A pilot study exploring sexual health clinician confidence and barriers to anal examination and proctoscopy in men who have sex with men

Keywords: anal cancer, anal warts, education, men who have sex with men, proctoscopy, proctitis, rectal chlamydia, rectal gonorrhoea, sexual health training, sexually transmitted infections.

There have been increasing rates of ano-rectal sexually transmitted infections (STIs) and anal neoplasia in men who have sex with men (MSM) over the past 20 years.^1–4 Anal examination and proctoscopy are important skills for clinicians to assess MSM presenting with anal and rectal symptoms to facilitate the diagnosis of STIs including warts, syphilis, herpes simplex, Neisseria gonorrhoea, Chlamydia trachomatis (including Lymphogranuloma venereum), and anal dysplasia and cancer.^1–5 Despite this, there are no published studies of clinician confidence and competence in anal examination and proctoscopy. As part of an educational needs assessment, we aimed to explore the confidence of sexual health clinicians in anal examination and proctoscopy and identify any barriers and training needs for our local sexual health network. Our sexual health clinics see approximately 9000 MSM per year for STI testing and treatment. MSM with ano-rectal symptoms including rectal discharge, pain, lumps or bleeding have an anal examination and proctoscopy. Both sexual health doctors and nurses are trained and expected to perform anal examination and proctoscopy.

In July 2021, we circulated an anonymous electronic survey to clinicians in our local clinician sexual health network to explore confidence and barriers in performing anal examination and proctoscopy. We asked clinicians who routinely examine MSM including performing anal examination and proctoscopy as part of a sexual health consultation to respond. We used Kruskal–Wallis tests to compare five-point Likert score responses. Thematic analysis was used to analyse free-text responses.

Overall, 40/65 (61.5%) clinicians (25 doctors and 15 nurses) responded to the survey. The clinicians had a median of 11 years’ (IQR = 3–19 years) experience in sexual health. In addition, 30/40 (75%) reported that they had previously received training in anal examination; 28/40 (70%) had received training in proctoscopy. Overall, clinicians were significantly more confident in performing anal examination than proctoscopy (median Likert score = 4/5 (IQR = 4–5) vs 3/5 (IQR = 2–5), P < 0.05). Doctors were significantly more confident in performing anal examination (5/5 vs 4/5, P < 0.008) and proctoscopy (4/5 vs 2/5, P < 0.005) compared to nurses. Clinicians with more than 15 years’ experience were significantly more confident in performing anal examination (5/5 vs 4/5, P < 0.001) and proctoscopy (3/5 vs 5/5, P < 0.007) compared to those with <15 years’ experience (Table 1). Barriers to anal examination and proctoscopy identified from the free-text responses were: (1) lack of opportunities for observed and supervised clinical training due to the increasing use of self-taken nucleic acid amplification test testing in MSM; (2) lack of formal training available within internal professional development programs; (3) concerns about patient reluctance to have an anorectal examination including proctoscopy; and (4) access to appropriate equipment and lighting in clinical environments. Clinicians suggested that an online video demonstration followed by supervised observed clinical training in anal examination and proctoscopy would be a valuable education tool.

Table 1.  Experience and confidence of clinicians in performing anal examination and proctoscopy.

Confidence in performing anal examination was significantly greater than for proctoscopy in all clinicians, and sexual health nurses have less confidence in anal examination and proctoscopy compared to doctors. We have identified some significant barriers such as the lack of training opportunities for clinical examination of MSM. Confidence in anal examination and proctoscopy was related to the number of years of experience. Prior to self-taken sampling for STIs, all MSM presenting for STI testing had ano-rectal examination, including proctoscopy, performed as part of routine (including asymptomatic) clinical assessment, so currently, there are less opportunities for training. As the sexual health workforce changes with an increasing proportion of nurse-led sexual health services and a reduction in face-to-face appointments due to digital health pathways and self-taken sampling, we need to be more innovative when up-skilling the specialist sexual health workforce using online training and optimising opportunities for observed supervised clinical training of anal examination and proctoscopy in MSM.

All data from this study are presented in this research letter.

None of the authors have any disclosure of conflict of interest for this work.

This research did not receive any specific funding.

This research was conducted in accordance with the World Medical Association Declaration of Helsinki. This was an educational needs assessment, so no participant consent was required.

DR designed the study; DR, RH, KN, JD, and CF designed the clinician survey; RH and DR analysed the data; DR, RH, CF, KN, and JD contributed to the final manuscript.