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• Syphilis proctitis in Men who have sex with men: Response to Richardson et al
  Gwamaka E Mwasakifwa, Colleen Nugent and Rick Varma
  Published on: 19 October 2020
• Syphilis proctitis in Men who have sex with men: response to Mwasakifwa GE et al
  Daniel Richardson, Colin Fitzpatrick and Nicolas Pinto-Sander
  Published on: 19 October 2020

• Published on: 19 October 2020

  Syphilis proctitis in Men who have sex with men: Response to Richardson et al

  • Gwamaka E Mwasakifwa, PhD Candidate The Kirby Insitute
  • Other Contributors:
    • Colleen Nugent, Registered Nurse
    • Rick Varma, Sexual Health Physician

  We thank Richardson et al., for their response to our recent publication titled “Proctitis in gay and bisexual men. Are microscopy and proctoscopy worthwhile?”[1]. The authors have previously reported findings of men who have sex with men (MSM) with proctitis, highlighting the polymicrobial nature of proctitis and symptomatic presentations with negative nucleic acid amplification testing (NAAT). However, they observed 8% (6/78) of MSM had syphilis proctitis based on NAAT from rectal mucosa[2] in contrast; we did not identify any.

  Our study and the Richardson study have three main differences. Firstly, in our study, only a small proportion of MSM were tested for rectal syphilis (10.5% (16/154), and all patients were syphilis NAAT negative. Data on syphilis serology was not collected. As per our local guidelines, NAAT for rectal syphilis is based on clinical signs. None of our remaining patients had an appropriate history or clinical signs (ulcers) which would have triggered targeted NAAT for anorectal syphilis.

  Secondly, 43% of GBM in our study were using pre-exposure prophylaxis (PrEP)and undergoing three monthly serological screening for Human Immunodeficiency Virus (HIV) and syphilis delivered as part of comprehensive sexually transmissible infections (STIs) and PrEP package. We postulate that this may have had a “protective” benefit against ‘symptomatic rectal syphilis”, through frequent STI testing or treatment of sexual contacts and engagement with heal...

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  We thank Richardson et al., for their response to our recent publication titled “Proctitis in gay and bisexual men. Are microscopy and proctoscopy worthwhile?”[1]. The authors have previously reported findings of men who have sex with men (MSM) with proctitis, highlighting the polymicrobial nature of proctitis and symptomatic presentations with negative nucleic acid amplification testing (NAAT). However, they observed 8% (6/78) of MSM had syphilis proctitis based on NAAT from rectal mucosa[2] in contrast; we did not identify any.

  Our study and the Richardson study have three main differences. Firstly, in our study, only a small proportion of MSM were tested for rectal syphilis (10.5% (16/154), and all patients were syphilis NAAT negative. Data on syphilis serology was not collected. As per our local guidelines, NAAT for rectal syphilis is based on clinical signs. None of our remaining patients had an appropriate history or clinical signs (ulcers) which would have triggered targeted NAAT for anorectal syphilis.

  Secondly, 43% of GBM in our study were using pre-exposure prophylaxis (PrEP)and undergoing three monthly serological screening for Human Immunodeficiency Virus (HIV) and syphilis delivered as part of comprehensive sexually transmissible infections (STIs) and PrEP package. We postulate that this may have had a “protective” benefit against ‘symptomatic rectal syphilis”, through frequent STI testing or treatment of sexual contacts and engagement with health services, as observed in our cohort. Lastly, almost half of the patients in the authors’ study, 47%(37/78), were HIV positive compared with 17% (26/154) in our study. HIV seropositivity is a known risk factor for anorectal syphilis[3].

  We agree that the rising incidence of infectious syphilis among GBM necessitate a tailored approach to facilitate early detection of anorectal syphilis. Further studies are required to establish the clinical utility of anoscopy in this setting.

  References
  1. Mwasakifwa GE, Nugent C, Varma R. Proctitis in gay and bisexual men. Are microscopy and proctoscopy worthwhile? Sex Transm Infect [Internet] 2020 [cited 2020 May 3];Available from: https://sti.bmj.com/content/early/2020/01/30/sextrans-2019-054197
  2. Pinto-Sander N, Parkes L, Fitzpatrick C, Richardson D. Symptomatic sexually transmitted proctitis in men who have sex with men. Sex Transm Infect [Internet] 2019 [cited 2020 May 1];95(6):471–471. Available from: https://sti.bmj.com/content/95/6/471
  3. Arando M, Fernandez-Naval C, Mota-Foix M, Martinez D, Armengol P, Barberá MJ, et al. Early syphilis: risk factors and clinical manifestations focusing on HIV-positive patients. BMC Infect Dis [Internet] 2019 [cited 2020 May 3];19(1):1–9. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-4269-8

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  Conflict of Interest:
  None declared.

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• Published on: 19 October 2020

  Syphilis proctitis in Men who have sex with men: response to Mwasakifwa GE et al

  • Daniel Richardson, Reader in Sexual Health Medicine Brighton & Sussex MEdical School
  • Other Contributors:
    • Colin Fitzpatrick, Sexual Health / HIV Clinical Nurse Specialist
    • Nicolas Pinto-Sander, Sexual Health Registrar

  We read with interesting the recent report by Mwasakifwa and colleagues demonstrating that presence of mucopurulent ano-rectal discharge on clinical examination was associated with identification of a sexually transmitted organism by NAAT testing in men who have sex with men (MSM) with symptomatic proctitis.1 We also showed that sexually transmitted proctitis in MSM is often associated with more than one organism and that even with sensitive NAAT testing, there are a significant proportion of cases of MSM with proctitis with negative microbiology tests.2 We were however surprised that Mwasakifwa and colleagues did not identify any cases of syphilis in their analysis. This may have been because syphilis PCR testing was only conducted in a small proportion of cases? Ano-rectal syphilis was first described between 1945-1966 although most of these cases had anal ulceration with pain on defecation. Syphilis ‘proctitis’ was first described in 1975 from the USA in a man with rectal pain and discharge.3 In our series of MSM with proctitis, we reported 6/78(8%) cases of syphilis based upon PCR testing from the rectal mucosa during proctoscopy.2 The recent increase in infectious syphilis particularly in MSM is likely to increase the number of cases of ano-rectal syphilis. The clinical features of syphilis as the epidemic evolves may be changing and more MSM are presenting with painful lesions than was previously believed. We do agree that clinical examination of the ano-rectal area...

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  We read with interesting the recent report by Mwasakifwa and colleagues demonstrating that presence of mucopurulent ano-rectal discharge on clinical examination was associated with identification of a sexually transmitted organism by NAAT testing in men who have sex with men (MSM) with symptomatic proctitis.1 We also showed that sexually transmitted proctitis in MSM is often associated with more than one organism and that even with sensitive NAAT testing, there are a significant proportion of cases of MSM with proctitis with negative microbiology tests.2 We were however surprised that Mwasakifwa and colleagues did not identify any cases of syphilis in their analysis. This may have been because syphilis PCR testing was only conducted in a small proportion of cases? Ano-rectal syphilis was first described between 1945-1966 although most of these cases had anal ulceration with pain on defecation. Syphilis ‘proctitis’ was first described in 1975 from the USA in a man with rectal pain and discharge.3 In our series of MSM with proctitis, we reported 6/78(8%) cases of syphilis based upon PCR testing from the rectal mucosa during proctoscopy.2 The recent increase in infectious syphilis particularly in MSM is likely to increase the number of cases of ano-rectal syphilis. The clinical features of syphilis as the epidemic evolves may be changing and more MSM are presenting with painful lesions than was previously believed. We do agree that clinical examination of the ano-rectal area, including proctoscopy is a vital skill for sexual health clinicians and in the age of self-taken samples: we need to continue to teach and maintain this skill. Whether syphilis causes a true proctitis or ulceration of the anal canal remains debatable and is difficult to distinguish clinically, however we recommend that all MSM presenting with proctitis are tested for Syphilis using both PCR testing and serology.

  1. Mwasakifwa GE, Nugent C, Varma R.Proctitis in gay and bisexual men. Are Microscopy and proctoscopy worthwhile? Sexually Transmitted Infections 2020 (online first)
  2. Pinto Sander N, Fitzpatrick C, Parkes L, Richardson D. Sexually transmitted proctitis in men who have sex with men. Sexually Transmitted Infections 2019;95:471.
  3. Nazemi MM, Musher DM, Schell RF, Milo S. Syphilitic proctitis in a homosexual JAMA 1975;231(4)389

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  Conflict of Interest:
  None declared.

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