Sexually transmitted infections & GI tract

Question 1

what is sex?

Answer 1

= contact between the penis and the vulva or the penis and the anus involving penetration, however slight; contact between the mouth and penis, vulva, or anus; or penetration of the anal or genital opening of another person by a hand, finger, or other object.

Question 2

how are infections transmitted during sex?

Answer 2

• sexual/genital secretions
• direct inoculation, skin on skin e.g. Herpes
• trauma, e.g. Hepatitis C virus
• IVDU = injection drug user e.g. HIV, HCV
• fomites = an innate object e.g. gonorrhoea
• ingestion, e.g. shigella, campylobacter

Question 3

True or false.

Anal sex is a pre-requisite for a rectal STI?

Answer 3

= FALSE

anal sex is NOT a pre-requisite for a rectal STI

Question 4

how can rectal STIs arise?

Answer 4

• Passive transfer of vaginal secretions (chlamydia, gonorrhoea)
• Oro-anal contact/“rimming” (gonorrhoea, herpes)
• On sex toys or fingers (gonorrhoea, chlamydia)
• Systemic/haematogenous spread (syphilis)
• Local spread (herpes, warts)

Question 5

what are risk factors for STIs?

Answer 5

• <25year olds
• changing sexual partner
• no Condom use
• men who have sex with men (MSM)
• past history/contact of STI
• large urban areas
• social deprivation
• black ethnicity

Question 6

where can STIs present?

Answer 6

= anywhere in GI tract from mouth to anus

Question 7

what is procto-colitis?

Answer 7

inflammation of rectum and colon

Question 8

how would you advice someone with a STI?

Answer 8

• not to have sex until end of antibiotics
• inform other people that need to know
• safe sex advice
• substance use

Question 9

what causes rectal gonorrhoea?

Answer 9

= neisseria gonorrhoea

gram negative cocci

Question 10

how is gonorrhoea transmitted?

Answer 10

= direct contact of mucosal surfaces with infected secretions

• for proctitis; anal sex, transmucosal spread, fomit

Question 11

what are symptoms of gonorrhoea?

Answer 11

• short incubation period (5-10days)
• lower abdominal pain, diarrhoea, rectal bleeding, anal discharge, tenesmus
• associated symptoms (urethral/vaginal discharge, dysuria)
• may be asymptomatic

Question 12

what investigation would you do for gonorrhoea?

Answer 12

= protocscopy

Question 13

what would you find on a protocscopy of gonorrhoea?

Answer 13

= inflamed mucosae

= purulent exudate

Question 14

what are complications of gonorrhoea?

Answer 14

• abscess formation

- increased susceptibility/transmissibility of HIV

Question 15

what causes the spread of rectal chlamydia?

Answer 15

= chlamydia trachomatis (serovars D-K)

Question 16

how is rectal chlamydia transmitted?

Answer 16

= same as gonorrhoea

= direct contact of mucosal surfaces with infected secretions

• for proctitis; anal sex, transmucosal spread, fomit

Question 17

what percentage of chlamydia in male sex with men is solely found in rectum?

Answer 17

= 50%

Question 18

what are symptoms of chlamydia?

Answer 18

• 70% asymptomatic
• milder than gonorrhoea
• anal discomfort/itch, discharge
• associated symptoms

Question 19

what would you find on a proctoscopy of rectal chlamydia?

Answer 19

= less severe

Question 20

how would you diagnose chlyamdia?

Answer 20

= gram stain rectal swab

• CT (and GC)
• PCR (all sites)

Question 21

how would you treat rectal chlamydia?

Answer 21

= doxycycline (7/7day course)

• better clearance at rectal sites
• test cure
• comprehensive STI testing
• public health intervention

Question 22

Yes or no.

Can you culture chlamydia?

Answer 22

= no

- but you can culture gonorrhoea

Question 23

in summary, what diagnosis/testing would you do fo chlamydia and gonorrhoea?

Answer 23

• gram stain of discharges
• chlamydia and gonorrhoea PCR
• gonorrhoea cultures
• STI testing of all sexual sites

Question 24

what is lymphogranuloma venereum associated with?

Answer 24

= chlamydia

Question 25

who often gets lymphogranuloma venereum?

Answer 25

• male sex with men

- often HIV

Question 26

what is lymphogranuloma venereum associated with?

Answer 26

• group sex
• drug use
• syphilis
• hepatitis C

Question 27

describe the clinical features of lymphogranuloma venereum?

Answer 27

Primary (3-30days)
- ulcer

Secondary (3-6/12)

• inguinal syndrome
• ano-rectal syndrome

Tertiary

• strictures
• fistulae
• genital elephantiasis

Question 28

who should you test for, for LGV?

Answer 28

• MSM with haemorrhagic proctitis
• HIV+ MSM with positive rectal chlamydia
• Suspicious ulcers in MSM
• Failed chlamydia test of cure
• Contact of LGV

Anyone diagnosed with LGV should be tested for HIV, hepatitis C, syphilis….

Question 29

describe the two types of syphilis?

Answer 29

Primary syphilis
- solitary painless ulcers

Secondary syphilis

• mucosal patches & ulcers
• mouth, anogenital, rectal
• condylomata lata (wart like lesions on genitelia)
• systemic inflammation
• hepatitis
• procto-colitis

Question 30

how is herpes simplex virus transmitted?

Answer 30

= ano-genital or oro-anal

= usually HSV 2 (in HSV proctitis)

= usually per-anal mucosa but may extend into rectum

Question 31

what are symptoms of herpes simplex virus?

Answer 31

• PAIN
• ulcers
• painful defaecation
• bleeding
• mucus
• viraemic symptoms (in primary infections)

Question 32

how is the human papllomavirus transmitted?

Answer 32

= ano-genital, oro-anal

wart virus

Question 33

describe the types of HPV?

Answer 33

• HPV 6, 11, 16, 18

Question 34

what does the human papilloma virus usually cause?

Answer 34

= anal warts

• can extend to the rectum
• increasing prevalence of AIN and anal cancers (MSM and HIV+ people)
• HPV vaccination for MSM available

Question 35

what is the largest immune compartment in the body?

Answer 35

= gut associated lymphoid tissue (GALT)

Question 36

what is the gut therefore, highly susceptible to?

Answer 36

= HIV infections

Question 37

what are some clinical consequences of loss of gut associated lymphoid tissue?

Answer 37

• unknown
• HIV enteropathies
• opportunistic infection (e.g. cryptosporidiosis)
• persistent immune activation = microbial translocation
• accelerated immune-senescence