Gonococcal Proctitis

Background

• Gonococcal proctitis refers to infection of the rectum with Neisseria gonorrhoeae.
• Infection is typically sexually transmitted and occurs via unprotected receptive anal sex, including oral-anal, digital-anal, and genital-anal exposures.
• Infection is asymptomatic in about half of patients but when present symptoms may include:
  • rectal pain
  • tenesmus
  • rectal discharge or bleeding
  • anal pruritus
• Complications of untreated infection include development of rectal abscess, extension of infection to the colon, and disseminated gonococcal infection.
• Concurrent diarrhea and abdominal pain suggest proctocolitis (extension of infection to the colon).

Evaluation

• Suspect gonococcal proctitis in patients with a history of unprotected receptive anal exposures and symptoms such as
  • anal itching
  • tenesmus
  • rectal pain or bleeding
• Findings on anoscopy consistent with proctitis include mucosal friability and purulent discharge.
• Diagnosis of proctitis is made by detection of purulent exudate on exam or polymorphonuclear cell on Gram stain of rectal exudate.
• Specific testing for Neisseria gonorrhoeae as the cause of proctitis, using rectal swab, may include:
  • culture
  • nucleic acid amplification testing
    • recommended by the European International Union against Sexually Transmitted Infections and World Health Organization (IUSTI/WHO)
    • may be more sensitive than culture for detection of gonococcal proctitis
• Gram stain of exudate, looking for gram-negative diplococci, is insensitive but may provide presumptive diagnosis.
• Additional evaluation for other sexually transmitted pathogens that cause proctitis, including Chlamydia trachomatis, herpes simplex virus, and Treponema pallidum should be performed.
• In patients with proctocolitis, consider additional testing for enteric pathogens reported to be transmitted via receptive anal sex, including Campylobacter sp., Shigella sp., Entamoeba histolytica, and lymphogranuloma venereum (LGV) serovars of Chlamydia trachomatis.
• All patients with suspicion for sexually transmitted infections should also be tested for HIV infection.

Management

• Due to the high rates of Chlamydia trachomatis coinfection, concurrent treatment for both gonorrhea and chlamydia is recommended if chlamydia infection has not been ruled out.
• First-line recommendation from Centers for Disease Control and Prevention (CDC) in adults with uncomplicated gonococcal infection consists of single dose of ceftriaxone:
  • 500 mg intramuscularly in a single dose for patients weighing < 150 kg (300 lbs)
  • 1 g intramuscularly in a single dose for patients weighing ≥ 150 kg (300 lbs)
  • if chlamydial coinfection has not been excluded, additional treatment recommended:
    • for nonpregnant patients, give doxycycline 100 mg orally twice daily for 7 days
    • for pregnant patients, give azithromycin 1 g orally in a single dose
• Due to the emergence of drug-resistant gonococci:
  • CDC no longer recommends oral cephalosporins as first line therapy for the treatment of gonorrhea and no longer recommends empiric azithromycin if chlamydial coinfection has been ruled out.
  • European International Union against Sexually Transmitted Infections/World Health Organization (IUSTI/WHO) recommends higher-dose therapy with ceftriaxone 1 g intramuscularly PLUS azithromycin 2 g orally in a single dose
  • alternatives to cephalosporins include spectinomycin, gentamicin, and higher-dose azithromycin but each has limitations
• Counsel patients to avoid sexual activity until ≥ 7 days after treatment is complete and both patient and partner no longer have symptoms.
• Treatment recommendations do not differ for patients with HIV.
• Patients should be instructed to refer sex partners for evaluation and treatment.
• A test-of-cure is not routinely recommended by CDC for patients who respond to therapy, though it is recommended by IUSTI/WHO to identify persistent or drug-resistant infection.
• Follow-up with retesting at 3 months is recommended for all patients due to high rates of reinfection.