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Sexually Transmitted Diseases Including HIV

Charles B. Whitlow, M.D.
Department of Colon and Rectal Surgery
Ochsner Clinic Foundation
1514 Jefferson Highway
New Orleans, LA 70123

There are over 25 diseases spread primarily by sexual means with an annual incidence of approximately 15 million cases in the United States. In 1994 the overall cost related to major sexually transmitted diseases (STDs) was estimated to be 17 billion dollars. As homosexual and anal-based erotic practices have increased, the incidence of sexually transmitted diseases of the anus and rectum has increased. Site and route of infection determine the symptoms caused by STDs. Infections of the distal anal canal, anoderm, and perianal skin are similar to lesions in other parts of the genitalia and perineum caused by the same organism. These are typically the result of anal receptive intercourse but in some instances represent contiguous spread from genital infections. Proctitis from sexually transmitted organisms is almost always from anal intercourse. Direct or indirect fecal-oral contact produces infection with organisms which cause proctocolitis or enteritis but which are generally thought of as food or waterborne diseases instead of as sexually transmitted diseases. Included in this group are Entamoeba histolytica, Campylobacter, Shigella, Giardia lamblia, and hepatitis A.

Difficulty in correct diagnosis and appropriate treatment of sexually transmitted disease of the anorectum is caused by several factors. The signs and symptoms of infection are more organ related than organism related so that no symptom or symptom complex or physical finding is diagnostic for many STDs. The presence of more than one organism is not uncommon, especially with anogenital ulcerations. Determining true pathogen from colonizing organism may be difficult. Lastly, there is a lack of rapid sensitive diagnostic tests for many STDs so that empiric treatment is frequently required.

Bacterial Infections

Gonorrhea

Neisseria gonorrhoeae, a gram-negative diplococcus, is the bacterium responsible for gonorrhea. Probably the most common bacterial sexually transmitted disease affecting the anorectum, gonorrhea rates decreased over the past several decades, until the mid-1990's but have slowly increased since that time to 650,000 cases annually. Peak incidence is in females ages 15 to 19 and males ages 20 to 24. Gonorrhea rates in African Americans are 30 times greater than in white Americans.

Infection with this organism occurs in columnar lined mucous membranes and is frequently asymptomatic but may result in symptoms related to the urethra, endocervix, rectum, and pharynx. The incubation period is generally 3 to 5 days but can be as long as 2 weeks. Untreated, gonorrhea may lead to disseminated gonococcal infection with transient bacteremia, arthritis and dermatitis; rare but severe sequelae include endocarditis and meningitis.

Anorectal transmission in homosexual males and some females is by anoreceptive intercourse. Thirty-five to fifty percent of women with gonococcal cervicitis have concomitant anorectal infection. Many of these are from contiguous spread from the genital infection. A large percentage of patients who culture positive for rectal gonorrhea are asymptomatic - up to 50% of males and 95% of females. Aymptomatic infection of the rectum constitutes the main reservoir of gonococcal infection in homosexual men. The classic symptom of anorectal gonorrhea is mucopurulent discharge but other symptoms include pruritis, tenesmus, or a bloody discharge. Anoscopy reveals a discharge (expressed with external pressure at the anus) and nonspecific findings of proctitis - erythema, edema, and friability. Culture and gram stain are obtained from directly visualized discharge. The use of lubricants on the anoscope, other than water, may introduce antibacterial agents and decrease the diagnostic yield of these tests. Thayer-Martin is the culture medium of choice with a diagnostic sensitivity of up to 95%. False negatives on Gram stain are not uncommon; therefore treatment should begin if there is a high index of suspicion. Nucleic acid amplification techniques such as polymerase chain reaction (PCR) and ligase chain reaction (LCR) and nonamplificied DNA probes are nonculture techniques used to diagnose gonorrhea. These techniques have reported sensitivities of 90 to 98% but do not provide antibiotic susceptibility data. DNA testing is becoming more commonly used in cervical and urethral infections but has not been widely studied for testing of anorectal infections.

Because of the prevalence of penicillinase-producing Neisseria gonorrhoeae (PPNG) starting in the 1970's, penicillin G is no longer the drug of choice for gonorrhea. The most current recommended treatment regimens from the Centers for Disease Control were published in 2002. Cefixime, 400mg orally as a single dose, or ceftriaxone, 125mg as an intramuscular injection are the cephalosporins recommended. Only a few isolates tested by the Gonococcal Isolate Surveillance Report (GISP) in the past 10 years showed decreased susceptibility to these cephalosporins. Fluoroquinolones included as recommended regimens (all as a single oral dose) are ciprofloxacin 500mg, ofloxacin 400mg, and levofloxacin 250mg. Quinilone resistant Neisseria gonorrhoeae (QRNG) have been detected in the past decade with increasing frequency in Asia and the Pacific. In the United States this is particularly important in Hawaii (where QRNG may account for as much as 14% of gonorrhea isolates) and California. Patients who are unable to tolerate cephalosporins or quinolones are be treated with intramuscular spectinomycin, 2gm. Concurrent HIV infection does not alter treatment regimens. Because of the high rate of concomitant infection with chlamydia, patients treated for gonoccocal infections should be given appropriate treatment for chlamydia at the same visit or measures to rule out chlamydial infection should be taken.

Routine follow-up at 3 months was recommended previously, but current treatment regimens have near 100% efficacy making that unnecessary. Sexual partners from the past 60 days should be treated and patients should abstain from intercourse until treatment is completed and symptoms resolved.

Chlamydia / Lymphgranuloma venereum(LGV)

Chlamydia is the sexually transmitted disease with the highest incidence in the United States - an estimated 3 million cases per year. The etiologic organism, Chlamydia trachomitis, is an obligate intracellular microorganism with many different immunotypes. Serovars D through K (non-LGV biovar) are responsible for proctitis and common genital infections. Lymphogranuloma venereum is caused by LGV serovars L1- L3. There is much overlap in symptoms between chlamydia and gonorrhea and simultaneous infection with both organisms is common.

The prevalence of anorectal chlamydia is 4 to 8% for men and 5 to 21% for women. Anorectal transmission is believed to be strictly through anorectal receptive intercourse although secondary anorectal involvement can occur as a late manifestation of genital infection. The clinical manifestations of chlamydia rectal infections are dependent on the immunotype. Non-LGV serovars are less invasive and cause symptoms of a mild proctitis (tenesmus, pain, discharge) but asymptomatic infection is common. LGV serovars cause a much more aggressive infection with perianal, anal, and rectal mucosal ulceration. The proctitis produced can be difficult to distinguish from Crohn's disease (including microscopic findings of granulomas) with resulting rectal pain and mucopurulent discharge. Perianal abscesses, fistulas and stricturing may also occur. Lymphadenopathy develops in draining nodal basins - iliac, perirectal, inguinal, femoral - several weeks after initial infection. Large indurated matted nodes and overlying erythema may produce a clinical picture similar to syphilis.

Because chlamydia is an obligate intracellular pathogen it requires tissue cell culture to grow in the laboratory. Specimens for tissue culture should be collected with a cotton-tipped swab, transported on specific medium and kept refrigerated or on ice until inoculated onto culture plates. The cost and technical requirements of tissue culturing have led to the search for nonculture diagnostic techniques.

Antigen detection by direct fluorescent antibody (DFA) and enzyme immunoassay (EIA) can be accomplished within 2 days of specimen collection. DFA is highly specific but EIA requires a confirmatory test to eliminate false positive results. Low sensitivities have limited the use of these tests. Gene probe testing has produced results similar to DFA and EIA. As with gonorrhea, newer DNA amplification techniques like PCR and LCR are becoming widely available and ongoing research should further define their value in the diagnosis of chlamydia. Little has been written about their use in anorectal infections. Serum antibody titers are still a frequently used diagnostic test for chlamydia but may take 2 to 4 weeks to rise to a detectable level. Confusion can be produced by cross-reaction with other Chlamydia strains and by the baseline high prevalence serpositivity for this organism.

The two recommended regimens for treatment of chlamydia are azithromycin, 1gm orally as a single dose or doxcycline, 100mg orally, twice a day for 7 days. Alternative regimens include erythromycin (less effective, GI side effects), ofloxacin ( 7 day course, more expensive than first line drugs), or levofloxacin ( 7 day course, no data on treatment). Guidelines for management of sexual partners are the same as for gonorrhea. Abstinence from sexual intercourse should last until seven days after treatment with azithromycin or completion of a 7 day course of doxycycline. It should continue until sexual partners have completed treatment to reduce the risk of reinfection. Patients with LGV are treated with doxycycline for 21 days. Erythromycin for 21 days is the alternative regimen.

Syphilis

Syphilis is a sexually transmitted disease that progresses in stages and is caused by the spirochete Treponema pallidum. The incidence of syphilis had its recent peak incidence of 107 per 100,000 people in 1991, but decreased to 2.2 per 100,000 in 2001, meaning that only 6,103 cases were reported that year. Anorectal syphilis is almost exclusively a disease of homosexual males and these patients comprise a large percentage of patients with syphilis. Recent increases in the incidence of syphilis in this high risk group have been reported in several large cities.

The primary stage of syphilis appears within 2 to 10 weeks of exposure. The chancre is begins as a small papule which eventually ulcerates. These ulcers are frequently painful (in contrast to genital chancres) and without exudates. They are single or multiple and located on the perianal skin, in the anal canal or distal rectum. Painless but prominent lymphadenopathy is common. Proctitis may be seen with or without the presence of chancres and tenesmus and mucoid discharge may be the presenting symptoms. Untreated lesions in this stage will usually heal in several weeks. Diagnosis in the primary stage is made by visualization of spirochetes on dark-field examination of scrapings from chancres. Spirochetes may also be demonstrated on Warthin-Starry silver stain of biopsy specimens. Antibody tests for T. pallidum antigens, FTA-ABS (fluorescent treponemal antibody absorption) and MHATP (microhemagglutination), become positive early and remain positive after infection. The so-called nontreponemal tests, RPR and VDRL are less specific but are useful for following treatment efficacy.

Left untreated, syphilis progresses by hematogenous dissemination to a secondary stage, 4 to 10 weeks after primary lesion appear. Systemic symptoms from this infection are nonspecific and include fever, malaise, arthralgias, weight loss, sore throat and headache. This presents as a maculopapular rash on the trunk and extremities. Condyloma lata, another secondary manifestation, are grey or whitish, wart-like lesions that appear adjacent to the primary chancre and are laden with spirochetes.

A single intramuscular injection of 2.4 million units of benzathine penicillin G is the treatment for primary or secondary syphilis. Penicillin allergic patients are treated with doxycyline (100mg orally, twice daily for 14 days) or tetracycline (500mg orally, four times a day for 14 days). Follow up serology (nontreponemal tests-VDRL or RPR) should be checked at 6 months after therapy for HIV negative patients and every three months for HIV positive patients. Treatment failures are re-treated with the same dose of penicillin but at weekly intervals for a total of 3 weeks.

Chancroid

Chancroid is an ulcerating sexually transmitted disease caused by the gram-negative, facultative anaerobic bacillus Haemophilus ducreyi. While there were approximately 5000 cases reported per year in the late 1980's and early 1990's in the United States, there were fewer than 200 cases reported in 1999. It is much more common in developing countries with a global annual incidence estimated at 6 million.

Transmission is strictly through sexual contact through breaks in the skin during intercourse and results in genital ulcers. The initial manifestation (hours to days after exposure) is of infection tender papules with erythema which subsequently develop into pustules and then (days to weeks) become ulcerated and eroded. Multiple ulcers are common and are generally painful, especially in males. While chancroid ulcers are most commonly located on the genitalia, perinal abscess and ulceration may occur. Painful inguinal lymphadenopathy accompanies half of cases and is usually unilateral. Abscess formation may result necessitating drainage. Besides causing genital ulcers, H. ducreyi facilitates transmission of HIV and vice versa. Diagnosis is by culture of the causative organism. Several treatment regimens are available. Azithromycin 1gm orally and Ceftriaxone 250mg intramuscularly are given as single-dose therapy. Ciprofloxacin, 500mg orally twice a day for 3 days or erythromycin base 500mg orally three times a day for 7 days are also acceptable treatment.

Granuloma Inguinale (Donovanosis)

Donovanosis is an ulcerating infection of the genitalia and anus caused by Calymmatobacterium granulomatis (also called Donovania granulomatis). It is rarely seen in the United States but is common in parts of Africa, South America and Australia. Morphologic manifestations include an ulcergranulomatous form (nontender, fleshy, beefy red ulcers), hypertrophic or verroucous lesions, necrotic ulcers, or cicatricial. Genital involvement is most common but contiguous involvement of the anorectum occurs. Development of sclerotic lesions causes anal stenosis. Diagnosis is made by tissue smear demonstrating Donovan bodies. First-line antibiotic treatment is doxycycline 100mg orally, twice daily or trimethoprim 800mg-sulfamethoxazole 160mg orally, twice daily. Treatment should be continued for at least 3 weeks. Alternative regimens are ciprofloxacin 750mg orally, twice daily; erythromycin base 500 mg orally, four times a day; azithromycin 1gm orally, once per week.

Viral Infections

Human Papilloma Virus

Human papilloma virus (HPV) is a DNA papovirus. It is the most common sexually transmitted disease in the United States with an estimated incidence of over 5 million cases per year. There are over 80 subtypes of HPV, almost one-third of which cause anogenital warts. Subtypes 6 and 11 are the most common of the low-risk HPV subtypes, while subtypes 16 and 18 are the ones with the greatest associated risk of anal dysplasia and anal cancer. Transmission is via sexual contact with infected individuals with or without gross lesions and asymptomatic infection is common. Perianal involvement can occur in the absence of receptive anal intercourse.

Presenting complaints of condyloma accuminata include presence of a growth, pruritis, bleeding, chronic drainage, pain and difficulty with hygiene. Physical examination is generally all that is required for diagnosis and shows the characteristic gray or pink fleshy, cauliflower-like growths of variable size in the perianal region. Anoscopy is an integral part of the evaluation. In the anal canal the lesion tend to be small papules and involvement above the dentate line is rare. Examination should include the genitalia (including vaginal speculum exam and Pap smear), perineum and groin folds.

The goal of treatment of condyloma acuminata is removal of all gross disease while minimizing morbidity, although this does not ensure eradication of infection. Tangential excision, cryotherapy, or fulguration of small lesions with local anesthesia can be performed as an office procedure with little discomfort or inconvenience to the patient. Larger lesions are treated by electrodesiccation followed by curretage or simply abrading the fulgurated tissue with gauze. Topical agents like podofilox and imiquimod can be applied by the patient but neither is approved for use in the anal canal. Podofilox is a purified active component of the antimitotic plant resin podophyllin and is available as a gel or solution. Toxicity concerns are less than those with podophyllin and clearance rates of up to 70% are reported with recurrence rates of 10 to 20%. Imiquimod is an immune response modifier that increases local production of interferon. Complete response can be expected in 50% of patients treated with imiquimod with 11% of patients experiencing a recurrence. Side effects of imiquimod include pain, burning, itching, and ulceration which may require cessation of therapy. Imiquimod is used 1) as initial treatment with electrodessication reserved for those who have incomplete response or 2)following destructive treatment and epithelial healing to treat remaining disease or decrease recurrence (no randomized data to support this use) Tricholoroacetic acid is applied topically and is useful for treating small lesions in the anal canal. Topical and intralesional interferon have been used to treat condyloma acuminata with mixed results.

Molluscum Contagiosum

The molluscum contagiosum virus is a member of the poxvirus family and causes a benign papular condition of the skin. Transmission is by sexual and nonsexual contact. The incubation period is 1 to 6 months, followed by development of 2 to 6mm flesh-colored, umbilicated papules. Symptoms are uncommon though pruritis or tenderness may occur. Immunocompromised hosts such as those with HIV are more prone to infection with molluscum contagiosum (compared to HIV negative) and may have a more severe form of the disease with hundreds of lesions. Diagnosis is usually made on clinical grounds but excisional biopsy demonstrates enlarged epithelial cells with intracytoplasmic molluscum bodies. Treatment is generally through eradication with curettage, electrodessication or cryotherapy. Podophyllotoxin (0.5%) and imiquimod (5%) have both been used as self-applied topical preparations with success. Neither is FDA approved for this use.

Herpes Simplex Virus

Herpes simplex virus (HSV) is a DNA virus of the family Herpesviridae which includes varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus. Two serotypes of HSV are described. HSV-1 infection most commonly presents with labial, oral, or ocular lesions while HSV-2 is most associated with anogenital infection. The seroprevalence of HSV-2 infection in the United States increased 30% between the 1970's and 1990's. Currently the seroprevalence is approximately 20% for the general population. Black women are the subgroup with the highest incidence - 80% lifetime incidence. Asymptomatic infection is common with a rate of clinical infection that is roughly 10% of those patients who are serologically positive for HSV-2.

Transmission is via close contact with an individual who is shedding the virus and infection results from penetration of mucosal surfaces or breaks in the skin. Productive infection causes viral replication within cells and cell death. Clinically, infection presents first with systemic symptoms (fever, headache, myalgias), followed by local symptoms (pain, pruritis). Vesicles appear over the anogenital area, increase in number and size, and eventually ulcerate and coalesce. Vesicles and ulcerations heal over a mean time of 3 weeks.

Anorectal involvement by HSV-2 is acquired by anorectal intercourse and HSV-2 is second only to gonorrhea as a cause of proctitis in homosexual men. Herpetic infection of the anorectum results in severe anal pain, tenesmus, hematochezia, rectal discharge. The ulcerative lesions may be perianal, in the anal canal, or distal rectum. The proctitis seen is typically limited to the distal 10 cm of the rectum with diffuse friability. Simultaneous with initial infection, HSV moves through peripheral sensory nerves to sensory or autonomic nerve root ganglia. Sacral radiculopathy of the lower sacral roots from this infection causes sacral parasthesias and neuralgias, urinary retention, constipation, and impotence. Tender inguinal adenopathy occurs in half of patients with HSV proctitis. Diagnosis is frequently made on clinical grounds alone. Cultures taken from ulcerations, rectal swabs, or biopsies confirm the diagnosis. Multinucleated giant cells with intranuclear inclusion bodies on Pap smear or Tzank preparation are less sensitive than viral culture. For cases in which cultures are not available paired type -specific serology demonstrating seroconversion or a fourfold or greater rise in titers confirms diagnosis.

Latent infection (stable virus maintained within a cell - usually neural) is characteristic of HSV. Recurrent infection results from reactivation of latent virus but the reasons for reactivation are not understood. Recurrent attacks are generally milder, shorter in duration and without the constitutional symptoms that occur with initial infection.

Treatment of patients with anorectal herpes includes sitz baths and oral analgesics. Oral acyclovir 400mg five times a day for 10 days shortens the duration of symptoms and period of viral shedding. A three times per day dosing has been shown to be effective for genital herpes but has not been evaluated for herpes proctitis. Other antiviral agents (valacyclovir and famciclovir) are used for genital herpes and are most likely effective for HSV proctitis but have not been clinically studied. Topical antiviral preparations are not effective. Recurrences are treated with one of the agents listed above for a 5 day course. Alternatively, for patients with more than 5 recurrences a year suppressive treatment reduces recurrences by 70 to 80%. As with all sexually transmitted diseases, counseling of patients with HSV is an important part of treatment. Specific items that should be addressed are the potential for recurrences, asymptomatic viral shedding and the risks of transmission.

HIV and AIDS

Infection from the human immunodeficiency virus was first described in 1981. The most current data available show that in 2001 there were approximately 344,000 people in the United States with AIDS and another 162,000 with HIV infection not meeting the criteria for AIDS. Cumulative totals showed a total of 807,075 cases of AIDS in the United States through 2001 and a death rate of 57% in this group. While the incidence of HIV infection has apparently leveled, the numbers of new AIDS cases and deaths from AIDS have decreased. This is in large part due to highly active antiretroviral therapy (HAART) - combinations of potent anti-HIV drugs which are nucleoside analogs, non-nucleoside reverse transcriptase inhibitors or protease inhibitors.

Surgery for anorectal diseases is the most common indication for surgery in HIV infected patients and in 5% of patients their anorectal complaint is the presenting symptom of their HIV infection. Most of the indications for surgery are common to the population at large but some are unique to AIDS patients. Several studies demonstrated poor wound healing and increased morbidity in the surgical treatment of anorectal disease in AIDS patients. Delayed or failed wound healing has been associated with presence of AIDS, absolute leukocyte count, and CD4 count. Morandi et al found that at 32 weeks after hemorrhoidectomy 50% of patients had incompletely healed wounds. The overall complication rate was significantly higher in the AIDS group than in those who were HIV positive without AIDS. They reported no correlation between wound healing and CD+ T-lymphocyte counts in patients with AIDS. Conversely, Lord reported decreased wound healing in HIV+ patients with T-lymphocyte count of less than 50. Others have shown longer interval and decreased complete wound healing in HIV+ patients with CD4+ T-lymphocyte counts of less than 200. What is clear is that wound healing is compromised in patients with AIDS. However, symptomatic relief is frequently attainable. Other factors to be considered in selecting appropriate treatment include any untreatable diarrheal conditions related to their disease or treatment, degree of fecal incontinence in patients with AIDS, and the effect of the proposed surgical procedure on incontinence (for example fistulotomy or lateral internal anal sphincterotomy).

Anal fissures that occur in the HIV+ patient must be distinguished from idiopathic AIDS- related anal ulcers and ulcerating sexually transmitted diseases such as HSV or syphillis. Anal fissures in this patient population are indistinguishable from those in the general population and their treatment is similar - initial conservative management with surgery for treatment failures. Treatment of fissure in HIV+ patients is modified by the factors discussed in the prior paragraph to include controlling diarrhea when possible and encouraging abstinence from anoreceptive intercourse. The incidence of AIDS-related anorectal ulcers has decreased markedly with HAART because these lesion are most frequently associated with clinical AIDS and lower CD4 counts. These ulcers can be distinguished from typical anal fissures because they are more proximal in the anal canal (frequently above the dentate line or anorectal ring), broader based, deeply ulcerating with destruction sphincter planes, and may demonstrate mucosal bridging. Debilitating anal pain is a common presenting symptom of these ulcers. Surgical debridement allows for adequate drainage of feculent or purulent material trapped in the ulcer and removes necrotic debris. Biopsy and culture identifies potentially treatable causes for ulceration - malignancy, acid fast bacilli, HSV, Haemophilus ducreyi, Treponema pallidum. Cytomegalovirus (CMV) has been cultured from these ulcers by some authors but is apparently not causal and therefore does not require treatment. Intralesional injection with steroids (methylprednisolone acetate 80 to 160mg, in 1cc 0.25% bupivicaine) provides relief in the majority of patients but not healing. Those who have persistent pain are reinjected.

Perianal suppurative diseases are common conditions in AIDS patients. Abscesses should be drained using small incisions and placement of a mushroom catheter will lessen recurrent sepsis. Broad spectrum antibiotics should be given. Culture (to include mycobacterium) and histopathologic evaluation identifies infection from atypical organisms and malignancy.

Nadal et al reported on fistulotomies performed in 31 HIV+ patients. Seven patients had failure of wound healing and all had clinical AIDS, CD4 count of less than 200, and absolute leukocyte counts of less than 3000/mm3. Based on this and the previously made points on anorectal surgery in AIDS patients the author treats anal fistulas in AIDS patients similar to Crohn's patients. Draining setons are placed liberally with selective use of fistulotomy for low uncomplicated fistulas Fistulotomy in HIV+ patients without AIDS is based on criteria similar to HIV- patients.

HIV and HPV

HIV positive patients are at increased risk for human papilloma virus infection which, as mentioned above, is associated with an increase risk of anal cancer. Treatment of gross HPV lesions in HIV positive patients is the same as outlined previously, however, recurrence is more common and tissue for histopathlogy should be obtained routinely. It is estimated that HIV positive male and female patients have 37 and 6 fold relative risk of developing anal cancer compared to the general population. Current understanding is that anal intraepithelial neoplasia (AIN) grades II and III are precursor lesions of anal canal cancer, although the incidence and timing of this progression is not defined. These changes are analogous to the neoplastic changes seen in the cervix which are related to HPV and well established precursors of cancer of the cervix. Limited study on the effect of HAART on AIN has shown no decrease in the incidence of AIN or the regression of AIN II or III. Controversy exists as to what is the best management for AIN. Screening for AIN in homosexual or bisexual males has been suggested at 2 to 3 year intervals, and involves anal cytology collected using Dacron swabs in the anal canal. Abnormal cytology is followed with high resolution anoscopy with biopsy of suspicious lesions - similar to colposcopy. HPV-related lesions are identified when they turn white after topical application of 3% acetic acid. Small AIN lesions are treated with topical imiquimod, podophyllotoxin, TCA, or liquid nitrogen as with HPV. Larger lesions (especially AIN II or III) are treated with fulguration or excision. However, for lesions that are circumferential, treatment is aimed at biopsies to identify early invasive cancers and resolution of symptoms. This avoids the risks of anal stenosis and incontinence associated with more aggressive resection. Close follow-up with repeat high resolution anoscopy at 4 to 6 months intervals is used for patients with untreated disease.

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