STDs and HPV
George Dreszer, MD.
Colon and Rectal Conference
10/19/05
St. Luke’s Roosevelt
Chlamydia Infection
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Chlamydia infection is now the most common
bacterial STIs in the US
4-8 Million new cases occurring each year
Most Frequently seen in the Homosexual
Population
Particularly High incidence among AfricanAmericans
Lymphogranuloma Venereum
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LGV is a suppurative STI caused by C.
Trachomatis
Historically Low incidence in US
Incidence is increasing as a complication in
patients with AIDS
Early symptoms are referable to GU tract
May lead to PID and infertility in Women
Rectovaginal Fistual has been described as a
complication
LGV
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Lesion initially appears as a herpetiform vesicle on the genital or
anal area
Complaints are typically of Dysuria, Pyuria and Mucopurulent
Discharge
Lower Abdominal Pain may be present
Unilateral lympadenopathy and systemic signs appear 1-4 weeks
following initial lesion
The nodes enlarge, from a mass and drain
May start in the rectum as proctitis with symptoms of rectal
discharge, bleeding and tenesmus
Anal fissures are not uncommon, and rectovaginal or perianal
fistulas may develop
Intestinal Obstruction may occur late
Frei Test-- Intradermal test similar to tuburculin test
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Treatment TCN, Erythromycin and DS Bactrim x 21
Days
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Rectal Stenosis may require a resective procedure or diversion
Gonorrhea
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Bacterial Infection caused by Niesseria
gonorrhoeae
Humans are the only known reservoir
Disease affects mucous membranes of the urethra,
cervix, rectum and oropharynx
Incidence is 40x higher in in black population as
compared to the white population
Incidence is about 400,000 cases which are
reported to CDC per Year
Symptoms: Discharge from Penis or Vagina
Can cause PID, ectopic pregnancy and infertility
Gonorrheal Proctitis
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Usually seen in the Homosexual popution
In women, this condition can be caused by spread from the
genital tract
To confirm the presence of the bacterium by culture, rectal
swabs are innoculated on Thayer-Martin Agar
Only the lower rectum is involved
Symptoms occur 5-7 days after exposure and include:
Pruritis, Rectal Bleeding, Diarrhea and disseminated
disease (septicemia, pericarditis, endocarditis, meningitis,
perihepatitis, and gonoccocal arthritis)
Proctosigmoidoscopy
reveals edematous, friable
mucosa with occasional areas of ulceration, however, in
many individuals no identifiable lesions will be noted
Treatment:
Single dose of Ceftriaxone IM, or One
dose PO Fluoroquinolones
Ceftrixone
is preferable because it also covers
incubating Syphilis
Herpes Simplex Proctitis
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HSV Proctitis is the most common non-gonoccocal
proctitis in sexually active male homosexual
Klausner and colleagues reported a 16% incidence among
homosexual men
HSV-2 is the most common cause of HSV Proctitis, but
HSV-1 can also produce HSV Proctitis
Herpes infections in AIDS patients may develop an
ulcerative proctitis which remains confined to the rectum
Symptoms include: Tenesmus, anorectal pain,
constipation, and perirectal ulceration
Anorectal incontinence may present during the acute
phase, with resolution after treatment of the HSV Infection
Perianal area reveals typical herpetic vesicles, pustules and
ulcerations (Digital exam and anoscopy are very painful)
Herpes Continued
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Sigmoidoscopy reveals an acute proctitis with
edematous, ulcerated, and friable mucosa
The infection is usually confined to the rectum and
in immunocompetant individuals rarely extends
beyond 15 CM
Diagnosis is established by Immunoassay of the
Ab to the virus, or by Immunofluorescent Staining
Treatment: Acyclovir PO, or Acyclovir IV in
AIDS patients
Suppressive therapy is recommended to decrease
relapses
Syphilis (Lues)
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Caused by the Spirochete Treponema Pallidum
Organism enters the skin or mucous membrane,
producing a Chancre approximately 3 weeks
following the infection (Primary Stage)
Chancre is a single painless open sore
In the homosexual male population the chancre is
usually situated at the anal margin or in the canal
(these lesions can be painful)
Symptoms include tenesmus, difficulty with
defecation, and discharge
Sometimes confused with anal fissure, but the
presence of lymphadenopathy should alert the
examiner
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Diagnosis clasically has been made by
identification of T. Pallidum on Dark-Field
Microscopy
However, since the absence of a positive test does
not rule out the diagnosis of Syphilis, it is
preferable to treat patients with suspicious clinical
lesions and wait for results of Serologic evaluation
It is important to remember that serologic tests for
Syphilis do not yield positive results until the
primary chancre has been present for several
weeks
Treatment: Benzathine PCN, or TCN in PCN
allergic patients. Erythromycin can also be used
Human Papilloma Virus
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Condyloma Acuminata represents the most
common STI in the practice of most surgeons
Caused by a DNA virus that is a member of the
Papovirus group
Most Commonly seen in Homosexual Male
population
19 % of patients with HIV have been found to
have anal condyloma
It is recommended that all patients with anal
condyloma undergo HIV testing because of this
high correlation
HPV
Symptoms include discharge, pruritis,
difficulty with defecation, anal pain,
tenesmus, foul odor, and rectal bleeding
 Patients have often received some form of
topical treatment which has failed
 Warts are usually, small, discrete, elevated
pink to grey vegetative excrescences
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HPV Histology
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Hyperplastic Epithelial Growth with irregular
acanthosis and marked Hyperkeratosis
Treatment of Anal
Condyloma
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American Society of Colon and Rectal Surgeon
Recommendations
“When Condylomata are limited to the peri-anal
skin, treatment with topical medications, local
destruction, or harvesting and immunotherapy can
be administered in an outpatient setting. Patients
with extensive perianal or anal canal condylomata,
or those patients with associated genital
condylomata may require inpatient care.”
Treatment Modalities
1. Podophyllin- cytotoxic chemical agent
very toxic to normal skin. Can only be used
on external warts.
 Dysplasia has been reported with prolonged
use.
 Multiple treatments are usually required
 Other caustic agents are available
 Eg. Bichloracetic Acid
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Immunotherapy
2. A Vaccine is created and the patient is
vaccinated with six consecutive weekly
injections
 Study of 200 patients showed excellent
results in 84%, Fair results in 11% and no
results in 5%
 Another study by Eftaiha et al reported
successful eradication in 94% of patients
 Recurrence rate at 13 Months was 4.6%
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Immunomodulators
(Imiquimod/Aldara)
3. Imidazoquinolines- a new class of
immune-response modulators
 Mechanism of action unknown, but thought
to play a role in cytokine-induced activation
of the immune system
 Application 3/week qhs x 16weeks
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Topical Cytostatics
4. Cheotherapeutic agents such as 5-FU,
Thiotepa and Bleomycin
 Bleomycin is given as an intra-lesional
injection q2-3weeks
 70% success rate reported
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Cryotherapy and Laser Therapy
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5. Cryotherapy- topical application of Liquid Nitrogen
commonly used by dermatologists for the treatment of
conventional warts
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6. Laser Therapy- work through thermonecrosis
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Success rate from 88-95%
Higher rate of recurrence seen than electrocoagulation
No difference in healing time, pain or scarring reported
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Fulgaration/Electrocoagulation
7. Fulgaration with excision of a portion to
send to pathology
 Gold Standard
 Very Painful if done too deeply, should not
be into the dermis or fat
 Risk of stricture formation if a large area is
to be treated
 Less than 50% have full resolution after one
treatment
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Anal Intraepithelial Neoplasia
Lesion thought to be precursor to Anal
Squamous Cell Carcinoma
 Seen most frequently in patients with
HIV/AIDS
 According to Cleveland Clinic Florida
Group, the incidence of AIN in patients
with anal condylomata is as high as 31%
 Incidence in HIV(+) group was 51% vs.
17% in HIV(-) population
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Anal Condylomata Summary
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External Condylomata without evidence of
Internal Warts can usually be effectively treated by
chemical means
If the response is unsatisfactory, physical
destruction by electrocoagulation is the preferred
approach
Obtaining tissue for pathologic confirmation,
especially with respect to premalignant or
malignant change is a a prudent philosophy