Gonococcal proctitis is usually acquired sexually and is most commonly seen in individuals who practice receptive anal intercourse. Proctitis alone may not produce systemic symptoms such as fever. Moreover, a large proportion of those affected are asymptomatic [1]. Symptomatic infection may present as gastrointestinal complaints that include tenesmus, diarrhea, lower abdominal pain in the left quadrant, and stool withholding behavior due to pain during defecation. A mucopurulent rectal discharge, rectal bleeding, and less commonly anal pain and itching may also be described. These clinical manifestations often appear a few days after anal intercourse without the use of a barrier protective method, and the disease course may either be acute or chronic. Furthermore, the presence of pharyngeal and genital gonococcal invasion may indicate the possibility of rectal infection [2]. This is particularly useful as some signs which are seen with gonococcal proctitis may be identical to those found in other inflammatory bowel conditions.

Visualization of the rectal mucosa through proctoscopy may reveal normal or inflamed mucosa, and in some cases, abscesses. Lesions do not normally extend past the dentate line to the anus, but those that do are more likely to produce symptoms.

• Unsafe Sexual Practices

  sexual practices) Having a partner who is an IV drug user Bisexual or homosexual partners Anal intercourse ( Anal sex with a condom decreases the risk of proctitis by STDs, but you can still get proctitis from anal trauma) Having unprotected intercourse [webmd.com]

  sexual practices) Having a partner who is an IV drug user Bisexual or homosexual partners Anal intercourse (Anal sex with a condom decreases the risk of proctitis by STDs, but you can still get proctitis from anal trauma.) [emedicinehealth.com]

  sexual practices) Having a partner who is an IV drug user Bisexual or homosexual partners Anal intercourse (Anal sex with a condom decreases the risk of proctitis by STDs, but you can still get proctitis from anal trauma) Having unprotected intercourse [tipdisease.com]

  The predisposing factors for urethritis are multiple sexual partners, unsafe sexual practices, a current sexually transmitted infection (STI), and recent urethral instrumentation. [infectiousdiseaseadvisor.com]

• Malaise

  On further questioning he also complained of malaise, myalgia and arthralgia. He admitted to unprotected receptive anal sexual intercourse with two male partners in the preceding 6 months. [fg.bmj.com]

  Fever and malaise commonly accompany local symptoms. The primary genital ulcer often resolves before or during this stage, but proctitis is likely to persist. [ecdc.europa.eu]

• Prostitute

  It is especially common in the tropics, where the prevalence is high in prostitutes, who transmit it to migrant male workers. [histopathology-india.net]

  Risk Factors for Gonococcal Infections Adults Age younger than 25 years Black race History of gonococcal infection or other STIs Inconsistent condom use Men who have sex with men New or multiple sex partners Prostitution Substance abuse Children Mothers [aafp.org]

• Tenesmus

  Symptomatic infection may present as gastrointestinal complaints that include tenesmus, diarrhea, lower abdominal pain in the left quadrant, and stool withholding behavior due to pain during defecation. [symptoma.com]

  Ulcerations are usually accompanied by rectal bleeding, straining of rectal muscles (tenesmus) and an anal discharge of bloody mucus. However, anal bleeding is seldom severe. [rarediseases.org]

  Symptoms of Proctitis Painful, frequent bowel movements Straining at stool (tenesmus) Hematochezia Rectal pain or bleeding, itching, and cramps Bloody, pus- or mucus-filled discharge Constipation or diarrhea Fever Blisters or open sores in or around the [healthcommunities.com]

  LGV proctitis can be asymptomatic, mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus. Chronic proctitis presents with rectal bleeding, diarrhea, urgency, tenesmus, incontinence, or pelvic pain. [statpearls.com]

• Anal or Rectal Pain

  Other common symptoms include but are not limited to: bloody bowel movements rectal bleeding a feeling of rectal fullness and incomplete evacuation anal or rectal pain soreness in your anal and rectal area severe cramps or pain during bowel movements [premiermedicalhv.com]

  […] pruritus, rectal pain, mucopurulent discharge, and tenesmus. 4 Untreated rectal infections cause symptomatic proctitis. 4 The CDC recommends nucleic acid amplification testing as the preferred approach to evaluating pharyngeal and rectal specimens. 1 [aafp.org]

• Failure to Thrive

  Fred Ferri’s popular "5 books in 1" format provides quick guidance on menorrhagia, Failure to Thrive (FTT), Cogan’s syndrome, and much more. [books.google.de]

• Suggestibility

  Access full-color images and more than 90 online-only topics at Expert Consult, as well as EBMs, Suggested Reading, Patient Teaching Guides, and additional algorithms. [books.google.com]

  The following recommendations apply only to men and women presenting with symptoms suggestive of sexually transmitted proctitis and not children. [canada.ca]

  Perianal and rectal examination revealed two fluctuant, tender areas of induration adjacent to the anal verge suggestive of abscesses. [fg.bmj.com]

• Sexual Dysfunction

  Dysfunction 1203 Chapter 104 Womens Sexual Dysfunction 1210 Chapter 105 Sexuality Education for Young People 1221 A CultureBound Sex Related Disorder in Indian Subcontinent 1225 Chapter 107 Clinical Services for Sexually Transmitted Infections and HIV [books.google.de]

• Neurologic Manifestation

  Manifestations of HIV 910 Chapter 77 Gastrointestinal Manifestations of HIV Infection and AIDS 927 Chapter 78 Renal Manifestations of HIV Infection and AIDS 951 Chapter 79 HIV and Endocrine Manifestations 960 Chapter 80 AIDS Associated Malignancies and [books.google.de]

A sexual history should be noted, and physical examination of the anus, genital tract and abdomen are important. The rectal mucosa can be inspected via proctoscopy, to note any pustules, erythema, ulcers or bleeding. The absence of lesions and an apparently normal mucosa do not rule out gonococcal proctitis. In addition, colonoscopy should be simultaneously performed, in order to view the extent of inflammation, as it may involve the sigmoid colon.

Rectal swabs must be taken from the rectal mucosa and from any discharge which is present. These samples can be tested in a number of ways:

• Gram staining and microscopy: Failure to detect gonococcal organisms does not rule out infection, and because this test is operator dependent, sensitivity is compromised [3] [4]. Despite this, its possible sensitivity is as high as 95% [2]. The concurrent use of other tests is recommended.
• Culture: This is currently the gold standard test.
• Polymerase chain reaction (PCR): PCR has a high sensitivity, hence its frequent use.
• Nucleic acid hybridization test
• Nucleic acid amplification test (NAAT): There is no consensus among medical professionals on the use of NAAT, and it is generally unauthorized for use on the rectal mucosa, however, many practitioners and laboratories have used it with success, under specific procedural guidelines [5] [6].

Genital and pharyngeal swabs may also be cultured along with rectal swabs. Further laboratory tests to be carried out are complete blood count, where a raised leukocyte count may be present, as well as anemia due to rectal hemorrhage, and the measurement of inflammatory markers such as C-reactive protein (CRP) which may be elevated, especially in patients with proximal involvement of the colon. Testing for chlamydial infection is indicated as co-infection is common. Partners of infected persons should also be notified and treated. Other organisms that may be tested include herpes simplex virus and Treponema pallidum, using the appropriate diagnostic tools.

• Multiple Ulcerations

  Colonoscopic examination disclosed reddish and granular mucosa from rectum to sigmoid colon and multiple ulcerative lesions in the rectum. [jstage.jst.go.jp]

1. Kent CK, Chaw JK, Wong W, et al. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis. 2005;41(1):67–74.
2. Bignell C, Fitzgerald M. UK national guideline for the management of gonorrhoea in adults. Int J STD AIDS. 2011;22(10):541–547.
3. Sherrard J, Barlow D. Gonorrhoea in men: clinical and diagnostic aspects. Genitourin Med. 1996;72(6):422–426.
4. Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1–110.
5. Deheragoda P. Diagnosis of rectal gonorrhoea by blind anorectal swabs compared with direct vision swabs taken via a proctoscope. Br J Vener Dis. 1977;53(5):311–313.
6. Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007;56(14):332–336.