Ano-rectal Syndrome (ARS)

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Is defined as soreness, burning, itching or other irritation of the rectum together with redness in the  area of anus. Sometimes it is accompanied by diarrhea and it may occur as a toxic side effect of oral  administration of certain broad-spectrum antibiotics. 

Causes

  • Neisseria gonorrhoeae  
  • Chlamydia trachomatis  
  • Treponema pallidum 
  • Herpes Simplex Virus
  • Shigella spp., or
  • Entamoeba histolytica  

Clinical presentation 

  • Purulent rectal discharge 
  • Mucous rectal discharge 
  • Watery rectal discharge 
  • Soreness, burning, itching or other irritation of the rectum together with redness in the area of anus 
  • There may also be ineffectual straining to defecate (“tenesmus”), sometimes mistakenly described as “constipation” by patients
  • The anus and rectum may be intensely painful, with external and internal ulceration 
  • Abdominal pain or cramping, abdominal swelling, distention or bloating
  • Bloody stool (blood may be red, black, or tarry in texture)
  • Burning feeling
  • Change in bowel habits, constipation, diarrhea
  • Fecal incontinence (inability to control stools) 
  • Flatulence; pain, which may be severe, in the abdomen, pelvis, or lower back
  • Urgent need to pass stool and watery diarrhea including multiple episodes
  • A proctoscopic examination (which should be done, if feasible) will reveal rectal pus, bleeding or ulceration

Note:  

  • Proctitis may be caused by Salmonella spp., Shigella spp., or Entamoeba histolytica as a  part  of  gastroenteritis,  which  may  manifest  as  diarrhoea  with  fever,  anorexia,  and  abdominal cramps.  
  • Antibiotics that destroy normal intestinal bacteria and allow other bacteria to grow in their place may also cause proctitis. 
  • Herpes  proctitis  may  be  mistaken  for  the  rectal  manifestation  of  ulcerative  colitis  or Crohn’s disease.  
  • Proctitis  typically  causes  painless  bleeding  or  the  passage  of  mucus  (sometimes mistaken for diarrhoea) from the rectum.  
  • All cases of proctitis in MSM should be treated for gonorrhoea and chlamydia infections.  
  • Symptoms  of  diarrhoea,  bloody  stools,  abdominal  cramping,  nausea,  and/or  bloating may indicate Giardia spp infection or amoebic dysentery. 

Other non-STI causes of ARS include: 

Anal fissure, fecal impaction, food intolerance, gastroenteritis (bacterial and viral), inflammatory  bowel disease (includes Crohn’s disease and Ulcerative colitis), neurological damage, and perirectal or perianal abscess. 

Other symptoms might occur with rectal discharge includes gastrointestinal symptoms which vary  depending on the underlying disease, disorder or condition. These may include: 

  • Abdominal pain or cramping, abdominal swelling, distention or bloating, bloody stool (blood  may  be  red,  black,  or  tarry  in  texture),  burning  feeling,  change  in  bowel  habits,  constipation, diarrhea, fecal incontinence (inability to control stools), flatulence, pain, which  may  be  severe,  in  the  abdomen,  pelvis,  or  lower  back,  urgent  need  to  pass  stool  and  watery diarrhea including multiple episodes. 

Investigation(s) if the HF has a Laboratory capable of doing:  

  • Wet preparation 
  • Gram stain 
  • Pap test (Papanicolaou’s test) 
  • Culture and Sensitivity 
  • Rapid Plasma Reagin (RPR) 
  • Treponema palladium particle agglutination (TPPA) 
  • ELISA 
  • Quantitative or qualitative PCR  
  • Genetic sequencing 
  • Fluorescent Microscopy 

Management and Treatment of ARS(see flow chart 12.5.)