Management of Tenesmus

Infectious Causes: Sexually Transmitted Proctitis

The American College of Physicians recommends obtaining a detailed sexual history and performing anoscopy to visualize rectal mucosa and identify inflammation limited to the distal 10-12 cm in patients with infectious proctitis 1
The Centers for Disease Control and Prevention suggests testing all patients for N. gonorrhoeae, C. trachomatis, T. pallidum, and HSV using NAAT or culture, and performing HIV and syphilis testing in all persons with acute proctitis 1
The guideline recommends initiating ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days if anorectal pus is present or polymorphonuclear leukocytes are found on Gram stain, with a strength of evidence rated as high 1
Partners who had sexual contact within 60 days before symptom onset must be evaluated, tested, and treated presumptively, according to the guideline 1

Argon plasma coagulation is the preferred modality for radiation-induced proctitis causing tenesmus and bleeding, as it is a noncontact technique with limited depth of coagulation (2-3 mm), with a response rate of 80% reported in a study 2
Multiple treatment sessions are typically required to achieve control of bleeding and symptoms, with a median of 3 sessions reported in a study 2

Dysenteric symptoms include fever, tenesmus, blood and/or pus in stool, occurring with Shigella, Salmonella, and Campylobacter infections, with a prevalence of 55-96% in Salmonella infections 3, 4
Empiric treatment with fluoroquinolone or azithromycin is indicated for ill immunocompetent patients with fever, abdominal pain, bloody diarrhea, and bacillary dysentery presumptively due to Shigella, with a strength of evidence rated as moderate 5
Avoid antimicrobial therapy for STEC O157 and other STEC producing Shiga toxin 2, as this may worsen outcomes, with a strength of evidence rated as high 5