What are the treatment options and recommendations for a patient experiencing bleeding after anal intercourse?

Bleeding After Anal Intercourse: Evaluation and Management

For a patient experiencing bleeding after anal intercourse, perform immediate anoscopy or sigmoidoscopy to identify the source of bleeding, assess vital signs and hemoglobin/hematocrit to determine severity, and rule out sexually transmitted infections (STIs) including gonorrhea, chlamydia, HSV, and syphilis, while providing empiric antibiotic coverage if proctitis is suspected. 1

Initial Assessment

Obtain a focused history and perform a complete physical examination including digital rectal examination to differentiate between minor mucosal trauma and more serious injuries. 1 Key historical elements include:

• Timing and severity of bleeding (minor spotting vs. significant hemorrhage) 2
• Associated symptoms: anorectal pain, tenesmus, rectal discharge, or fever 1
• Sexual practices and number of partners (assess STI risk) 1
• HIV status (herpes proctitis can be especially severe in HIV-positive patients) 1

Check vital signs, hemoglobin, hematocrit, and coagulation parameters immediately to evaluate bleeding severity and guide resuscitation needs. 1 In cases of severe bleeding, obtain blood typing and cross-matching. 1

Diagnostic Evaluation

Anoscopy or sigmoidoscopy should be performed as the first-line diagnostic procedure to visualize the rectal mucosa and identify the bleeding source. 1, 3 This examination can differentiate between:

• Minor anal fissures or mucosal tears (most common, typically self-limited) 4, 2
• Proctitis (inflammation limited to distal 10-12 cm of rectum) 1
• Serious injuries including rectovaginal fistulas or rectal perforations (extremely rare but require urgent surgical intervention) 5, 6

If anorectal pus is visualized or polymorphonuclear leukocytes are found on Gram-stained smear of anorectal secretions, this indicates infectious proctitis requiring treatment. 1

Management Based on Findings

For Minor Bleeding (Anal Fissures/Mucosal Tears)

Minor rectal bleeding from anal fissures or small mucosal tears is neither uncommon nor serious following anal intercourse. 2 Treatment includes:

• Conservative management: sitz baths, stool softeners, and analgesics 4
• Intravenous fluid replacement if needed 1, 3
• Observation and reassurance 2

For Suspected Infectious Proctitis

Acute proctitis of recent onset in persons who have recently practiced receptive anal intercourse is most often sexually transmitted. 1 The most common pathogens are N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV. 1

Empiric antibiotic treatment should be initiated immediately if proctitis is suspected (presence of anorectal pus or polymorphonuclear leukocytes on Gram stain): 1

• Ceftriaxone 125 mg IM (or another agent effective against anal and genital gonorrhea) 1
• PLUS Doxycycline 100 mg orally twice daily for 7 days 1

For herpes proctitis (which can be especially severe in HIV-coinfected patients), refer to specific HSV treatment protocols. 1

For Severe Bleeding

If significant hemorrhage is present:

• Maintain hemoglobin >7 g/dL during resuscitation 1, 3
• Maintain mean arterial pressure >65 mmHg while avoiding fluid overload 1, 3
• Correct coagulopathy 1, 3
• Consider endoscopic interventions (endoscopic variceal ligation, sclerotherapy) if bleeding source is identified 3
• Surgical consultation for suspected rectal perforation, sphincter injury, or rectovaginal fistula 4, 5, 6

STI Testing and Prophylaxis

All patients should be evaluated for STIs including cultures or nucleic acid amplification tests for N. gonorrhoeae and C. trachomatis, serologic testing for syphilis, and HSV testing if ulcers are present. 1

Prophylactic STI treatment is recommended for patients with vaginal or anal penetration, using the regimen above (ceftriaxone plus doxycycline). 1 Additionally, consider:

• Metronidazole 2 g orally once (for trichomonas and bacterial vaginosis coverage) 1
• HIV prophylaxis should be considered when there is mucosal trauma with bleeding, multiple perpetrators, or high HIV prevalence in the geographic area 1

Follow-Up Care

Follow-up within 1 week is essential to: 1

• Assess injury healing 1
• Review STI test results and modify treatment if needed 1
• Ensure counseling has been arranged 1
• Repeat syphilis testing at 6-12 weeks and HIV testing at 3-6 months if initial tests were negative 1

Critical Pitfalls to Avoid

• Do not dismiss significant pain or ongoing bleeding as minor trauma—rare but serious injuries including rectovaginal fistulas and rectal perforations can occur from consensual intercourse 5, 6
• Do not delay anoscopy/sigmoidoscopy—visualization is essential to rule out serious injury 1, 3
• Do not overlook STI screening and prophylaxis—sexually transmitted proctitis is common in this population 1
• Reinfection may be difficult to distinguish from treatment failure—ensure sex partner evaluation and treatment 1