Anorectal syndromes

• Sexually acquired proctitis
  • Herpes simplex viruses (HSV Types 1 and 2)
  • Chlamydia trachomatis, particularly strains that cause lymphogranuloma venereum (LGV)
  • Neisseria gonorrhoeae
  • Treponema pallidum (syphilis)
  • Mycoplasma genitalium
• Sexually aquired proctocolitis
  • LGV
  • Shigella
  • Campylobacter
  • Entamoeba histolytica

• Anorectal symptoms in people with a history of anal sex
• NB It is important to take a sexual history in people with anorectal symptoms, as sexual practices may not otherwise be disclosed

• Patients should ideally be referred to a specialist sexual health service, as management may be complex, and further testing may be required
• If referral is not possible, discussion with a sexual health physician is recommended
• The patient should be examined, and tests should be clinician-collected. Ideally this should be done via proctoscope

Investigations

• STI screening as per sexual health check guideline
• In addition, rectal culture swab for Neisseria gonorrhoeae (if available)
• Rectal herpes swab
• Request LGV if rectal chlamydia positive. This must be discussed with a sexual health physician or microbiologist
• If diarrhoea, faecal specimen for bacterial pathogens

 Note: 21-day course of doxycycline to cover the possibility of LGV, which requires a long course of treatment

• If specific STI tests are negative, corresponding treatment for the pathogen can be ceased
• LGV testing is not routinely offered in the community and MUST be discussed with a sexual health physician or microbiologist
• If all tests are negative, cease medications and seek specialist advice if symptoms persist
• Advise to abstain from sex or use condoms until treatment complete and symptoms resolved, and until partner(s) tested and treated (if indicated)

• Contact tracing is important to prevent re-infection and reduce transmission
• All sexual contacts in the last 3 months should be notified
• Most patients choose to tell contacts themselves; giving written information can be helpful
• Notifying all contacts may not be possible e.g. if there is insufficient information or a threat of violence

Management of sexual contacts

• Contacts should have a sexual health check, including testing for LGV if index case positive
• Advise contacts to abstain from sex or use condoms until results are available, and treatment (if any) completed
• If index case or contacts test positive for an STI, see appropriate STI guideline for management
• Patient-delivered partner therapy is not legal in Aotearoa New Zealand

Referral to or discussion with a sexual health specialist is recommended for:

• Patients with anorectal symptoms and a history of receptive anal sex, where there is a high suspicion that symptoms are STI related
• Screening and treatment of sexual contacts if clinician wishes
• Allergy or contraindication to standard treatment options
• Complicated clinical situations for further management

• 100% of patients with proctitis have been investigated with appropriate tests to exclude STIs