Sexually Transmitted Diseases Including HIV

P. Terry Phang, MD
Associate Professor of Surgery
University of British Columbia
Vancouver, BC Canada

The colorectal surgeon’s role is biopsy, drainage, and debridement of anal ulceration and perianal infection. The colorectal surgeon is not usually the primary treating physician that first sees the patient with presenting symptoms related either to proctitis or to anal ulceration/ perianal infection.

Patients presenting with proctitis (bloody diarrhea, mucopurulent discharge, tenesmus) are investigated and treated for the most common causes including gonorrhea, Chlamydia, and syphilis. History taking includes questioning about receptive rectal sex and contacts. Swabs are taken for gram stain, culture (Thayer-Martin), PCR/LCR (polymerase / ligase chain reaction for gonorrhea/Chlamydia), direct fluorescent antibody (DFA-Chlamydia), dark-field exam (syphilis). Blood is taken for Chlamydia Ab, syphilis Ab, rapid plasma reagin (RPR - syphilis), VDRL, and HIV. Treatment is usually given for both gonorrhea and Chlamydia as concomitant infection is common. Gonorrhea is treated using oral cefixime 400mg or intramuscular ceftriaxone 125mg. Chlamydia is treated using oral doxycycline 100mg BID for 7 days or if severe (lymphogranuloma venereum, LGV) then doxycycline 100mg BID is given for 3 weeks. If there is high degree of suspicion for syphilis or positive tests are returned for dark-field exam of rectal swab or syphilis Ab in blood, then, the patient is treated with a single dose of intramuscular Benzathine penicillin 2.4 million units.

Patients presenting with anal ulceration and/ or perianal infection (pain, tenesmus, mucopurulent discharge) are investigated and treated for the most common causes including herpes (HSV) and syphilis. HSV is also a cause of proctitis. Swabs and/or scrapings are taken for Giemsa stain (Tzanck prep), DFA-HSV, viral culture, dark-field exam. Blood is taken for syphilis Ab, rapid plasma reagin (RPR), VDRL, and HIV. HSV is treated with oral Acyclovir 400mg 3x daily for 5 days, or famciclovir 125mg 2x daily for 5 days, or valacyclovir 1gm daily for 5 days.

If there is persisting ulceration / lesion, perianal sepsis or lack of specific diagnosis for the perianal lesion, examination and biopsy by a colorectal surgeon is indicated. This procedure is optimally performed under general anesthesia. Biopsy is sent for culture (bacterial, viral, TB, fungal) and histology (infectious, carcinoma, lymphoma). Anal ulceration should be debrided to remove necrotic tissue and to excise edges of poorly drained “pockets”. Perianal sepsis should be drained. Small lesions can be excised or destroyed using cautery.

Perianal pain can also be caused from a typical benign, non-infectious fissure that is superficial, distal to the dentate line, and either in the posterior or anterior midline. Treatment begins with conventional conservative measures including psyllium, sitz baths, and topical vasodilators (nitroglycerin, nifedipine, diltiazem). Botox and internal sphincterotomy are relatively contraindicated in patients who have chronic diarrhea. Fissures and sphincterotomy wounds may have delayed healing depending on HIV status.

Perianal infections can manifest as typical perianal abscesses and fistulas. Perianal infections are treated using standard antibiotics and surgical drainage. Fistulotomy that involves significant sphincterotomy is relatively contraindicated in patients who have chronic diarrhea or poor HIV status. In such cases, seton drainage is recommended.

In patients with poor HIV status, large ulcers may occur proximal to the dentate line that can extend through the sphincters into the ischiorectal fat. Severe pain is relieved by drainage and debridement. Biopsies commonly show HSV, CMV, and HIV particles. Intralesional injection of methylprednisolone 80mg and bupivicaine can relieve pain from these ulcers. TB, Cryptococcus, squamous carcinoma, and lymphoma can also cause anal ulceration and pain in these patients, are diagnosed on biopsy, and require specific treatments.

Other anorectal STD’s are Hemophilus ducreyi (chancroid), Donovania granulomatis (granuloma inguinale), human papilloma virus (HPV), and molluscum contagiosum. These STD’s are diagnosed on biopsy and treated with antibiotics (chancroid, granuloma inguinale) or destruction/ excision (HPV, molluscum).

In summary, the colorectal surgeon should be familiar with the approach to the non-responsive anal ulcer in the setting of sexually-transmitted diseases and HIV infected patients.

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