Agnieszka Białas
Proctitis – case report
Zapalenie odbytnicy – opis przypadku
Department of General Surgery, BCM Hospital in Bielsko-Biała
Streszczenie
Termin proctitis obejmuje zapalenie odbytnicy, które może mieć charakter ostry lub przewlekły. Objawy kliniczne to: krwawienia z odbytu, wydzielina śluzowo-krwista z odbytu, ból i parcie na stolec. Zapalenie odbytnicy może występować w przebiegu nieswoistych chorób zapalnych jelit (NChZJ), takich jak wrzodziejące zapalenie jelita grubego i choroba Leśniowskiego-Crohna. W diagnozowaniu etiologii należy wziąć też pod uwagę zakaźne przyczyny zapalenia odbytnicy, m.in. choroby przenoszone drogą płciową (STI), ponieważ mogą one przypominać objawy i patologię NChZJ. W artykule przedstawiamy przypadek pacjenta MSM leczonego w Poradni Proktologicznej z powodu krwawień z odbytu i biegunek. W wykonanej kolonoskopii postawiono rozpoznanie wrzodziejącego zapalenia jelita grubego. Jednak po otrzymaniu dodatkowych wyników badań laboratoryjnych w kierunku zakażenia kiłą i rzeżączką zmieniono rozpoznanie. Pacjent był leczony skutecznie doksycykliną, z całkowitym ustąpieniem dolegliwości. Przypadek ten podkreśla znaczenie przeprowadzenia wywiadu dotyczącego preferencji seksualnych i uwzględnienia STI jako przyczyny zapalenia odbytnicy. Pozwoli to zaplanować odpowiednie badania diagnostyczne i szybkie leczenie, a potencjalnie także uniknąć niepotrzebnych badań endoskopowych i medycznych, które mogłyby opóźnić rozpoznanie.
Summary
The term proctitis refers to inflammation of the rectum, which may be acute or chronic in nature. Clinical symptoms include rectal bleeding, mucous-bloody discharge from the rectum, pain, and urgency to defecate. Proctitis may occur in the course of inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn’s disease. When diagnosing the etiology of proctitis, infectious causes – including sexually transmitted infections (STIs) – should be considered, as they can mimic the symptoms and pathology of IBD. This article presents a case of an MSM patient treated at a proctology outpatient clinic for rectal bleeding and diarrhea. Ulcerative colitis was initially diagnosed during colonoscopy. However, after additional laboratory test results confirmed syphilis and gonorrhea infections, the diagnosis was revised. The patient was effectively treated with doxycycline, resulting in complete resolution of symptoms. This case highlights the importance of taking a thorough sexual history and considering STIs as a potential cause of proctitis. This approach allows for planning appropriate diagnostic tests and prompt treatment, potentially avoiding unnecessary endoscopic and medical procedures that could delay diagnosis.
Key words: proctitis, gonorrhea, syphilis
Introduction
The development of proctitis can be associated with multiple underlying conditions, such as inflammatory bowel diseases (IBD), radiation therapy, or infectious diseases caused by bacteria, viruses, or fungi. The following case report describes a patient with proctitis associated with syphilis and gonorrhea.
Case report
A 46-year-old MSM (men who have sex with men) patient, HIV-positive, presented to the Proctology Outpatient Clinic in early December 2022. The medical history revealed defecation problems persisting since September 2022 – including mucous discharge from the rectum, occasionally occurring independently of bowel movements, accompanied by a sensation of rectal urgency and pain. The patient reported loose bowel movements, up to several times a day, sometimes passing only mucus, and occasionally mucus with blood. He denied having fever or low-grade fever, but experienced night sweats. The symptoms subsided on their own, without treatment.
Subsequently, in October 2022, the patient stayed abroad – in third-world countries. Upon returning, the patient underwent diagnostic testing, including serologic tests for syphilis, a rectal swab for gonorrhea, and a colonoscopy. Tests performed on 8 November 2022 revealed the following: rectal swab for gonorrhea (PCR): positive; VDRL: negative; FTA: positive; TPHA: strongly positive.
On 18 November 2022, a colonoscopy up to the caecum was performed (Boston score 2/3/3), which revealed the following findings: friable mucosa of the rectal ampulla, circumferential inflammatory infiltrate in the rectum with loss of visible vascular pattern, areas of mucosal hypertrophy with an uneven surface, numerous ulcers present, and in the lower part, two large ulcers covered with fibrin and purulent discharge – suspicion of ulcerative proctitis, proctitis, solitary rectal ulcer (?). Biopsy samples were taken for histopathological examination. The results were obtained in December 2022: the microscopic findings support a diagnosis of active-phase ulcerative colitis (UC); correlation with clinical and endoscopic findings is required.
After receiving the bacteriological test results, the patient consulted his primary care physician, who initiated oral antibiotic therapy around 20 November 2022: doxycycline 100 mg twice daily for 30 days, along with a probiotic.
Following this treatment, the patient experienced improvement – the frequency of bowel movements and pain decreased, and the sensation of urgency to defecate resolved. Mucus was still present in the stool, but there was no longer any bleeding.
The man remained under regular care at the Infectious Diseases Outpatient Clinic and was undergoing chronic treatment with Biktarvy (bictegravir + emtricitabine + tenofovir). His current viral load is undetectable, and his CD4 lymphocyte count is within the normal range. The patient denied any other chronic illnesses. However, in his medical history, he reported unprotected anal sexual contacts.
On digital rectal examination and anoscopy, the rectal mucosa appeared edematous and friable in places, without visible ulcerations; mucous discharge was present, but no blood; grade II hemorrhoids were noted; sphincter tone was normal; the perianal area showed no abnormalities.
Continuation of antibiotic therapy was recommended. Additionally, mesalazine suppositories 1 g (at bedtime) were introduced, and fecal calprotectin testing was ordered. A follow-up examination was scheduled in approximately one month.
The patient did not inform the endoscopist performing the procedure that he was undergoing diagnostic evaluation for sexually transmitted infections (STIs). Due to doubts regarding the accuracy of the UC diagnosis (rapid symptom improvement after antibiotic therapy, lack of complete clinical data for the pathologist), the Department of Pathomorphology was asked to re-evaluate the specimens, taking into account the possibility of infectious diseases.
In the repeat histopathological examination, the overall picture was consistent with ulceration associated with active colitis. According to the pathologist, ulcerative colitis could rather be ruled out; a solitary ulcer (related to infection or antibiotic therapy) was considered a more likely diagnosis.
The patient presented for a follow-up visit in January 2023. He had completed the course of antibiotic therapy but had not used all the mesalazine suppositories or had fecal calprotectin levels checked. All previously reported symptoms had resolved: bowel movements were regular, with no diarrhea, mucus, or blood. Anoscopy showed significant improvement – the rectal mucosa was slightly reddened, with no ulcerations, no mucus or blood. Watery content was visible, but the patient had administered an enema prior to the examination.
Considering the overall clinical picture and the new histopathological findings, a diagnosis of infectious proctitis of syphilitic and chlamydial etiology was established.
In case of symptom recurrence, the patient was instructed to undergo a fecal calprotectin test and schedule a rectoscopy with repeat biopsy. He was advised of the necessity of using condoms during sexual activity.
At the next follow-up visit, approximately six months later, the patient reported no complaints, and physical evaluation – including the proctological examination – revealed no abnormalities. He did not report back to the outpatient clinic.
Discussion
Although homosexual men constitute a minority of the male population, the incidence of STIs in this group is proportionally much higher than among heterosexual men. Important factors contributing to the spread of STIs in this community have been – and continue to be – delayed medical consultations and concealment of sexual orientation (1, 2).
In 2021, the European Academy of Dermatology and Venereology published guidelines on the diagnosis and treatment of patients with gastrointestinal symptoms and suspected STI (3). Although most research on these infections has focused on men who have sex with men, women who engage in anal sex may also be at risk.
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Piśmiennictwo
1. Mroczkowki T (red.): Choroby przenoszone drogą płciową. Tom II. Wyd. IV. Wydawnictwo Czelej, Lublin 2022: 269-287.
2. Levy I, Gefen-Halevi S, Nissan I et al.: Delayed diagnosis of colorectal sexually transmitted diseases due to their resemblance to inflammatory bowel diseases. Int J Infect Dis 2018; 75: 34-38.
3. de Vries HJC, Nori AV, Kiellberg Larsen H et al.: 2021 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. J Eur Acad Dermatol Venereol 2021; 35(7): 1434-1443.
4. Lourtet Hascoet J, Dahoun M, Cohen M et al.: Clinical diagnostic and therapeutic aspects of 221 consecutive anorectal Chlamydia trachomatis and Neisseria gonorrhoeae sexually transmitted infections among men who have sex with men. Int J Infect Dis 2018; 71: 9-13.
5. Siwak E, Suchacz MM, Cielniak I et al.: Inflammatory Bowel Disease in Adult HIV-Infected Patients-Is Sexually Transmitted Infections Misdiagnosis Possible? J Clin Med 2022; 11: 5324.
6. Lamb CA, Lamb EIM, Mansfield JC et al.: Sexually transmitted infections manifesting as proctitis. Frontline Gastroenterol 2013; 4: 32-40.
7. O’Byrne P, MacPherson P, Orser L: Approach to sexually transmitted infection testing for men who have sex with men. Can Fam Physician 2024; 70(7-8): 449-455.
8. Oliver L, Pak K, Maier A, Sadowski B: Chlamydial Proctitis Mimicking Inflammatory Bowel Disease in a Young Active Duty Sailor With Undiagnosed Human Immunodeficiency Virus Infection: A Case Report. Mil Med 2025; 190(1-2): e426-e428.
9. Peters RP, Verweij SP, Nijsten N et al.: Evaluation of sexual history-based screening of anatomic sites for chlamydia trachomatis and neisseria gonorrhoeae infection in men having sex with men in routine practice. BMC Infect Dis 2011; 11: 203.
10. Szondy I, Meznerics FA, Lőrincz K et al.: Doxycycline prophylaxis for the prevention of sexually transmitted infections: A systematic review and meta-analysis of randomized controlled trials. Int J Infect Dis 2024; 147: 107186.
11. IUSTI Europe Position Statement on use of DoxyPEP: June 2024.
12. Close E, Jones A, Noggle W: Doxycycline Postexposure Prophylaxis for Sexually Transmitted Infection Prevention. J Am Board Fam Med Nov 2024; 37(6): 1140-1142.
13. Bachmann LH, Barbee LA, Chan P et al.: CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep 2024; 73(2): 1-8.
