Gum and the Anus

Ben Goorney,Consultant Genitourinary Physician, Salford

Powerpoint File

The anorectum is frequently involved in sexually transmitted infections (STI).
The Main mode of transmission is receptive anal sex, although not exclusively so, and can arise via contamination from genital tract.
STI,s frequently co-exist and if one is detected then should prompt referral for a full STI screen.
These infections are broadly divided into General STI,s arising directly from sexual transmission.And those that are specifically HIV related and affect anorectum as a manifestation of underlying immunosupression.

GENERAL STI,S- CLINICAL PRESENTATION:

PROCTITIS
- Gonorrhoea- Usually acute with purulent rectal discharge,
Diagnosis confirmed by direct microscopy and culture from rectal samples.
Chlamydia Trachomatis- Sub-acute, Diagnosis confirmed by Microbiological Identification from rectal samples.
Non-Specific – Similar to above, but no organisms isolated, presence of pus cells on direct microscopy.
Lymphogranuloma Venereum(LGV)- A serovar of Chlamydia, has become a re-emergent disease amongst MSM(men have sex with men) (1)causes marked rectal pain.
Clinical and pathological course similar to Crohns disease, Rectal stricture and perforation been reported.(2)
Diagnosis made by microbiological identification of serovar(L1-13) from rectal samples.
Serology with elevated titres.
High HIV co-infection rate(80%)

ULCERATION
Herpes(Types 1 and 2)- Causes multiple painful peri-anal ulceration, may extend into anal canal and rectum.
With primary episode may be associated with autonomic disturbance,and systemic upset . Is particularly persistant and aggressive in HIV infected persons.
Diagnosis is confirmed on viral swabs from Ulcer
Syphilis –Perianal ulcers usually painless(primary) but can be painful when secondarily infected.Perianal Mucous patches (Secondary),may have other mucocutaneous signs of Secondary Syphilis.
Diagnosis is direct dark ground microscopy from anal samples and positive Syphilis Serology.Recent epidemic, frequently associated with HIV co-infection.

LUMPS/SWELLINGS

Warts(Condylomata Accuminata) Caused by “low risk “ HPV genotypes 6,11 and 33.
Can present incidentally or pruritis ani.
In secondary bacterial infection cause tenesmus and bleeding PR
A third of cases extend into anal canal,proctoscopy recommended in recalcitrant cases.
Diagnosis clinical or biopsy carried out if malignancy suspected.
New quadrivalent vaccine should prevent most cases in future.

Secondary Syphilis- As Condylomata Lata- Soft fleshy anal papules usually painless.(3)
May have other features of secondary Syphilis
Diagnosis direct microscopy of expressed fluid, and syphilis serology.

COMMON SPECIFIC HIV ASSOCIATED CONDITIONS

Bacterial-Atypical Mycobacteria-
Enteropathogens

Protozoal- Cryptosporidiosis-
Amaebiasis -
Diagnosis is confirmed by Microbiological identification on stool sample, and biopsies if required.

Viral- CMV(Cytomegalovirus)-
Idiopathic Ulcer
Diagnosis is confirmed on virological identification on rectal samples,serology(CMV) and histological appearance.

Opportunistic Tumours- Kaposis Sarcoma
Non Hodgkins Lymphoma

Diagnosis confirmed on endoscopic, and histological appearance

HIV TESTING

Since there are now effective anti-retroviral drugs for this condition, maintaining pts in good health for many yrs, prompt diagnosis is now considered imperative. Therefore if there is a clinical indication for HIV testing, this should be considered with pts informed consent.
In certain situations such as in suspected HIV cases ,referral to GUM for further pre-test discussion may be appropriate.

REFERENCES

1.-Van de Laar, MJW. GotzHM,Zwart O de,et al.
Lymphogranuloma venereum among MSM –Netherlands,2003-2004. MMWR weekly,Oct 29th,2004.53(42);885-988.

2-Coutts WE: Lymphogranuloma venereum: a general review. Bull WHO:545,1950.

3.-DHH Robertson, A .Mcmillan and H Young. Acquired syphilis: early stage, in Clinical practice and sexually transmitted disease,2nd edition,1980 pp126-143.