A 37-year-old man comes to the clinic complaining of rectal problems. He has had a constant urge to defecate for the past 2-3 days. When he does have a bowel movement, it is a small volume that contains purulent material sometimes streaked with blood. He has no fever but feels tired with generalized malaise. He recently had unprotected anal-receptive sex with a new male partner. He is in otherwise general good health and takes no medications. He has no history of similar illness.
His vital signs are within normal limits. Cardiopulmonary and abdominal examinations are also within normal limits. There are no lesions visible in the perianal area. There is no inguinal lymphadenopathy.
Which of the following is the most likely cause of his symptoms?

Question

A 37-year-old man comes to the clinic complaining of rectal problems.  He has had a constant urge to defecate for the past 2-3 days.  When he does have a bowel movement, it is a small volume that contains purulent material sometimes streaked with blood.  He has no fever but feels tired with generalized malaise.  He recently had unprotected anal-receptive sex with a new male partner.  He is in otherwise general good health and takes no medications.  He has no history of similar illness.
His vital signs are within normal limits.  Cardiopulmonary and abdominal examinations are also within normal limits.  There are no lesions visible in the perianal area.  There is no inguinal lymphadenopathy.
Which of the following is the most likely cause of his symptoms?

Quizplus · Accepted Answer

11ec193a_9802_ca54_853d_e9fd27516ef3_MD0002_00 This patient's presentation of tenesmus, purulent discharge, and small-volume stools containing blood is consistent with proctitis. Proctitis has multiple causes, including ulcerative colitis, radiation treatment, and infections. Given this patient's history, a sexually transmitted infection is most likely. Neisseria gonorrhoeae is the most common cause of sexually transmitted proctitis in individuals with history of anal-receptive intercourse. Patients with rectal symptoms should undergo anoscopy or sigmoidoscopy with mucosal biopsies. Purulent discharge should be cultured and sent for Gram stain, Tzanck prep and culture for herpes simplex virus, and PCR for Chlamydia trachomatis. In addition, patients should have serum RPR and HIV. Treatment is based on results of the investigation. (Choice A) Bacteria that can cause inflammation of the gastrointestinal tract include Campylobacter, Salmonella, Shigella, and some strains of Escherichia coli. However, these organisms do not commonly cause proctitis. (Choice B) Crohn's disease involving the large bowel usually spares the rectum. Proctitis is more commonly associated with ulcerative colitis, which is less likely given this patient's recent sexual history. (Choice C) Herpes simplex virus can be sexually transmitted to the perianal and rectal areas but usually presents with perianal vesicles. (Choice D) Human papilloma virus infection is associated with warts and anal cancer but does not cause proctitis. Educational objective: Proctitis typically presents with tenesmus, purulent discharge, and small-volume stools containing blood. Sexually transmitted infections should be considered in proctitis patients engaging in anal intercourse; N gonorrhoeae is the most common causative organism. __________ References: Sexually transmitted proctitis. (http://www.ncbi.nlm.nih.gov/pubmed/17099092)

A 37-Year-Old Man Comes to the Clinic Complaining of Rectal