Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Evaluation of anorectal symptoms in men who have sex with men

C Mel Wilcox, MD
Section Editor
Joann G Elmore, MD, MPH
Deputy Editor
Howard Libman, MD, FACP


Anorectal symptoms in men who have sex with men (MSM) may be caused by conditions related to infections for which they are at increased risk (eg, proctitis, perianal abscess/anal fistula, anal warts/dysplasia, human papillomavirus [HPV]-associated anal cancer) or conditions seen in the general population (eg, anal fissure, hemorrhoids, pruritus ani) [1-5].

The evaluation of anorectal symptoms in MSM will be addressed in this topic. The management of common anal problems in the general patient population, with the exception of proctitis, which is covered here, are discussed separately. (See "Perianal and perirectal abscess", section on 'Management' and "Anorectal fistula: Clinical manifestations, diagnosis, and management principles" and "Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in men" and "Clinical features, staging, and treatment of anal cancer" and "Anal fissure: Medical management" and "Anal fissure: Surgical management" and "Home and office treatment of symptomatic hemorrhoids" and "Surgical treatment of hemorrhoidal disease" and "Approach to the patient with anal pruritus", section on 'Management'.)


The anal canal, which is surrounded by internal (involuntary) and external (voluntary) sphincter muscles, extends 2.5 to 3.5 cm to the anal verge (visible lower edge of sphincter) inferiorly. In the mid-point of the anal canal is the dentate line, which is the demarcation between columnar epithelium superiorly and squamous epithelium inferiorly (figure 1). Along the dentate line lie crypts, which have small glands at their base. The squamous epithelium between the dentate line and anal verge is called “anoderm,” which is similar to normal skin but highly sensitive, and the squamous epithelium outside the anal verge is the perianal skin.


General approach — The cause of anorectal symptoms in men who have sex with men (MSM) is often suggested by history and physical examination findings (table 1). Patients should be evaluated by obtaining a detailed history, performing an external rectal exam for visible abnormalities (eg, anal warts, hemorrhoids) and performing a digital rectal exam for palpable abnormalities (eg, perianal abscess, rectal mass). In addition, anoscopy is recommended for patients with rectal pain, bleeding, and/or bloody or purulent discharge and in patients with a palpable abnormality on digital rectal exam (See 'History' below and 'Physical examination' below and 'Anoscopy' below.)

If digital rectal exam reveals a palpable abnormality that cannot be visualized on anoscopy, the patient should be referred for transrectal ultrasound or pelvic magnetic resonance imaging (MRI) scan (with and without contrast) to determine if the finding represents a cystic or solid lesion. The former would be suggestive of a perianal abscess, while the latter would raise concern for anal cancer.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Sep 28, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hoentjen F, Rubin DT. Infectious proctitis: when to suspect it is not inflammatory bowel disease. Dig Dis Sci 2012; 57:269.
  2. Singhrao T, Higham E, French P. Lymphogranuloma venereum presenting as perianal ulceration: an emerging clinical presentation? Sex Transm Infect 2011; 87:123.
  3. Salit IE, Lytwyn A, Raboud J, et al. The role of cytology (Pap tests) and human papillomavirus testing in anal cancer screening. AIDS 2010; 24:1307.
  4. Hamadani A, Haigh PI, Liu IL, Abbas MA. Who is at risk for developing chronic anal fistula or recurrent anal sepsis after initial perianal abscess? Dis Colon Rectum 2009; 52:217.
  5. Barrett WL, Callahan TD, Orkin BA. Perianal manifestations of human immunodeficiency virus infection: experience with 260 patients. Dis Colon Rectum 1998; 41:606.
  6. Klein EJ, Fisher LS, Chow AW, Guze LB. Anorectal gonococcal infection. Ann Intern Med 1977; 86:340.
  7. Singh R, Nime F, Mittelman A. Malignant epithelial tumors of the anal canal. Cancer 1981; 48:411.
  8. Schneider TC, Schulte WJ. Management of carcinoma of anal canal. Surgery 1981; 90:729.
  9. Schraut WH, Wang CH, Dawson PJ, Block GE. Depth of invasion, location, and size of cancer of the anus dictate operative treatment. Cancer 1983; 51:1291.
  10. Workowski K, Bolan GA. Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015. MMWR Morb Mortal Wkly Rep 2015; 3.
  11. Cranston RD, Hart SD, Gornbein JA, et al. The prevalence, and predictive value, of abnormal anal cytology to diagnose anal dysplasia in a population of HIV-positive men who have sex with men. Int J STD AIDS 2007; 18:77.
  12. Mayer KH. Sexually transmitted diseases in men who have sex with men. Clin Infect Dis 2011; 53 Suppl 3:S79.
  13. Fox PA. Human papillomavirus and anal intraepithelial neoplasia. Curr Opin Infect Dis 2006; 19:62.
  14. Lee PK, Wilkins KB. Condyloma and other infections including human immunodeficiency virus. Surg Clin North Am 2010; 90:99.
  15. Machalek DA, Poynten M, Jin F, et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol 2012; 13:487.
  16. Foxx-Orenstein AE, Umar SB, Crowell MD. Common anorectal disorders. Gastroenterol Hepatol (N Y) 2014; 10:294.
  17. McMillan A, Young H. Clinical correlates of rectal gonococcal and chlamydial infections. Int J STD AIDS 2006; 17:387.
  18. Nieuwenhuis RF, Ossewaarde JM, Götz HM, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clin Infect Dis 2004; 39:996.
  19. White JA. Manifestations and management of lymphogranuloma venereum. Curr Opin Infect Dis 2009; 22:57.
  20. Quinn TC, Stamm WE, Goodell SE, et al. The polymicrobial origin of intestinal infections in homosexual men. N Engl J Med 1983; 309:576.
  21. Klausner JD, Kohn R, Kent C. Etiology of clinical proctitis among men who have sex with men. Clin Infect Dis 2004; 38:300.
  22. de Vries HJ, Zingoni A, White JA, et al. 2013 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. Int J STD AIDS 2014; 25:465.
  23. Simard EP, Pfeiffer RM, Engels EA. Cumulative incidence of cancer among individuals with acquired immunodeficiency syndrome in the United States. Cancer 2011; 117:1089.
  24. Shiels MS, Pfeiffer RM, Engels EA. Age at cancer diagnosis among persons with AIDS in the United States. Ann Intern Med 2010; 153:452.