Proctitis: Difference between revisions
 
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==Evaluation==
==Evaluation==
 
*Consider Gram stain and culture
===[[Condyloma Acuminata]]===
 
===[[Gonorrhea]]===
*Symptoms vary from none to severe rectal pain with yellow, bloody discharge
*Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt
*Diagnosis made by Gram stain and culture
*Also consider dissemination to heart, liver, CNS, and joints
 
===[[Chlamydia]]===
*Infection due to direct anorectal infection or via vaginal seeding to perirectal lymphatics
*Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge
*Lymphogranulomatous variety
**Acutely painful anal ulcerations associated with unilateral lymph node enlargement
**[[Fever]] and flulike symptoms
**May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas
 
===[[Syphilis]]===
*Primary
**Anal chancres appear ~2-6 weeks after intercourse, are often painful
***May be misdiagnosed as simple fissure
****Symmetric lesion on opposite side of anal margin is distinguishing feature
****Inguinal adenopathy is often present
*Secondary
**Condylomata lata (flatter and firmer than condylomata acuminata)
 
===[[Herpes Simplex Virus-2]]===
*Itching and soreness in perianal area progressing to severe anorectal pain
**Accompanied by flulike illness, inguinal adenopathy
*Early lesions are small, discrete vesicles on erythematous base
**Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers


==Management==
==Management==
Line 85: Line 55:
===[[Herpes Simplex Virus-2]]===
===[[Herpes Simplex Virus-2]]===
*[[Acyclovir]] 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes
*[[Acyclovir]] 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes
===[[Lymphogranuloma Venereum]]===
*Consider in patients with bloody discharge, perianal or mucosal ulcers, chlamydia NAAT+, and MSM
*Extend [[doxycycline]] 100mg PO BID for 21 days total<ref>Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1</ref>


==Disposition==
==Disposition==

Latest revision as of 05:06, 30 July 2021

Background

Causes

  • Radiation treatment
  • Autoimmune
  • Vasculitis
  • Ischemia
  • Infectious (STI and enteric organisms)

Clinical Features

General

  • Inflammation of the rectal mucosa
  • Pain on defecation
  • Tenesmus
  • Mucoid discharge
  • Inguinal lymphadenopathy (may be seen with T. pallidum)

By Causative Agent

  • Condyloma Acuminata
  • Gonorrhea
    • Symptoms vary from none to severe rectal pain with yellow, bloody discharge
    • Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt
  • Chlamydia
    • Infection due to direct anorectal infection or via vaginal seeding to perirectal lymphatics
    • Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge
    • Lymphogranulomatous variety
      • Acutely painful anal ulcerations associated with unilateral lymph node enlargement
      • Fever and flulike symptoms
      • May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas
  • Syphilis
    • Primary
      • Anal chancres appear ~2-6 weeks after intercourse, are often painful
        • May be misdiagnosed as simple fissure
          • Symmetric lesion on opposite side of anal margin is distinguishing feature
          • Inguinal adenopathy is often present
    • Secondary
      • Condylomata lata (flatter and firmer than condylomata acuminata)
  • Herpes Simplex Virus-2
    • Itching and soreness in perianal area progressing to severe anorectal pain
      • Accompanied by flulike illness, inguinal adenopathy
    • Early lesions are small, discrete vesicles on erythematous base
      • Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers

Differential Diagnosis

Anorectal Disorders

Non-GI Look-a-Likes

Evaluation

  • Consider Gram stain and culture

Management

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[1]

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

  • Gonorrhea
    • Ceftriaxone IM x 1
      • 500 mg, if weight <150 kg
      • 1 g, if weight ≥150 kg
  • Chlamydia


Ceftriaxone contraindicated

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

Syphilis

Herpes Simplex Virus-2

  • Acyclovir 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes

Lymphogranuloma Venereum

  • Consider in patients with bloody discharge, perianal or mucosal ulcers, chlamydia NAAT+, and MSM
  • Extend doxycycline 100mg PO BID for 21 days total[2]

Disposition

See Also

External Links

References

  1. ↑ Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
  2. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1
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