STD’s in Anorectum
The opening of anal canal called anus, functions as passage for expulsion of stool, sexual organ, peep into the colon by endoscope for diagnosing various diseases and intake orifice for treatment e.g. enemas, suppository. Sexually transmitted diseases (STDs) can be transmitted through anal sex and affect the anorectum. Anal sex is prevalent among men but women also at times have anal sex. Damage to internal and external skin and tissue around anus is occurred during first act of anal sex or during aggressive anal sex. This causes pain and impairs the function.
The abundance of nerve endings in the anal region and rectum makes anal sex pleasurable for many men and women. Some men get pleasure from anal penetration which stimulates the prostate gland.
Many diseases are created by anal sex, some common problems are discussed.
ANAL FISSURE: Presents as a painful tear of anus, occurs when anal sex is done without lubrication, it may bleed and increase the risk of spread of STDs.
HAEMORRHOIDS: Anal sex do not cause piles but may exacerbate them. Frequent anal sex leads to decrease in tone of anus and may cause prolapse of piles or even bleeding.
GONNORRHEA: Caused by gram negative bacterie Neisseria Gonnorrhea. It attacks genital tract, vagina, penis and rectum. It is commoner in males and in men it is contacted during anal sex with infected male, but in females, anal sex as well as extension of infection from vagina to the anal canal can occures. It causes itching, creamy discharge, tenesmus, painful defecation, at times pus with blood. More commonly disease only cause minimal discomfort – just a slight amount of anal moisture and pruritis. Large proportion of the patient are symptoms free. It takes two -seven days after infection to become symptomatic.
Diagnosis is made by history, taking pus for culture and sensitivity and sigmoidscopy showing characteristic mucopurulent pus laden fragile, oedematous mucosa. Treatment is easy as it is sensitive to many routine antibiotics ciprofloxacillin, ofloxacillin, terramycin, doxycycline etc.
SYPHILIS: Time old disease presenting in various stages. In anus after a incubation period of two to three weeks it appears as a painless ulcer called Chancre, it may have multiple contact lesions and it may go undetceted. It may have offensive discharge, which cause perianal skin to become sodden. The inguinal glands are enlarged and have ‘rubbery’ feel. These lesion disappears even if not treated after few weeks. At times this primary lesion is painful due to secondary infection and then it has to be differentiated with fissure in ano and squamous cell carcinoma. Diagnosis is made by identifying spirochete under dark ground illumination from the discharge of the ulcer, VDRL and other serological test for syphilis. In second stage rash, fever, lymphadenopathy, numerous coloured skin lesions, lesions resembling anal warts known as Condylomata Lata appears. Inguinal lymph nodes are also enlarged.
Broad based papule are present in anus in this stage and they are full of spirochetes.
Third stage of syphilis is rare and it frequently present as strictures. Gumma of rectum is occasionally encountered.
Syphilis is treated by Penicilins and if patient is sensitive to penicillins – erythromycin and tetracyclines can be used.
CHANCROID: This is also known as soft chancre or venereal sore, caused by Haemophilus Duceryi a gram negative red. It causes painful, irregularly shaped sore, the inguinal lymphnodes are enlarged and called bubo, which may swell up with pus and rupture to form a ulcer. Diagnosis is made by Gram stain of smear, culture and biopsy. Treatment is by single dose azithromycin, erythromycin and trimethoprim.
HERPES: Caused by Herpes virus hominis type I and type II, spread by hetero or homosexual intercourse. Causes annoying blisters and sores. Itching and soreness around anus and sometimes radiating to the groin. It is one of the condition causing severe pain. Clusters of vesicles with erythematous areas of skin around it are characteristic. Inguinal lymphodes are often enlarged. Diagnosis is generally clinical and it can also be done by virus culture, antibodies in blood for herpes and slide made of vesicle fluid and staining it with Geimsa stain for inclusion bodies. Treatment is symptomatic though antiviral drugs like Idoxuridine can be used. Photoinactivation of the virus is effective.
LYMPHOGRANULOMA VENEREUM: Infection is acquired as a result of sexual intercourse. Initial lesion, blister or lump appear at the site of infection slowly enlarging into open sore, these lesions may be painless. In some cases in females it was the backward spread from lesion in posterior wall of vagina to the rectum. Clinical features are of proctitis followed by strictures in rectum. This disease is a common cause of benign strictures of rectum. In proctitis passage of blood and mucopus and occurrence of spurious diarrhea, later strictures are formed which cause sub acute intestinal obstruction. Diagnosis is established by Frei test and complement fixation test. Treatment with antibiotics, erythromycin and chlortetracycline for two weeks is effective, at times periodic dilation, Colostomy and excisional surgery for strictures of rectum can be done.
CONDYLOMATA ACUMINATA (ANAL WARTS): Romans called this ‘figs’ and regarded it as a clear indicationof patient having anal intercourse. Some patients are even associated with Genital Warts. They clinically appear as numerous sessile or pedunculated skin coloured cauliflower like growth around anus. Frequently they exude an irritating discharge with a disagreeable odour. In females extension of warts to the vulva is also very common. They are caused by Human Papiloma Virus, more than 30 types HPV are there.
Most of the patients are aware of their presence and have slight complaints as irritation, discharge and occasional bleeding during defecation. It has to be differentiated with squamous cell carcinoma with the help of biopsy.
Treatment by local application of podophyllin and bichloracetic acid can be done. Surgical destruction by Diathermy, Cryotherapy, Surgical Excision and Immunotherapy are effective.
HIV and Hepatitis are two sexually transmitted disease having no symptoms in the anal canal though serious in nature.
CHLAMYDIA: This is a STD caused by different strains of Chlamydia Bacterium. It may remain asymptomatic, and makes screening important for diagnosis. It causes proctitis or may cause pain, mild discharge or even low grade fever. Pain is especially aggravated during anal sex. At times infection may spread and cause epididymitis, non specific urethritis. Diagnosis is done by culture of the bacteria, by Amplicor Chlamydia Trachomatic test. Treatment is easy by using any of the antibiotic – azithromycin, tetracycline, ofloxicillin, erythromycin, amoxicillin. Use of vaccine to prevent infection is under trial and research.
As incidence of homosexuality / anal sex between male and female is on the rise, anal health and hygiene play a important role in prevention of disese, Lubrication, cleanliness, and use of condoms are essentials for healthy anal sex. Anal canal does not produce any lubricant of its own and, therefore, lubrication is necessary. Lubricant should be water based, oil based lubricant destroy the latex of condom, Washing of anal region before and after anal sex reduce the chances of spread of infection. In oral – to – anal sex use of dental dam is safest , it is sheet like condom that provide barrier between mouth or fingers and anus.
Incidence of anal cancer is less than 5 per cent of the total colonic caner. Risk of anal caner is a concern in persons having anal sex. It can produce malignant tumor inside or outside the anal canal. Many people with anal cancer in early stage have no symptoms. The major risk of cancer is with the infection of HIV. Many practitioners are advising pap smear for early detection of malignancy in anal canal. Person with history of anal sex should be regularly screened for malignancy, and person who re HIV positive should be very closely watched as they have almost the double rate of incidence of anal cancer in comparison to normal persons.
Thus to sum up, anal sexually transmitted disease are important health hazard in the present scenario, it’s incidence is on the rise. A detailed history, examination and relevant tests lead to early diagnosis and treatment.
Dr. Vinay Saxena, MS, FACR
Suraj Hospital, Krishna Mandir, Bees Dukan, Adarsh Nagar, Jaipur. Ph.2600883
Email: [email protected]
Suraj Hospital, Krishna Mandir, Bees Dukan, Adarsh Nagar, Jaipur. Ph.2600883
