Self-reported anal symptoms and their association with anal pathology among gay and bisexual men: a cross-sectional observational analysis
Sian L. Goddard
A B M , I. Mary Poynten A , Kathy Petoumenos C , Fengyi Jin A , Richard J. Hillman D , Carmella Law D , Jennifer M. Roberts E , Christopher K. Fairley F G , Suzanne M. Garland H I J , Andrew E. Grulich A , David J. Templeton A K L and on behalf of the Study of the Prevention of Anal Cancer (SPANC) Research Team
A HIV Epidemiology and Prevention Program, The Kirby Institute, UNSW Sydney, Level 6,Wallace Wurth Building, High Street, Sydney, NSW 2052, Australia.
B Infection and Immunity, Ambrose King Centre, Barts Health NHS Trust, London, E1 2BB, UK.
C Biostatistics and Databases Program, The Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia.
D Dysplasia and Anal Cancer Services, HIV Immunology and Infectious Disease Department, St Vincent’s Hospital, Sydney, NSW 2010, Australia.
E Cytology Department, Douglass Hanly Moir Pathology, Sydney, NSW 2113, Australia.
F Central Clinical School, Monash University, Melbourne, Vic. 3044, Australia.
G Melbourne Sexual Health Centre, Melbourne, Vic. 3053, Australia.
H Centre for Women’s infectious Diseases, Royal Women’s Hospital, Melbourne, Vic. 3052, Australia.
I Infection Immunity, Murdoch Children’s Research Institute, Parkville, Vic. 3052, Australia.
J Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Vic. 3052, Australia.
K Department of Sexual Health Medicine and Sexual Assault Medicine, Sydney Local Health District, Camperdown, NSW 2050, Australia.
L Sydney Medical School, The University of Sydney, NSW 2006, Australia.
M Corresponding author. Email: sgoddard@kirby.unsw.edu.au
Sexual Health 18(2) 123-129 https://doi.org/10.1071/SH20104
Submitted: 13 June 2020 Accepted: 9 September 2020 Published: 12 March 2021
Journal Compilation © CSIRO 2021 Open Access CC BY-NC-ND
Abstract
Background: Anal symptoms may indicate serious pathology. Receptive anal intercourse (RAI) and sexually transmissible infections (STIs) may contribute to a higher prevalence of symptoms among gay and bisexual men (GBM). This study investigated associations with anal symptoms among GBM. Methods: The Study of the Prevention of Anal Cancer was a longitudinal study of anal human papillomavirus and related lesions in Sydney, Australia. GBM aged ≥35 years were recruited from community settings between September 2010 and August 2015. Information about anal symptoms (discharge, itch, pain defecating, lump, bleeding, ‘sores’, tearing, tenesmus), STIs and sexual behaviours was collected. High-resolution anoscopy (HRA) and STI testing were performed. Logistic regression analyses on baseline data were performed to assess associations with each symptom. Results: Among 616 participants (median age 49 years, 35.9% HIV positive), 35.3% reported at least one anal symptom within the past week and 65.3% were diagnosed with fistula, fissure, ulcer, warts, haemorrhoids and/or perianal dermatoses at HRA. Anal symptoms were not associated with anal chlamydia, gonorrhoea, warts or syphilis. Self-reported ‘sores’ were associated with previous anal herpes simplex virus (HSV; P < 0.001). ‘Sores’ (P < 0.001), itch (P = 0.019), discharge (P = 0.032) and lump (P = 0.028) were independently associated with ulceration. Among participants diagnosed with fissure, fistulae, haemorrhoids and perianal dermatoses, 61.9%, 100%, 62.0% and 63.9% respectively were asymptomatic. Only self-reported anal tear was independently associated with recent RAI. Conclusions: Previous anal HSV was the only STI associated with any symptom. Anal pathology was highly prevalent, but often asymptomatic. Anal symptoms do not appear to be useful markers of most anal pathology in GBM.
Keywords: anal sex, gay men, prevalence, sexually transmissible infections.
References
[1] Tournu G, Abramowitz L, Couffignal C, Juguet F, Senejoux A, Berger S, et al Prevalence of anal symptoms in general practice: a prospective study. BMC Fam Pract 2017; 18 78| Prevalence of anal symptoms in general practice: a prospective study.Crossref | GoogleScholarGoogle Scholar | 28774265PubMed |
[2] Read TR, Huson KL, Millar JL, Haydon A, Porter IW, Grulich AE, et al Size of anal squamous cell carcinomas at diagnosis: a retrospective case series. Int J STD AIDS 2013; 24 879–82.
| Size of anal squamous cell carcinomas at diagnosis: a retrospective case series.Crossref | GoogleScholarGoogle Scholar | 23970608PubMed |
[3] Manavi K, McMillan A, Young H. The prevalence of rectal chlamydial infection amongst men who have sex with men attending the genitourinary medicine clinic in Edinburgh. Int J STD AIDS 2004; 15 162–4.
| The prevalence of rectal chlamydial infection amongst men who have sex with men attending the genitourinary medicine clinic in Edinburgh.Crossref | GoogleScholarGoogle Scholar | 15038860PubMed |
[4] Charles J, Miller G, Fahridin S. Perianal problems. Aust Fam Physician 2010; 39 365
| 20628672PubMed |
[5] Lister NA, Chaves NJ, Phang CW, Smith A, Fairley CK. Clinical significance of questionnaire-elicited or clinically reported anorectal symptoms for rectal Neisseria gonorrhoeae and Chlamydia trachomatis amongst men who have sex with men. Sex Health 2008; 5 77–82.
| Clinical significance of questionnaire-elicited or clinically reported anorectal symptoms for rectal Neisseria gonorrhoeae and Chlamydia trachomatis amongst men who have sex with men.Crossref | GoogleScholarGoogle Scholar | 18361859PubMed |
[6] Rosa-Cunha I, Cardenas GA, Dickinson G, Metsch LR. Addressing anal health in the HIV primary care setting: a disappointing reality. AIDS Patient Care STDS 2010; 24 533–8.
| Addressing anal health in the HIV primary care setting: a disappointing reality.Crossref | GoogleScholarGoogle Scholar | 20731611PubMed |
[7] Chiu S, Joseph K, Ghosh S, Cornand RM, Schiller D. Reasons for delays in diagnosis of anal cancer and the effect on patient satisfaction. Can Fam Physician 2015; 61 e509–16.
| 26889506PubMed |
[8] Vajdic CM, van Leeuwen MT, Jin F, Prestage G, Medley G, Hillman RJ, et al Anal human papillomavirus genotype diversity and co-infection in a community-based sample of homosexual men. Sex Transm Infect 2009; 85 330–5.
| Anal human papillomavirus genotype diversity and co-infection in a community-based sample of homosexual men.Crossref | GoogleScholarGoogle Scholar | 19342375PubMed |
[9] Goddard SL, Templeton DJ, Petoumenos K, Jin F, Hillman RJ, Law C, et al Association of anal symptoms with anal high grade squamous intraepithelial lesions (HSIL) among men who have sex with men: baseline data from the study of the prevention of anal cancer (SPANC). Cancer Epidemiol 2019; 58 12–16.
| Association of anal symptoms with anal high grade squamous intraepithelial lesions (HSIL) among men who have sex with men: baseline data from the study of the prevention of anal cancer (SPANC).Crossref | GoogleScholarGoogle Scholar | 30439602PubMed |
[10] Abramowitz L, Benabderrahmane D, Baron G, Walker F, Yeni P, Duval X. Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era. Dis Colon Rectum 2009; 52 1130–6.
| Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era.Crossref | GoogleScholarGoogle Scholar | 19581857PubMed |
[11] Coplan PM, Gortmaker S, Hernandez-Avila M, Spiegelman D, Uribe-Zuniga P, Mueller NE. Human immunodeficiency virus infection in Mexico City: rectal bleeding and anal warts as risk factors among men reporting sex with men. Am J Epidemiol 1996; 144 817–27.
| Human immunodeficiency virus infection in Mexico City: rectal bleeding and anal warts as risk factors among men reporting sex with men.Crossref | GoogleScholarGoogle Scholar | 8890660PubMed |
[12] Goddard SL, Poynten IM, Petoumenous K, Jin F, Hillman RJ, Law C, et al Prevalence, incidence and predictors of anal Chlamydia trachomatis, anal Neisseria gonorrhoeae and syphilis among older gay and bisexual men in the longitudinal Study for the Prevention of Anal Cancer (SPANC). Sex Transm Infect 2019; 95 477–83.
| Prevalence, incidence and predictors of anal Chlamydia trachomatis, anal Neisseria gonorrhoeae and syphilis among older gay and bisexual men in the longitudinal Study for the Prevention of Anal Cancer (SPANC).Crossref | GoogleScholarGoogle Scholar | 31018992PubMed |
[13] Machalek DA, Grulich AE, Hillman RJ, Jin F, Templeton DJ, Tabrizi SN, et al The Study of the Prevention of Anal Cancer (SPANC): design and methods of a three-year prospective cohort study. BMC Public Health 2013; 13 946
| The Study of the Prevention of Anal Cancer (SPANC): design and methods of a three-year prospective cohort study.Crossref | GoogleScholarGoogle Scholar | 24107134PubMed |
[14] Peters RP, Verweij SP, Nijsten N, Ouburg S, Mutsaers J, Jansen CL, et al Evaluation of sexual history-based screening of anatomic sites for Chlamydia trachomatis and Neisseria gonorrhoeae infection in men having sex with men in routine practice. BMC Infect Dis 2011; 11 203
| Evaluation of sexual history-based screening of anatomic sites for Chlamydia trachomatis and Neisseria gonorrhoeae infection in men having sex with men in routine practice.Crossref | GoogleScholarGoogle Scholar | 21791061PubMed |
[15] van Liere GA, van Rooijen MS, Hoebe CJ, Heijman T, de Vries HJ, Dukers-Muijrers NH. Prevalence of and factors associated with rectal-only chlamydia and gonorrhoea in women and in men who have sex with men. PLoS One 2015; 10 e0140297
| Prevalence of and factors associated with rectal-only chlamydia and gonorrhoea in women and in men who have sex with men.Crossref | GoogleScholarGoogle Scholar | 26713628PubMed |
[16] Foschi C, Gaspari V, Sgubbi P, Salvo M, D’Antuono A, Marangoni A. Sexually transmitted rectal infections in a cohort of ‘men having sex with men’. J Med Microbiol 2018; 67 1050–7.
| Sexually transmitted rectal infections in a cohort of ‘men having sex with men’.Crossref | GoogleScholarGoogle Scholar | 29927376PubMed |
[17] Ruanpeng D, Chariyalertsak S, Kaewpoowat Q, Supindham T, Settakorn J, Sukpan K, et al Cytological anal squamous intraepithelial lesions associated with anal high-risk human papillomavirus infections among men who have sex with men in northern Thailand. PLoS One 2016; 11 e0156280
| Cytological anal squamous intraepithelial lesions associated with anal high-risk human papillomavirus infections among men who have sex with men in northern Thailand.Crossref | GoogleScholarGoogle Scholar | 27227684PubMed |
[18] Eslick GD, Kalantar JS, Talley NJ. Rectal bleeding: epidemiology, associated risk factors, and health care seeking behaviour: a population-based study. Colorectal Dis 2009; 11 921–6.
| Rectal bleeding: epidemiology, associated risk factors, and health care seeking behaviour: a population-based study.Crossref | GoogleScholarGoogle Scholar | 19175652PubMed |
[19] Gott CM, Rogstad KE, Riley V, Ahmed-Jushuf I. Delay in symptom presentation among a sample of older GUM clinic attenders. Int J STD AIDS 1999; 10 43–6.
| Delay in symptom presentation among a sample of older GUM clinic attenders.Crossref | GoogleScholarGoogle Scholar | 10215129PubMed |
[20] Royal College of Surgeons of England. Commissioning guide: rectal bleeding. 2013. Available online at: https://www.rcseng.ac.uk/library-and-publications/rcs-publications/docs/rectal-bleeding-guide/ [verified 21 October 2020].
[21] Klausner JD, Kohn R, Kent C. Etiology of clinical proctitis among men who have sex with men. Clin Infect Dis 2004; 38 300–2.
| Etiology of clinical proctitis among men who have sex with men.Crossref | GoogleScholarGoogle Scholar | 14699467PubMed |
[22] Kent CK, Chaw JK, Wong W, Liska S, Gibson S, Hubbard G, et al Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis 2005; 41 67–74.
| Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003.Crossref | GoogleScholarGoogle Scholar | 15937765PubMed |
[23] Read PJ, Donovan B. Clinical aspects of adult syphilis. Intern Med J 2012; 42 614–20.
| Clinical aspects of adult syphilis.Crossref | GoogleScholarGoogle Scholar | 22697151PubMed |
[24] Metcalf A. Anorectal disorders: five common causes of pain, itching, and bleeding. Postgrad Med 1995; 98 81–94.
| Anorectal disorders: five common causes of pain, itching, and bleeding.Crossref | GoogleScholarGoogle Scholar | 29224554PubMed |
[25] Gilson R, Mayura N, Sonnex C, Lazaro N, Keirs T. UK national guidelines on the management of anogenital warts 2015. 2015. Available online at: https://www.bashhguidelines.org/media/1075/uk-national-guideline-on-warts-2015-final.pdf [verified 16 March 2020].
[26] Hoentjen F, Rubin DT. Infectious proctitis: when to suspect it is not inflammatory bowel disease. Dig Dis Sci 2012; 57 269–73.
| Infectious proctitis: when to suspect it is not inflammatory bowel disease.Crossref | GoogleScholarGoogle Scholar | 21994137PubMed |
