Anorectal emergencies

Table 2 Diagnosis and treatment of common infectious organisms causing sexually transmitted proctitis (by the frequency of occurrence)

Disease (causative organism)	Common symptoms and signs	Suggested investigations	Recommended first line treatment
Chlamydia (Chlamydia trachomatis serovars D-K)	Commonly asymptomatic, mild proctitis, cervicitis, vaginitis, urethritis	Nucleic acid amplification test (NAAT) from rectal, endocervical or urethral swab specimens	Azithromycin 1 g orally in a single dose
			OR
			Doxycycline 100 mg orally twice a day for 7 d
Gonorrhea (Neisseria gonorrhoeae)	Lower abdominal pain, diarrhea, rectal bleeding, tenesmus, purulent rectal discharge, urethral discharge and/or pharyngeal infection	Gram stain (Gram-negative diplococci) and bacterial culture from anogential and pharyngeal swab	Ceftriaxone 250 mg IM in a single dose
			PLUS
			Azithromycin 1 g orally in a single dose
Herpes simplex virus (Herpes simplex virus)	Painful multiple vesicular or ulcerative lesions at perianal skin and anal canal, painful defecation, fever	Viral culture or polymerase chain reaction (PCR) from vesicular lesions	Acyclovir 400 mg orally three times a day for 7-10 d
			OR
			Acyclovir 200 mg orally five times a day for 7-10 d
Syphilis (Treponema pallidum)	Depending on the stage of infection - Primary syphilis: painless ulcers or chancre in the anorectal region	Darkfield examination and test to detect T. pallidum from lesion exudate or tissue	Benzathine penicillin G 2.4 million unit IM in a single dose
	Secondary syphilis: maculopapular rash, condyloma lata, snail-track ulcer and mucous patch at the rectum, lymphadenopathy		OR
			Ceftriaxone 1-2 g either IV or IM for 10-14 d
			OR
			Doxycycline 100 mg orally twice a day for 14 d
Lymphogranuloma venereum (Chlamydia trachomatis serovars L1, L2 and L3)	Anal pain, mucous or bloody rectal discharge, anorectal ulcer, fever, inguinal or femoral lymphadenopathy	Culture, direct immunofluorescence or nucleic acid detection form rectal lesion and lymph node specimen	Doxycycline 100 mg orally twice a day for 21 d
			OR
			Erythromycin base 500 mg oral four times a day for 21 d