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Most venereal diseases involving the anorectal area manifest themselves initially with itching, seepage, and mild pain or irritation. Some infections may persist with mild to minimal symptoms, rendering the patient a carrier of the disease. Most venereal infections, however, will produce significant symptoms of pain, bleeding, and discharge in addition to a bothersome pruritus.

CONDYLOMATA ACUMINATA Condylomata acuminata, commonly known as anal warts, are caused by a papillomavirus and are probably sexually transmitted in more than 90 percent of cases. They begin as discreet, soft, fleshy growths on the skin of the perianal area as well as on the squamous epithelium of the anal canal. Occasionally, the mucosa of the lower rectum becomes involved. Patients usually first notice the presence of a growth in the perianal areas as well as associated pruritus and varying degrees of anal pain. With time, bleeding and anal discharge become part of the symptom complex. Evaluation of a patient with condyloma acuminata must include ruling out the presence of other STDs. These patients should be referred to an appropriate specialist for definitive treatment. Because cases of squamous cell carcinoma arising in association with condyloma acuminata have been reported, multiple biopsies must be taken.

GONORRHEA Symptoms of gonococcal proctitis vary, ranging from none to severe rectal pain with profuse yellow discharge. Patients in the acute phase generally have mild and burning and/or pruritus with some purulent seepage. Proctoscopic examination during this phase of the disease reveals marked hyperemia and edema of the rectal mucosa and diffuse inflammation with purulent discharge from the anal crypts. Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt. Diagnosis is made by Gram's stain and cultures.

CHLAMYDIAL INFECTIONS Chlamydia trachomatis is an obligate human intracellular parasite that causes, among other conditions, both urogenital and anorectal infections. The lymphogranulomatous (LGV) variety occurs mainly in tropical and subtropical climates. Infection can involve the rectum by perirectal lymphatic invasion from vaginal seeding or from direct anorectal mucosal infections. The non-LGV chlamydial organisms may infect the rectal mucosa, although they do not cause the extensive rectal scarring and stricturing that its lymph gland-invading cousin from the tropics does. A patient with chlamydial proctitis may be asymptomatic or may present with nonspecific symptoms, including anal pruritus, pain, and purulent discharge. Bleeding may also be present.

The more severe form of proctitis occurring with this infection is usually due to the LGV type of chlamydia. In addition to rectal scarring, which is a late sequel, infection of the perirectal tissue results in perirectal abscesses and chronic fistulas.

Chlamydia may be identified by culture. The LGV forms may be distinguished from the non-LGV variety by the Frei intradermal test or the LGV complement fixation test. Treatment for LGV chlamydial infections should be maintained for at least 21 days.

SYPHILLIS Chancres, the characteristic lesion of primary syphilis, usually manifest themselves at the anal verge or in the anal canal. Rarely will a chancre involve the rectal mucosa, although proctitis due to syphilis can occur in the absence of a chancre. Anal chancres may be very painful. If they are not identified and treated, they will resolve and the patient will proceed to develop secondary and tertiary syphilis. Condylomata lata, which are flatter and firmer than condylomata acuminata, appear in the perianal region as a manifestation of the secondary stage of syphilis.

HERPES Anorectal herpes is almost always caused by the type II herpes simplex virus (HSV-2). Symptoms are itching and soreness in the perianal area progressing to severe anorectal pain. Initially, the virus manifests itself as small, discreet groups of vesicles superimposed on an erythematous base. These vesicles enlarge, coalesce, and rupture, forming exquisitely tender aphthous ulcers that appear on the perianal skin, the anoderm, and even the rectal mucosa. The pain and tenesmus from these lesions may be so intense that the patient is reluctant to have a bowel movement, resulting in constipation and possibly fecal impaction.

AIDS-RELATED INFECTIONS Ironically, infection of the rectum by the human immunodeficiency virus (HIV) per se does not cause any local reaction or symptoms, but its effect on the patient inoculated with this virus can be devastating. Patients who have been rendered immunodeficient by the HIV virus are subject to a variety of opportunistic infections that affect the intestinal, anorectal, and other body systems. Chronic perianal infections with herpes simplex type I as well as type II are commonly seen in AIDS patients. Table...78z3 lists other, more common enteric organisms that infect AIDS patients. Severe rectal pain, diarrhea, and hematochezia are common presenting symptoms.

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