Alexander McMillan1, 2
Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk
University of Edinburgh, Edinburgh, Uk
Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer
As in Case 1,a specific history should be taken to elicit any symptoms that the individual may not have recognized as being those of a sexually transmissible infection (STI). In addition to the questions posed in that Case, he should be asked if he has symptoms suggestive of distal proctitis: anal discharge or streaking of the stool with “slime,” anorectal bleeding, perianal pain, constipation, or a feeling of incomplete defecation. He should also be asked if he has a sore throat. Gonococcal infection of the pharynx is usually symptomless, but a few men (and women) complain of sore throat. (Although there is a good correlation between pharyngeal symptoms and fellatio, this is not the case with respect to gonococcal infection).
James is a 43-year-old man who attends a Gay Man’s Health Clinic and requests screening for sexually transmissible infections.
4.1 What History Would You Obtain from James?
As in Case 1, a specific history should be taken to elicit any symptoms that the individual may not have recognized as being those of a sexually transmissible infection (STI). In addition to the questions posed in that Case, he should be asked if he has symptoms suggestive of distal proctitis: anal discharge or streaking of the stool with “slime,” anorectal bleeding, perianal pain, constipation, or a feeling of incomplete defecation. He should also be asked if he has a sore throat. Gonococcal infection of the pharynx is usually symptomless, but a few men (and women) complain of sore throat. (Although there is a good correlation between pharyngeal symptoms and fellatio, this is not the case with respect to gonococcal infection).
A detailed sexual history should then be obtained so that a risk assessment for STIs can be made, and so that the appropriate microbiological tests can be offered.
The history should follow that described in Case 1. In addition:
· Has he ever had anal intercourse, and if so, did he have insertive or receptive intercourse, or both? If he has had anal intercourse, was there consistent condom use? When was the last time, if ever, that he had unprotected anal intercourse?
· Are condoms are always used during oral–genital sex? As oral–genital sexual contact is almost universal among MSM, it is not usually necessary as to make specific enquiry about this activity.
· Has he been treated previously for syphilis? In many industrialized countries this infection is more prevalent among men who have sex with men (MSM) than among men who have sex with women (MSW). The accurate interpretation of serological tests for syphilis depends on obtaining a good past history (see Cases 18, 19, and 34).
· Has he ever had hepatitis A or B virus infections, or has he been vaccinated against these viruses? Hepatitis B virus (HBV) infection is more prevalent among MSM in geographical areas where the infection is not endemic (see Case 32), and there have been outbreaks of acute hepatitis A among MSM in various countries.
James is symptomless. His last sexual contact had been 3 days previously with the partner with whom he has been in a relationship for 5 years. He has unprotected insertive and receptive oral and anal sex. Both he and his partner had had an HIV antibody test shortly after they had begun the relationship; neither was HIV infected. James has had over 100 lifetime male partners. He has had four casual sexual contacts within the preceding 3 months, the most recent having been 2 weeks previously. Although he does not have genital–anal sex with these casual partners, he does have unprotected receptive and insertive oral–genital and oral–anal contact. He knows that his regular partner also has casual sexual contacts. Most of his partners have been Caucasian, mostly from the United Kingdom or Western Europe, but he is unaware of the country of origin of the other men. He was treated for urethral gonorrhoea when he was 19 years old, but he gives no history of syphilis, hepatitis A, or hepatitis B. He has not been vaccinated against hepatitis A or B. His general health is good, and other than acute appendicitis when he was a young man, he has had no significant past medical problems. He is not currently receiving any medication. Neither he nor, to his knowledge, any of his partners have injected recreational drugs. He uses “poppers” (inhaled alkyl nitrites) to facilitate receptive anal intercourse.
4.2 Outline the Physical Examination You Would Perform and Indicate Which Microbiological Tests You Would Undertake in This Case
The physical examination should follow that described for the heterosexual man (Case 1). However, there are additional considerations:
· Take material from the pharynx for culture or for a nucleic acid amplification assay (NAAT) (but see Note 1 in Case 3) for Neisseria gonorrhoeae (see Case 3 for details). Pharyngeal gonorrhoea is common among MSM (Fig. 4.1).
· With the patient lying in the left lateral position, examine the perianal region for lesions such as warts (Fig. 4.2 and see Case 15).
Anatomical sites of gonococcal infection in 155 MSM. U = urethra; P = pharynx; R = anorectum.
Perianal warts (condylomata acuminata).
Some clinicians pass an anoscope and examine the anal canal, to diagnose or exclude conditions such as warts, and the distal rectum for signs of proctitis. Few conditions are identified in symptomless patients, however, and as anoscopy is an unpleasant examination for many men, this examination is often omitted. As the anorectum in a common anatomical site of gonococcal and chlamydial infections among MSM (Figs. 4.1 and 4.3), and as receptive anal intercourse may not be the only means of their acquisition, specimens for the detection of gonococcal and chlamydial infections should always be taken:
· Rectal gonorrhoea is diagnosed or excluded as described in Case 3.
· Rectal chlamydial infection is diagnosed or excluded using a NAAT (see Case 3).
· Offer serological testing for
· HIV infection. HIV antibody testing of MSM should be actively encouraged. Early identification of infection results in better health care, and there is evidence that sexual risk-taking is reduced when an individual is known to be HIV infected. Post-exposure prophylaxis can also be made available to serodiscordant couples.
· Current or past HBV infection.
· Previous infection with HAV (the laboratory staff should be asked to test for anti-HAV IgG).
· Hepatitis C virus (HCV) infection. This is an uncommon infection among MSM who do not inject illicit drugs. There is evidence of an association between “fisting” (the insertion of a clenched fist into the rectum) and HCV infection.
Anatomical sites of chlamydial infection in 155 MSM. U = urethra; R = anorectum.
James is offered and accepts vaccination against hepatitis A and B (for vaccination schedule see Case 3 ), and he is given the first dose of combined vaccine before he leaves the clinic. He is also counseled about safer sexual practices and he is encouraged to use condoms for anal sex with his partner. He is also encouraged to use condoms for oral–genital sex with casual partners and to use a “dental dam” (a square of latex) for oral–anal sex to reduce the risk of acquisition of intestinal pathogens (seeCase 31 ).
James returns the next day and is given a negative HIV antibody test result.
He re-attends the clinic 1 week later to obtain the results of the various tests that had been undertaken (Table 4.1 ).
Results of laboratory tests.
Urethral, pharyngeal, and rectal cultures for N. gonorrhoeae: NEGATIVE.
Testing of urine and rectal material by NAAT for C. trachomatis: NEGATIVE.
Enzyme immunoassay for treponemal infection: NEGATIVE.
Anti-HAV IgG: POSITIVE; anti-HAV IgM: NEGATIVE.
Hepatitis B surface antigen (HBsAg): NEGATIVE
Anti-hepatitis B core (anti-HBc): POSITIVE
Anti-hepatitis B surface antigen (anti-HBs): POSITIVE
4.3 How Do You Interpret the Hepatitis A and B Serology Results?
James has been infected previously with HAV. Most acute infections acquired in childhood are symptomless, but about 80% of acute infections in adults are symptomatic. In acute hepatitis A infection, anti-HAV IgM is detectable in the serum; a positive IgG assay indicates previous exposure to the virus. Unlike hepatitis B and C, there is no persistent carrier state.
James has also been infected previously with HBV but has cleared the infection. This is indicated by the negative HBsAg and the positive anti-HBc (and anti-HBs). If the anti-HBc test had been negative, and the anti-HBs test positive, previous vaccination or a false positive anti-HBs would be possible explanations. The majority of acute HBV infections are symptomless, and more than 90% of individuals clear the virus spontaneously. Other persons become persistent carriers (see Case 32), and at risk of the complications of hepatic cirrhosis and hepatocellular carcinoma.
In view of the laboratory findings, it is unnecessary to continue the course of vaccination against either hepatitis A or B.