What are the appropriate diagnostic and treatment steps for a patient experiencing bleeding during anal intercourse, potentially indicating a sexually transmitted infection (STI) or anal trauma?

Bleeding During Anal Intercourse: Diagnostic and Treatment Approach

For a patient experiencing bleeding during anal intercourse, immediately perform anoscopy to visualize the rectal mucosa and obtain anorectal specimens for testing of N. gonorrhoeae, C. trachomatis, T. pallidum, and HSV, then initiate empiric treatment with ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 7 days if inflammation is present. 1, 2

Initial Clinical Assessment

Obtain a detailed sexual history specifically documenting:

• Receptive anal intercourse practices, as this is the primary risk factor for sexually transmitted proctitis 1
• Timing and nature of bleeding (during intercourse, after, or ongoing) 3
• Associated symptoms including anorectal pain, tenesmus, rectal discharge, or constipation 1
• Oral-anal contact history, which may indicate enteric pathogen exposure 1
• HIV status, as this affects disease severity and treatment approach 1, 2

Physical examination must include:

• Visual inspection for perianal ulcers, bloody discharge, or mucosal ulcers (these findings suggest lymphogranuloma venereum requiring extended treatment) 1
• Digital rectal examination to assess for masses, tenderness, or palpable abnormalities 4
• Anoscopy to visualize the distal 10-12 cm of rectum and identify inflammation characteristic of proctitis 3, 1

Diagnostic Testing Protocol

Immediate laboratory evaluation:

• Gram-stained smear of any anorectal exudate for polymorphonuclear leukocytes—if present, this indicates acute inflammation requiring immediate empiric treatment 3, 1, 2
• NAAT or culture for N. gonorrhoeae and C. trachomatis from anorectal specimens 1, 2
• If C. trachomatis is positive, perform molecular PCR testing specifically for LGV serovars, as this determines whether 3-week versus 7-day treatment is needed 1, 2
• HSV testing by PCR or culture 1
• Syphilis serology (T. pallidum testing) 1, 2
• HIV testing in all patients 1, 2

Consider imaging only if:

• Suspicion exists for concomitant anorectal diseases such as abscess, inflammatory bowel disease, or neoplasm 3
• Severe trauma is suspected based on mechanism or examination findings 3

Treatment Algorithm

Initiate empiric treatment immediately if:

• Anorectal pus is present on examination, OR
• Polymorphonuclear leukocytes are found on Gram-stained smear 3, 1, 2

Standard empiric regimen:

• Ceftriaxone 250 mg IM single dose (covers N. gonorrhoeae)
• PLUS Doxycycline 100 mg orally twice daily for 7 days (covers C. trachomatis) 3, 1, 2

Extended treatment for LGV proctitis:

• If bloody discharge, perianal ulcers, or mucosal ulcers are present, extend doxycycline to 100 mg twice daily for a total of 3 weeks 1, 2
• LGV proctitis is increasingly found in HIV-negative men who have sex with men 5

Pathogen-specific considerations:

• N. gonorrhoeae and C. trachomatis (including LGV serovars) are the most common sexually transmitted pathogens causing proctitis 3, 1, 2
• HSV proctitis can be especially severe in HIV-infected individuals and requires antiviral therapy 3, 1, 2
• In HIV-positive patients with severe symptoms, consider opportunistic infections including CMV 3, 1

Trauma Assessment

Evaluate for mechanical trauma if:

• History suggests forceful penetration or use of objects 6, 7
• Severe pain or extensive bleeding is present 7
• Physical examination reveals tears or lacerations 7

Consensual anal intercourse can rarely cause serious injuries including rectovaginal tears, though most trauma is minor 7. Failure to identify significant trauma can lead to delayed treatment and poor outcomes 7.

Partner Management

All sexual partners require evaluation:

• Partners who had sexual contact within 60 days before symptom onset must be evaluated, tested, and treated presumptively 1, 2
• Both patient and partners should abstain from sexual intercourse until treatment completion (7-day regimen) and symptom resolution 1, 2

Follow-Up Protocol

Scheduled reassessment:

• For proctitis associated with gonorrhea or chlamydia, retest for the respective pathogen 3 months after treatment to detect treatment failure or reinfection 1, 2
• Patients with persistent symptoms after treatment require evaluation for reinfection, treatment failure, or alternative diagnoses 1, 2
• HIV-positive patients require more vigilant follow-up due to risk of severe disease and opportunistic infections 1

Critical Pitfalls to Avoid

Do not delay treatment while awaiting culture results if inflammation is present on examination or Gram stain 3, 1, 2. The majority of rectal chlamydia and gonococcal infections are asymptomatic and can only be detected by laboratory tests 5.

Do not assume condom use provides complete protection—sexually transmitted infections often spread without penile penetration 1, 5.

Do not overlook LGV—if initial C. trachomatis testing is positive, failure to test for LGV serovars will result in inadequate treatment duration (7 days instead of required 21 days) 1, 2.

Do not miss Mycoplasma genitalium—in patients with symptomatic proctitis after exclusion of N. gonorrhoeae, C. trachomatis, syphilis, and herpes, consider M. genitalium as a cause 5.