Sexual Health
Service Guidelines
Proctitis in MSM
Background
This guideline is to be used for assessment and management of men who have sex with men
(MSM) presenting with symptoms of proctitis as this is predominantly an issue for this
population.
Men and women may be at risk of sexually transmissible anorectal or intestinal infections
through a variety of sexual practices, including receptive anal intercourse, oral–anal sexual
contact, digital penetration or use of sex toys.
Proctitis is defined as an inflammatory syndrome of the distal 10–12 cm of the anal canal,
also called the rectum. It may be due to a variety of sexually transmitted infections or
enteric pathogens.
Possible Causes of Sexually Transmissible Procto-colitis and Enteritis
Distal Proctitis
Procto-colitis
Enteritis
N. gonorrhoeae
Shigella spp
Giardia duodenalis
C. trachomatis serotypes
Salmonella spp
Cryptosporidium spp
D-K and LGV serotypes L1
Campylobacter
Microsporidium spp
to L3
E. coli
HAV
T. pallidum ssp pallidum
Entamoeba histolytica
Herpes simplex virus
Cryptosporidium spp
M. genitalium
CMV
Note:
Most rectal infections with non LGV chlamydia serotypes and gonorrhoea are
asymptomatic
Target populations for screening
MSM with symptoms of proctitis
All cases should be discussed or referred to a doctor or NP
Tests
The following investigations should be requested:
Pharyngeal swab and FVU for gonorrhoea and chlamydia testing by NAAT PLUS
Rectal smear for Gram staining for PMNLs and Gram negative diplococci
Rectal gonorrhoea culture
2 Rectal NAAT swabs for testing for chlamydia and gonorrhoea-request LGV testing if
swab positive for chlamydia (indicate on lab form)
Viral swab for HSV testing
Authored date
21/05/2020
Review date
21/05/2021
Owner
Service Clinical Director
Version
V1.0
1
Sexual Health
Service Guidelines
DFA for treponemes if ulcerative lesions seen
Serology for HIV, syphilis
Serology for HAV if not previously screened or vaccinated
Serology for and HBV if indicated (refer HBV guideline)
Serology for HCV if clinically indicated
Arrange stool specimens if patient has symptoms or signs of colitis or enteritis
Mycoplasma genitalium
While this has been documented as a cause of proctitis in MSM, routine testing is
not recommended
Testing may be indicated in men with persisting proctitis symptoms with no other
aetiology for their symptoms (refer MG guideline)
Clinical signs and symptoms
Symptoms of rectal STI include anal discharge or bleeding, rectal pain or discomfort,
and/or tenesmus
There may be systemic symptoms such as fever, malaise, headache, sore throat
Symptoms of colitis include diarrhoea with blood or mucopus, abdominal pain
Symptoms of enteritis include diarrhoea, abdominal pain, nausea and vomiting
Clinical evaluation
Check temperature if systemic symptoms
Examine genital area (see guideline for male examination)
Palpate the abdomen: Tenderness over the colon suggests colitis
Inspect the perianal region: Perianal ulceration may suggest syphilis, HSV infection or
LGV
Ideally anoscopy should be performed to inspect for mucosal inflammation and
infiltration/swelling and/or ulceration however may not be possible due to pain or
may not be acceptable to the patient
Note: Rectal swabs may be self-collected following clinical examination if more acceptable
to patient.
Management and treatment (see Pregnancy section where relevant)
If clinically colitis or enterocolitis advise patient:
to keep hydrated
wash hands regularly especially after going to the toilet or preparing food
To stay at home till symptoms resolve and/or results of tests are back
If clinically proctitis: Treat empirically while waiting for results.
Authored date
21/05/2020
Review date
21/05/2021
Owner
Service Clinical Director
Version
V1.0
2
Sexual Health
Service Guidelines
For mild cases where gonorrhoea is not clinically suspected:
doxycycline 100 mg bd po for 7/7
If more severe symptoms and gonorrhoea suspected:
Ceftriaxone 500 mg im stat PLUS
Azithromycin 1 g po stat PLUS
Doxycyline 100 mg bd po for 7 to 21/7 (depending on results of NAAT tests. Note:
LGV more likely if HIV +ve)
PLUS (if herpes proctitis is clinically suspected)
Valaciclovir 500 mg bd po for 7/7
OR Aciclovir 400 mg tds po for 7/7
If syphilis is clinically suspected treat empirically for syphilis while waiting for results.
Pregnancy
N/A
General advice
Advise patient to avoid sexual contact or to use condoms for 7 days following
initiation of treatment and for 1 week after sexual partner(s) have been treated
Patients should be given a detailed explanation of their condition with particular
emphasis on the implications for the health of themselves and their partner(s). This
should be reinforced, if necessary, with clear and accurate written information
Discuss risk reduction and use of condoms to reduce risk of reinfection
Contact tracing
Depends on diagnosis
For chlamydia and gonorrhoea notify contacts within 90 days of diagnosis
For syphilis as per syphilis guideline
Herpes- contact tracing is not required
Enteric infections are notifiable conditions and occurs automatically by the lab-will
be followed up by Medical officer of health
Follow-up
Advise repeat STI check in 3 months as re-infection is common
Authored date
21/05/2020
Review date
21/05/2021
Owner
Service Clinical Director
Version
V1.0
3
Sexual Health
Service Guidelines
Arrange follow-up appointment for review if clinically indicated e.g. severe
symptoms otherwise patient should be followed up by either txt or a phone call 1
week after treatment initiated to review contact tracing and adherence
Create TC appointment on HCC grid (#TNAB column) 1 week later
1 phone call for follow-up of compliance/contact tracing and if no response, send
standard adherence text/email x 1, then NFA
Culture results and susceptibilities should be checked to ensure that adequate
treatment has been given. This is the responsibility of the person who requested the
test
Management of contacts
If symptomatic
Examine, perform a sexual health screen and manage syndromically -consult
relevant guideline e.g. urethritis
If asymptomatic
Perform a sexual health check and treat empirically as indicated by provisional
diagnosis or test results of index cases
Recall for positive result
Initiate on receipt of result or no more than 14 days from date of last visit
o If STI tests are positive and untreated infection -Create TC appointment on
HCC grid (#UNRX column) for nurse to action
2 types of contact, a phone call, txt, letter, or email 1 week apart asking patient to
contact the clinic. If no response, enter alert on HCC for untreated infection and
document
Enter correct diagnostic code for encounter
Management of recalls
N/A
HCC code
Proctitis non-specific (only if no positive diagnostic tests)
Gonorrhoea of anorectum-confirmed
Chlamydia of anorectum-confirmed
Herpes of anorectum-1st episode
Authored date
21/05/2020
Review date
21/05/2021
Owner
Service Clinical Director
Version
V1.0
4