Postgrad Med J: first published as 10.1136/pgmj.57.673.705 on 1 November 1981. Downloaded from Postgraduate Medical Journal (November 1981) 57, 705-711 A microbiological study of non-gonococcal proctitis in passive male homosexuals P. E. MUNDAY*t S. G. DAWSONt M.B., M.R.C.O.G. M.B. B.S. A. P. JOHNSON* M. J. OSBORN* B.Sc., Ph.D. H.N.C. B. J. THOMAS* S. PHILIPS B.Sc., Ph.D. F.I.M.L.S. D. J. JEFFRIES§ J. R. W. HARRISt B.Sc., M.B., M.R.C.Path. M.R.C.P., D.T.M.&H. D. TAYLOR-ROBINSON* M.D., F.R.C.Path. *The Sexually Transmitted Diseases Research Group, MRC Clinical Research Centre arrow,o The Praed Street Clinic, St Mary's Hospital, Paddington, and the Departments of$Microbiology and § Virology, St Mary's Hospital Medical School, London copyright. Summary in the rectum producing a proctitis which may or In a study of 180 male homosexual patients attending may not be symptomatic (Fluker et al., 1980). Many a venereal disease clinic, a correlation was sought male homosexuals admitting to passive peno-anal between symptoms and signs of proctitis and the coitus complain of symptoms related to the lower isolation of Neisseria gonorrhoeae, group B strepto- bowel. In addition, asymptomatic patients when cocci, Chlamydia trachomatis, Ureaplasma urea- examined by proctoscopy may be found to have lyticum, Mycoplasma hominis and herpes simplex abnormal signs in the absence of gonococcal infec- http://pmj.bmj.com/ virus. Faecal specimens were examined for enteric tion. The aetiology of these non-gonococcal proctitis pathogens and serological tests for hepatitis B virus, (NGP) 'infections' is unknown and the management syphilitic and chlamydial infections were performed. empirical. There was no association between proctitis, as It is reasonable to suppose that NGP might arise diagnosed by examination of a Gram-stained rectal from known gastrointestinal pathogens or as a smear, and the isolation of any micro-organism or result of infection from organisms transmitted from detection of a positive serological test. There was, the active sexual partner. It has been recognized in addition, no association between any symptom or recently that many intestinal pathogens including on October 1, 2021 by guest. Protected abnormal physical sign and any positive micro- Giardia lamblia (Meyers, Kuharic and Holmes, biological findings. Since 23 % of patients from whom 1977), Entamoeba histolytica (Schmerin, Gelston N. gonorrhoeae was isolated had no abnormal and Jones, 1977), Shigella spp. (Dritz and Back, physical signs, it is difficult to assign a pathogenic role 1974) and Salmonella spp. (Dritz and Braff, 1977) to other micro-organisms isolated from patients with previously thought to be acquired from infected and without clinical signs of proctitis. Approaches to sources of food and water, may be sexually trans- further investigation of the problem are discussed. mitted. Furthermore, micro-organisms known to be pathogenic or suspected of pathogenicity in the male Introduction urethra may be transmitted to the rectum and it is Neisseria gonorrhoeae is believed to be a pathogen possible that some cause proctitis. Chlamydia trachomatis which to cause of cases of Address for reprints: Dr P. E. Munday, Division of appears 50% Communicable Diseases, Clinical Research Centre, Watford non-gonococcal urethritis (NGU) has been isolated Road, Harrow HA1 3UJ, Middlesex. sporadically from the rectum (Darougar et al., 0032-5473/82/0100-0705 $02.00 © 1982 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.57.673.705 on 1 November 1981. Downloaded from 706 P. E. Munday et al. 1972; Goldmeier and Darougar, 1977; McMillan, The following specimens were obtained, using Sommerville and McKie, 1981) but its association cotton-wool-tipped swabs unless otherwise stated, with NGP is unknown. Ureaplasma urealyticum in the order indicated: (i) a perianal swab, for may cause a proportion of cases of NGU and can be isolation of GBS, which was transported in modified isolated from the anal canal of females without Ames medium (Transwab: M.W.E. Co., Ltd) to difficulty (Munday, Furr and Taylor-Robinson, the laboratory; (ii) a rectal wall smear, which was 1981) but there are no reports of the micro-organism Gram-stained and examined (x 800) for Gram- having been isolated from the rectum of male negative diplococci and polymorphonuclear leucocy- homosexuals. Mycoplasma hominis has been as- tes (PMNL); (iii) a similar specimen for inoculation sociated with NGU but evidence that it is a pathogen on to pre-warmed serum-free Neisseria Isolation is lacking (Taylor-Robinson and McCormack, Medium (Difco) for the isolation of N. gonorrhoeae; 1980). Herpes simplex virus (HSV) undoubtedly may (iv) a polyester sponge swab (Oates, Selwyn and cause a severe proctitis (Curry et al., 1978) associated Breach, 1971) which was agitated in 2SP transport with a more widespread syndrome of bladder in- medium (Thomas et al., 1977) and this put in liquid volvement and sensory neurological changes. The nitrogen for transport and storage until tested for C. sexual transmission of hepatitis B virus (HBV) trachomatis; (v) a swab which was agitated in myco- has been suspected since 1971 (Hersh et al., 1971) plasma transport medium (Taylor-Robinson et al., and studies of homosexual men have suggested that 1971) and also stored in liquid nitrogen until tested they have a higher incidence of HBV antigens and for U. urealyticum and M. hominis; (vi) a swab which antibody than heterosexuals (Szmuness et al., was placed in virus transport medium (0-08 % 1975). However, there are no reports of viral bovine albumin in digest broth) for subsequent proctitis attributed to HBV. Group B streptococci identification of HSV; (vii) a swab from the rectal (GBS) have been isolated from the genital tract but wall for GBS isolation; and (viii) when possible, a the perianal skin has been thought to be the primary faecal specimen, obtained through the proctoscope site of colonization (Easmon et al., 1981). Faecal for identification of enteric bacteria and parasites. carriage of GBS has been recorded (Islam and A specimen of blood was obtained for serologicalcopyright. Thomas, 1980) but it is not known if the rectum is tests for syphilis, identification of HBV surface colonized by these organisms and whether they are antigen (HBsAg) and chlamydial antibody studies. pathogenic at this site. Finally, the patient was asked to submit 2 or 3 In an attempt to establish what role these various faecal specimens. micro-organisms play in NGP the authors conducted a prospective study of 180 male homosexual patients Isolation of N. gonorrhoeae attending a large clinic for sexually transmitted The inoculated plates were incubated overnight at diseases in West London. 37°C in an atmosphere of 7% CO2 in air and 90% humidity. Any oxidase positive, Gram-negative Patients and methods cocci were identified by their ability to ferment http://pmj.bmj.com/ The design of the study was approved by the glucose but not maltose, lactose or sucrose. Negative ethics committee. As far as possible consecutive cultures were re-incubated and re-examined after a male patients attending for the first time or pre- further 24 hr. viously registered patients who had not attended in the previous month and who admitted to passive peno-anal coitus were selected for study provided Isolation of C. trachomatis that they gave informed consent to participate; had Samples were inoculated on to cycloheximide- not suffered from ulcerative colitis, Crohn's disease treated McCoy cells as described previously (Thomas on October 1, 2021 by guest. Protected or other intestinal disorder which might affect the et al., 1977) with the modification that the tissue rectum; and had not taken antibiotics in the pre- culture medium was supplemented with gentamicin vious month. A full clinical history was taken and (10 ,ug/ml). The cells were stained with Giemsa, and each patient was examined by one of the two chlamydial inclusions were detected by dark participating clinicians. The perianal area was ground microscopy. inspected and fissures, condylomata, haemorrhoids or other lesions noted. A proctoscope, lubricated Isolation of U. urealyticum and M. hominis with KY jelly was then passed and the rectal mucosa Samples were thawed rapidly and serial 10-fold inspected. The presence of erythema, pus, blood, dilutions, up to 10-3, were made in urea-containing mucus or other abnormality was recorded. Speci- and arginine-containing mycoplasma liquid media mens were taken, as described below, before with- (Taylor-Robinson et al., 1971). Organisms which drawal of the proctoscope. The findings were produced a colour change from yellow to magenta recorded on a standardized data sheet. in urea-containing medium were regarded as U. Postgrad Med J: first published as 10.1136/pgmj.57.673.705 on 1 November 1981. Downloaded from Non-gonococcal proctitis 707 urealyticum while those which hydrolysed arginine Patient groups were regarded as M. hominis Patients from whom N. gonorrhoeae was isolated comprised one group (presumptive gonococcal Isolation ofgroup B streptococci proctitis). In 13 cases, Gram-negative diplococci Swabs were plated on Islam's medium as described were seen in the smear but N. gonorrhoeae was not previously (Easmon et al., 1981) and swabs and isolated. These smear results were regarded as false faeces were also passed through a selective Todd- positives and the patients allotted to NGP or control Hewitt broth as an enrichment medium. groups after review of their smears. Patients from whom N. gonorrhoeae was not isolated were divided Examination offaecal specimens into 2 groups on the basis of an arbitrary number of Up to 3 specimens were examined from each PMNL: those with > 15 PMNL/HPF on their patient. Wet preparations were made in normal Gram-stained smear (NGP group); and those with saline and in iodine and were examined micro- < 15 PMNL/HPF (negative control group).