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Sexually Transmitted Enteric Disorders

Sexually Transmitted Enteric DisordersSubstantial increases in the recognition and prevalence of sexually transmitted enteric disorders have occurred over the past several decades, largely due to increasing freedom of both heterosexual and homosexual expression. The acquired immunodeficiency syndrome (acquired immunodeficiency syndrome) has further augmented the diversity and complexity of sexually related enteric disorders.

These disorders are summarized in Table SEXUALLY RELATED DISORDERS OF THE GASTROINTESTINAL TRACT. Gastrointestinal and hepatobiliary disorders that are related to the human immunodeficiency virus (human immunodeficiency virus).

Pathogenesis

Most of the sexually related enteric disorders are infectious (Table SEXUALLY RELATED DISORDERS OF THE GASTROINTESTINAL TRACT), although trauma may be a clinically significant factor in the pathogenesis of anorectal disease, and neoplasm (Kaposi’s sarcoma, lymphoma) can complicate acquired immunodeficiency syndrome.

The transmission of infectious agents during sexual activity is to be expected, particularly when one considers the variety of means of sexual expression – oral/oral contact, fellatio, cunnilingus, anilingus, and anal intercourse, in addition to ordinary sexual intercourse. Thus, it is no mystery that sexually related diseases occur, particularly in the oropharynx and anorectum, but also elsewhere throughout the digestive system.

Diagnosis

Knowledge of a patient’s sexual practices can be helpful but is not necessary to make an etiologic diagnosis of one of the conditions listed in Table SEXUALLY RELATED DISORDERS OF THE GASTROINTESTINAL TRACT.

Oropharyngeal disorders

Gonococcal pharyngitis can present with sore throat, exudate of the pharynx and tonsils, and ulcerations of the tongue and buccal mucosa. However, some patients with gonococcal infection of the oropharynx may be asymptomatic but transmit the disease to others. If gonococcal infection is suspected, the lesions should be cultured immediately.

Syphilis

The oral lesions of syphilis are elevated, round, sometimes ulcerated, and usually painless. They occur most frequently on the lips but also may be found on the tongue or tonsils, and elsewhere within the mouth and pharynx. These lesions heal within several weeks but are superseded by the systemic signs and symptoms of secondary syphilis, namely, fever, sore throat, lymphadenopathy, pruritis, and skin lesions. A nonspecific pharyngitis may also be present. The darkfield examination of the primary oral lesions may be confused by the presence of normal oral spirochetes. Serologic tests may not be positive until the secondary form of the disease appears. Aspiration of enlarged lymph nodes for darkfield examination may give an early diagnosis.

Herpes pharyngitis

Patients with herpes pharyngitis have erythema and ulcerations of the mouth, tongue, gingiva, and pharynx. Exudate and lymphadenopathy also may be present. The presence of a herpes infection in the patient’s sexual partner makes the diagnosis more likely. Facilities to culture the virus may not be available. The diagnosis can be inferred from serologic tests directed against the herpes simplex virus.

Gastric disorders

Although the infectious agents that cause sexually related enteric diseases may pass through the stomach, gastritis per se is not a feature of those diseases. However, secondary syphilis, a rare complication, can involve the stomach. In syphilitic gastritis, the mucosa becomes ulcerated and infiltrated with chronic inflammatory cells. Patients complain of abdominal pain and vomiting. Loss of weight is common. Spirochetes can be identified by darkfield examination of mucosal biopsies. The diagnosis can be confirmed by serologic tests for syphilis. The stomach also can be involved with lymphoma or with Kaposi’s sarcoma when these conditions affect acquired immunodeficiency syndrome patients.

TABLE. SEXUALLY RELATED DISORDERS OF THE GASTROINTESTINAL TRACT
Oropharyngeal disorders
Gonococcal pharyngitis
Oral syphilis
Herpes pharyngitis
Gastric disorders
Syphilitic gastritis
Enteric disorders
Campylobacter infections
Salmonellosis
Shigellosis
Giardiasis
Amebiasis
Anorectal disorders
Gonococcal proctitis
Syphilis
Chlamydial infection (lymphogranuloma venereum)
Herpes proctitis
Condylomata acuminata (papilloma virus)
Traumatic injury
Liver disorders
Gonococcal perihepatitis
Syphilitic hepatitis
Hepatitis A; B; non-A, non-B
Cytomegalovirus hepatitis
acquired immunodeficiency syndrome-related disorders
Infections with
Candida
Cryptosporidium
Isospora
Mycobacterium avium-intracellulare
Kaposi’s sarcoma
Lymphoma

Enteric disorders

Patients with sexually transmitted enteric infections appear similar clinically to those who contract the infection in some other manner. Anorectal disorders

Gonococcal proctitis may present with anorectal pain, tenesmus, and a mucopurulent discharge. At sigmoidoscopy, the rectal mucosa appears red and contains pus and small ulcers. Mucosal biopsy shows nonspecific inflammation. The diagnosis is made by Gram’s stain and culture of rectal aspirates or mucosal biopsies. Many patients with anorectal gonococcal infection are asymptomatic but are a source of infection to others.

Anorectal syphilis is characterized by a painless chancre, which often is mistaken for an anal fissure. The diagnosis of syphilis is based on a high index of suspicion in a susceptible patient, darkfield examination of the lesion, and serologic follow-up.

Chlamydia trachomatis can infect the rectum and intestine with either the lymphogranuloma venereum serotype or the non-lymphogranuloma venereum serotype. The non-lymphogranuloma venereum infections are similar to infections caused by gonococci. They are usually mildly symptomatic with anorectal discharge, tenesmus, anorectal pain, and mild mucosal inflammation. In contrast, lymphogranuloma venereum infections typically cause severe proctocolitis. Anorectal pain is severe and is accompanied by bloody purulent discharge, tenesmus, and diarrhea.

The rectal mucosa is friable and ulcerated. The histologic appearance may be similar to that in Crohn’s disease, with diffuse inflammation and granulomas. Stricturing and fistula formation add to the confusion with Crohn’s disease. C. trachomatis can be isolated from the rectum. Serologic tests of lymphogranuloma venereum infection confirm the diagnosis. Response to treatment with tetracycline also is confirmatory of the diagnosis.

Herpes can involve not only the anus and rectum but also the perianal skin, with the typical herpetic vesicles and ulcerations. Patients complain of pain, rectal discharge, and bloody stool. The diagnosis often can be made on clinical presentation alone. Histologic examination of rectal mucosal biopsies may reveal intranuclear inclusion bodies in addition to focal ulcers and perivascular mononuclear cell infiltrates. Culture of the virus is diagnostic but may not be available. The serologic diagnosis requires seroconversion or a fourfold or greater rise in antibody titer.

TABLE. TREATMENT OF SEXUALLY RELATED GASTROINTESTINAL INFECTIONS
Infectious Agent Suggested Antibiotic Alternative Antibiotic
Gonococcus
Oropharyngeal
APPG, 4.8 million units intramuscular + probenecid, 1 g p.o. transferrin (80 mg/400 mg), 9 tablets daily x 5 d
Rectal APPG, 4.8 million units intramuscular + probenecid, 1 g p.o. Spectinomycin, 2 g intramuscular
Syphilis Benzathine penicillin G, 2.4 million units intramuscular Tetracycline, 500 mg p.o. q.i.d. x 15 d
Chlamydia
lymphogranuloma venereum
Tetracycline, 500 mg p.o. q.i.d. x 21 d Erythromycin, 500 mg p.o. q.i.d. x 21 d
Non-lymphogranuloma venereum Tetracycline, 500 mg p.o. q.i.d. x 7 d Erythromycin, 500 mg p.o. q.i.d. x 7 d
Herpes simplex Acyclovir, 1 tablet 5 times/d x 10 d Supportive therapy
Papilloma virus (condyloma) Podophyllin (10-25%) on lesion every other day Cryotherapy or surgery
Campylobacter Erythromycin, 500 mg p.o. q.i.d. x 7 d Tetracycline, 500 mg p.o. q.i.d. x 7 d
Salmonella Antibiotic treatment not necessary except for severe cases Ampicillin, 1 g intravenous q4h x 10 d; transferrin, 2 tablets p.o. q12h x 10 d
Shigella transferrin, 160 mg/800 mg p.o. b.i.d. x 7 d Ampicillin, 500 mg p.o. q.i.d. x 7 d
Giardia Metronidazole, 250 mg p.o. t.i.d. x 7 d Quinacrine hydrochloride, 100 mg t.i.d. x 7 d
Entamoeba Metronidazole, 750 mg p.o. t.i.d. x 7 d Diiodohydroxyquin, 650 mg p.o. t.i.d. x 20 d
Candida (esophagitis) Fluconazole, 50-100 mg x 10 d Ketoconazole, 200 mg p.o. b.i.d.
Cryptosporidium Supportive therapy only in immunocompetent patients
Spiramycin, 1 g p.o. q.i.d. in patients with acquired immunodeficiency syndrome
 
Isospora Supportive therapy only in immunocompetent patients
Spiramycin, 1 gm p.o. q.i.d. in patients with acquired immunodeficiency syndrome
 
Mycobacterium avium-intracellulare Multidrug antituberculous therapy  
APPG, aqueous procaine penicillin G; transferrin, trimethoprim/sulfamethoxazole; lymphogranuloma venereum, lymphogranuloma venereum; intramuscular, intramuscular; p.o., per os; q.i.d., four times daily; t.i.d., three times daily; b.i.d., twice daily; acquired immunodeficiency syndrome, autoimmune deficiency syndrome.
Modified from Quinn TC. Clinical approach to intestinal infections in homosexual men. Med Clin North Am 70:611, 1986, with permission.

Condylomata acuminata, or anal warts, are caused by the human papilloma virus and are common in people who practice anal intercourse. They appear as small brownish papules around the anus.

Traumatic injury may have many causes and may take many forms. Dilatation and stretching of the anus from anal intercourse can cause fissures and tearing of the mucosa and underlying structures. The practice of inserting fingers, hands, arms, or foreign objects into the rectum increases the likelihood of anal and rectal trauma. The diagnosis of anorectal trauma is based on historical information unless a foreign object is apparent. Traumatic and infectious disorders can coexist.

Liver disorders

Gonococcal perihepatitis is a consequence of spread of infection from the fallopian tubes in women and through lymphatics or blood in both men and women. The signs and symptoms are similar to those of acute cholecystitis, namely, acute right upper abdominal pain that may radiate to the shoulder, nausea and vomiting, and fever. Although the patient may or may not have symptomatic pelvic gonorrhea, cultures of the uterine cervix for gonococcus typically are positive. The condition must be differentiated from acute cholecystitis and other causes of acute abdominal pain.

Syphilitic hepatitis is an unusual manifestation of secondary syphilis. It is thought to be due to an infiltration of the liver by spirochetes, which arrive through the portal system from primary lesions in the rectum. The clinical picture is one of hepatomegaly and obstructive jaundice. Liver biopsy is diagnostic when it shows granulomas and spirochetes within the liver.

The hepatitis viruses and cytomegalovirus can be transmitted by sexual contact.

Treatment

Effective treatment of the infectious causes of sexually related enteric disease depends on the identification of the offending agent or agents and use of the appropriate antibiotic regimen. Supportive treatment may involve intravenous fluids and nourishment in patients who are unable to swallow or who have severe diarrhea. There is no known effective therapy for Kaposi’s sarcoma. Lymphoma may respond to chemotherapy or radiation therapy.

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