STDs and HPV

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STDs and HPV

• George Dreszer, MD.
• Colon and Rectal Conference
• 10/19/05
• St. Lukes Roosevelt

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Chlamydia Infection

• 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
  African-Americans

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Lymphogranuloma Venereum

• 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

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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
• Treatment TCN, Erythromycin and DS Bactrim x 21
  Days
• Rectal Stenosis may require a resective procedure
  or diversion

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Gonorrhea

• 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

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Gonorrheal Proctitis

• 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)

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• 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

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Herpes Simplex Proctitis

• 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)

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Herpes Continued

• 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

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Syphilis (Lues)

• 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

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Human Papilloma Virus

• 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

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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

• Hyperplastic Epithelial Growth with irregular
  acanthosis and marked Hyperkeratosis

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Treatment of Anal Condyloma

• 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.

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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

• 5. Cryotherapy- topical application of Liquid
  Nitrogen commonly used by dermatologists for the
  treatment of conventional warts
• 6. Laser Therapy- work through thermonecrosis
• 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

• 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

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