strictures | Aspirate from bubo Crypt abscess and granuloma |
Same, prolonged therapy | Strains L1, 2, 3 Elephantiasis Strictures/fissure |
| Treponema pallidum (syphilis) | Proctitis chancre—painful or painless fissure like, unusual location; rectal masses; lymphadenopathy |
Spirochete, mobile Dark field examination Fluorescent treponemal antibody absorption test or microhemagglutination assay VRDL/RPR |
Penicillin 2.4 M units intramuscularly for 2 wk | ||
| CMV | Proctocolitis, diarrhea, fever, hemorrhage, perforation |
Submucosal hemorrhage Mucosal ulcerations |
Intranuclear viral inclusion bodies Cytoplasmic Inclusion bodies |
Ganciclovir Foscarnet | 94% homosexual males positive Perforation |
| HSV | Fever, tenesmus, constipation, radiculopathy |
Associated with coalesced vesicles and pustules Distal 10 cm |
Viral isolation Monoclonal antibody |
Acyclovir 400 mg 5 times/day × 5 d (increased dose for proctitis) Foscarnet or valacyclovir |
Abbreviations: CMV, cytomegalovirus; HSV, herpes simplex virus; RPR, rapid plasma reagin; VRDL, Venereal Disease Research Laboratory.