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Chronic Abdominal Pain and Rectal Bleeding: A Missed Opportunity
The Journal for Nurse Practitioners 15 (2019) e127ee130
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Case Challenge
Chronic Abdominal Pain and Rectal Bleeding: A Missed Opportunity Courtney Pitts, DNP, FNP-BC a b s t r a c t Keywords: abdominal pain human immunodeficiency syndrome men who have sex with men
Abdominal pain and rectal bleeding among men who have sex with men are common complaints treated in primary and urgent care settings. These common primary care complaintsdoften vague and recurrentdrequire a comprehensive and thorough investigation of the patient’s history and lifestyle to ensure an accurate diagnosis and treatment. This case highlights the importance of removing barriers to care from the patient’s and provider’s perspectives to more accurately diagnose and effectively treat common symptoms experienced among men who have sex with men. © 2019 Elsevier Inc. All rights reserved.
Case Study M.J., a 30-year-old man, presents with a chief complaint of abdominal pain and some rectal bleeding for the past several weeks. He was seen in the primary care clinic a few days ago for similar symptoms and was also seen in the emergency department (ED) a week ago. He is following up because he continues to experience symptoms even with pharmacologic and nonpharmacologic recommendations. History of Present Illness M.J., a 30-year-old man, presents to the primary care clinic for a follow-up of a complaint of abdominal pain for several weeks. He initially presented to the ED approximately 1 week ago complaining about a “lump inside rectum with rectal bleeding” for 1 week. During the ED visit, he reports that he was treated with “pain medication” and referred to a gastroenterologist for evaluation. M.J. presented to the primary care clinic 3 days after the ED visit complaining of “stomach pain” that worsens with bowel movement. He stated that he had taken all of the pain medication, which provided minimal relief. He was prescribed a schedule II narcotic, a laxative, and a stool softener. A computed tomography scan of the abdomen was ordered during this appointment. A complete metabolic panel, complete blood count, thyroid stimulating hormone cascade, and lipid panel were ordered as well. Today, he describes the pain as bloating, cramping, and aching. He states that pain is located “all over” his abdomen. The pain is constant and makes it difficult for him to sleep. He rates the pain as a 9 on a scale of 10. He states that the pain intensity increases with defecation. Although this episode has been going on for several weeks, he has experienced symptoms intermittently for the past 2 years. He experiences moderate relief with use of “pain medication.” He denies fever, chills, body aches, nausea, vomiting, https://doi.org/10.1016/j.nurpra.2019.02.019 1555-4155/© 2019 Elsevier Inc. All rights reserved.
difficulty swallowing, or changes in stools. He denies any recent episodes of rectal bleeding. He also denies the presence of penile discharge, penile ulcers, or pain with urination. He reports a personal history of kidney stones, irritable bowel syndrome (IBS), thyroid disease, and foreign travel. M.J.’s medical history includes renal stones, IBS, thyroid disease, obesity, and human immunodeficiency virus (HIV) syndrome. He is currently taking Triumeq (ViiV Healthcare, Research Triangle Park, NC), one 600-50-300-mg tablet by mouth, once daily. He has no known drug allergies. M.J. is single without children. He is sexually active with multiple male partners. He has inconsistent condom use during sexual encounters. He has not been able to be sexually active in the past few weeks due to symptoms. He denies cigarette, alcohol, or illicit drug use. He admits to high school drug use. Family History His mother died of cancer at 37 years old. Her medical history is unknown. Father is living. His medical history is unknown. Physical Examination A review of M.J.’s systems include: Constitutional: Denies fatigue, fever, chills, or weight loss. Head, ears, eyes, nose, and throat: Denies any change in vision, sore throat, or ear pain or drainage. Pulmonary: Denies difficulty breathing at rest or with exertion. Cardiovascular: Denies chest pain, shortness of breath, swelling of extremities. No history of hypertension or hyperlipidemia. Gastrointestinal: Reports abdominal pain with bloating, cramping, and aching. History of rectal bleeding. Last episode of rectal bleeding was 1 week ago. Some painful bowel movements. Denies nausea, vomiting, constipation, or diarrhea. Denies difficulty swallowing. Denies history of hemorrhoids.
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Genitourinary: Denies penile discharge or ulcers. M.J.’s vital signs: blood pressure, 120/83 mm Hg; heart rate, 87 beats/min; respirations, 16 breaths/min; O2 saturation, 95%; oral temperature, 98 F; height, 5 ft 10 in; and weight, 205 lbs. His other physical examination findings are as follows: Constitutional: healthy, well nourished, and well developed. Psychologic: Good judgment, normal mood, and affect. Active and alert. Recent and remote memory normal. Pulmonary: unlabored, clear to auscultation. Cardiovascular: Normal S1 and S2, regular rate and rhythm. Gastrointestinal: No masses or costovertebral angle tenderness. Bowel sounds normal. Positive guarding. Epigastric, right upper quadrant, and right lower quadrant tenderness. Appears distended. Could not palpate due to tenderness of right lower quadrant. Positive inflammation and tenderness of anal canal. No apparent ulcerations or warts. Sphincter tone intact. Fecal blood occult test result positive. The diagnostic and laboratory results from his ED and previous visit are available. Results of complete blood count, lipid panel, comprehensive metabolic panel, and the thyroid stimulating hormone test are within normal limits. Colonoscopy
and esophagogastroduodenoscopy results found no polyps, but several ulcers at the rectum. Abdominal computed tomography was not completed because M.J. did not keep the appointment.
Case Challenge Questions and Answers 1. What differential diagnoses should be considered for M.J. at this time? 2. What diagnostic tests would be helpful to determine a diagnosis? 3. What are the next steps in the management of this patient? 4. Were there potential barriers that possibly influenced M.J.’s diagnosis and management throughout his visits?
If you believe you know the answers to the following questions, then test yourself and refer to page e129 for the answers.
C. Pitts / The Journal for Nurse Practitioners 15 (2019) e127ee130
e129
Case Challenge
Chronic Abdominal Pain and Rectal Bleeding: A Missed Opportunity (continued from page e128) Case Challenge Questions and Answers 1. What differential diagnoses should be considered for M.J. at this time? There are a number of diagnoses to consider. MJ’s clinical presentation of abdominal pain or cramping and bloating mimic the symptoms of IBS. However, the symptoms, physical examination, and results of diagnostic/laboratory testing may lead providers to possibly diagnose M.J. with infectious causes such as Crohn disease, ulcerative colitis, “rectal pain,” hemorrhoids, proctitis, sexually transmitted infections, or rectal cancer. Noninfectious causes may be radiation-associated proctitis/proctopathy, diversion colitis, or ischemia. However, a noninfectious cause is unlikely because M.J. has no history of cancer. M.J.’s anorectal symptoms are consistent with proctitis and anusitis. Complaints of pruritus, pain on defecation, bloody or purulent discharge, and pain on digital rectal examination or anal intercourse are common symptoms of proctitis. There are different types of proctitis. Individuals with chronic proctitis may complain of rectal bleeding, urgency, diarrhea, incontinence, pelvic pain, tenesmus, or a combination of these. Individuals with proctitis related to an inflammatory bowel disease or radiation treatment may present with some of the previously mentioned symptoms. However, diagnostic testing will reveal perianal abscess, fistulae, and fissure. If proctitis is related to a sexually transmitted infection (STI), an individual may present with rectal or perianal ulcers, chancres, condyloma, or inguinal lymphadenopathy. Lymphogranuloma venereum proctitis, caused by Chlamydia, can present asymptomatically clinically. A patient who is symptomatic may experience any or all of anal pain, mucoid or hemorrhagic rectal discharge, tenesmus, constipation, or fever.1 The leading causes of STI-related proctitis include Neisseria gonorrhoeae (30%), C trachomatis (19%), herpes simplex virus (16%), and Treponema pallidum (2%).2,3 More specifically, C trachomatis and N gonorrhoeae are the second and third leading causes of proctitis in men who have sex with men (2%).2,3 Therefore, it is highly likely that M.J. is experiencing proctitis resulting from a sexually transmitted infection. 2. What diagnostic tests would be helpful to determine a diagnosis? With colonoscopy results revealing several rectal ulcers, an unremarkable esophagogastroduodenoscopy, and laboratory results within normal limits, M.J. should be tested for STIs in all
orifices in which sexual penetration occurred. Being that he is also living with HIV and the high rates of primary and secondary syphilis coinfection, it is imperative to include a syphilis serology when testing for the presence of an STI.4 The following tests should be ordered for M.J. based on his personal history:
Syphilis serology Urethral infection of N gonorrhoeae and C trachomatis Rectal infection of N gonorrhoeae and C trachomatis Pharyngeal infection of N gonorrhoeae and C trachomatis Herpes simplex virus-2 infection with type-specific serologic tests
When confirming or ruling out possible differential diagnoses, clinicians may find laboratory results to be within normal limits, with diagnostic tests revealing mucosal nodularities and rectal ulcers. 3. What are the next steps in the management of this patient? Suspicion of an STI as the cause of proctitis should result in STI screening. Confirmation of the causative agent would lend to the appropriate treatment (Table). In addition, a presentation consistent with proctitis, especially in patients with receptive anal intercourse, should result in the initiation of therapy while awaiting laboratory results. Providers should encourage patients to notify their partners so that they can be evaluated for possible treatment. Patients should be discouraged from engaging in sexual intercourse until treatment is completed. During future visits, individuals with a history of risk factors or diagnosis of proctitis related to STI should undergo STI screening at least annually. More frequent screening should be implemented based on each individual’s history and risk factors. Retesting should be performed 3 months after the treatment of any chlamydial or gonococcal infections.2 It is paramount that providers counsel individuals with these risk factors about consistent, safe sex practices. Addressing transmission, risk factors, decision making, and communication surrounding condom use prove beneficial in the prevention and reinfection of STIs related to proctitis.5 4. Were there potential barriers that possibly influenced M.J.’s diagnosis and management throughout his visits? M.J.’s clinical presentation can easily be deemed as “vague” and attributable to his medical history of IBS. In addition, the lack of a
Table Treatment Regimens for Sexually Transmitted Infections of the Rectum Pathogen
Diagnosis
Treatment
Gonorrhea Chlamydia
Gram stain, NAAT, culture LGV: NAAT, immunofluorescence, culture Non-LGV: NAAT, culture NAAT, viral culture VDRL, RPR, Treponemal antibody IgG
Ceftriaxone 250 mg IM or cefixime 400 mg POa LGV: Doxycycline 100 mg PO, 2 times daily for 3 weeks Non-LGV: Doxycycline 100 mg PO, 2 times daily for 1 week Acyclovir 400 mg PO, 3 times daily for 10 days 2.4 million units of Bicillinb IM oncec
HSV-2 Syphilis
HSV-2 ¼ herpes simplex virus-2; IgG, immunoglobulin G; IM ¼ intramuscular; LGV ¼ lymphogranuloma venereum; NAAT ¼ nucleic acid amplification test; PO, by mouth; RPR ¼ rapid plasma reagin/ VDRL ¼ Venereal Disease Research Laboratory. Adapted from Centers and Disease Control and Prevention.2 a Consider treatment of ceftriaxone plus doxycycline for 1 week because there is typically a coinfection of Chlamydia with diagnoses of gonorrhea. b Pfizer Inc, New York, NY. c Frequency changes with exposure of unknown duration.
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C. Pitts / The Journal for Nurse Practitioners 15 (2019) e127ee130
thorough history of his present illness assessment played a critical role in the misdiagnosis of M.J.’s proctitis from the provider’s and patient’s standpoints. It is quite possible that the previous diagnosis of IBS might be erroneous in light of the fact that the clinical presentation of both IBS and proctitis is similar. A nurse practitioner’s prudent approach to care during a visit that involves the disclosure of sensitive information, such as sexual practices, can reduce the likelihood of a missed opportunity for an accurate, timely diagnosis. An increase in knowledge about the common causes of proctitis, especially in men who have sex with men, can reduce office visits, result in appropriate treatment, and improve patient-provider rapport. Conclusion Proctitis is commonly diagnosed in primary and urgent care settings. A thorough history, including sexual history, followed by a thorough examination, will enable the nurse practitioner to differentiate between infectious and noninfectious causes. When evaluating the clinical symptoms of a man who has sex with men, it is important to rule out STIs as a cause, especially in the presence of an HIV infection, to reduce the likelihood of misdiagnosis. It is imperative that the appropriate diagnostic screenings occur during
the clinical visit to ensure that the true cause of proctitis is treated with the appropriate follow-up testing.
References 1. Stoner B, Cohen S. Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment. Clin Infect Dis. 2015;61(S8):S865-S873. 2. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines: Proctitis, Proctocolitis, and Enteritis. https://www. cdc.gov/std/tg2015/proctitis.htm. 2015. Accessed January 15, 2019. 3. Lee K, Kim J, Shin D, et al. Chlamydial proctitis in a young man who has sex with men: misdiagnosed as inflammatory bowel disease. Chonnam Med J. 2015;51: 139-141. 4. Workowski K, Bolan G; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. 5. O’Connor E, Lin J, Burda B, Henderson J, Walsh E, Whitlock E. Behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections: a systematic review for the U.S. Preventative Services Task Force. Ann Intern Med. 2014;161:874-883.
Courtney Pitts, DNP, MPH, FNP-BC, is an assistant professor at Vanderbilt University School of Nursing, Nashville, TN, and can be contacted at courtney.j.pitts@vanderbilt. edu. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Case Challenge
Chronic Abdominal Pain and Rectal Bleeding: A Missed Opportunity Courtney Pitts, DNP, FNP-BC a b s t r a c t Keywords: abdominal pain human immunodeficiency syndrome men who have sex with men
Abdominal pain and rectal bleeding among men who have sex with men are common complaints treated in primary and urgent care settings. These common primary care complaintsdoften vague and recurrentdrequire a comprehensive and thorough investigation of the patient’s history and lifestyle to ensure an accurate diagnosis and treatment. This case highlights the importance of removing barriers to care from the patient’s and provider’s perspectives to more accurately diagnose and effectively treat common symptoms experienced among men who have sex with men. © 2019 Elsevier Inc. All rights reserved.
Case Study M.J., a 30-year-old man, presents with a chief complaint of abdominal pain and some rectal bleeding for the past several weeks. He was seen in the primary care clinic a few days ago for similar symptoms and was also seen in the emergency department (ED) a week ago. He is following up because he continues to experience symptoms even with pharmacologic and nonpharmacologic recommendations. History of Present Illness M.J., a 30-year-old man, presents to the primary care clinic for a follow-up of a complaint of abdominal pain for several weeks. He initially presented to the ED approximately 1 week ago complaining about a “lump inside rectum with rectal bleeding” for 1 week. During the ED visit, he reports that he was treated with “pain medication” and referred to a gastroenterologist for evaluation. M.J. presented to the primary care clinic 3 days after the ED visit complaining of “stomach pain” that worsens with bowel movement. He stated that he had taken all of the pain medication, which provided minimal relief. He was prescribed a schedule II narcotic, a laxative, and a stool softener. A computed tomography scan of the abdomen was ordered during this appointment. A complete metabolic panel, complete blood count, thyroid stimulating hormone cascade, and lipid panel were ordered as well. Today, he describes the pain as bloating, cramping, and aching. He states that pain is located “all over” his abdomen. The pain is constant and makes it difficult for him to sleep. He rates the pain as a 9 on a scale of 10. He states that the pain intensity increases with defecation. Although this episode has been going on for several weeks, he has experienced symptoms intermittently for the past 2 years. He experiences moderate relief with use of “pain medication.” He denies fever, chills, body aches, nausea, vomiting, https://doi.org/10.1016/j.nurpra.2019.02.019 1555-4155/© 2019 Elsevier Inc. All rights reserved.
difficulty swallowing, or changes in stools. He denies any recent episodes of rectal bleeding. He also denies the presence of penile discharge, penile ulcers, or pain with urination. He reports a personal history of kidney stones, irritable bowel syndrome (IBS), thyroid disease, and foreign travel. M.J.’s medical history includes renal stones, IBS, thyroid disease, obesity, and human immunodeficiency virus (HIV) syndrome. He is currently taking Triumeq (ViiV Healthcare, Research Triangle Park, NC), one 600-50-300-mg tablet by mouth, once daily. He has no known drug allergies. M.J. is single without children. He is sexually active with multiple male partners. He has inconsistent condom use during sexual encounters. He has not been able to be sexually active in the past few weeks due to symptoms. He denies cigarette, alcohol, or illicit drug use. He admits to high school drug use. Family History His mother died of cancer at 37 years old. Her medical history is unknown. Father is living. His medical history is unknown. Physical Examination A review of M.J.’s systems include: Constitutional: Denies fatigue, fever, chills, or weight loss. Head, ears, eyes, nose, and throat: Denies any change in vision, sore throat, or ear pain or drainage. Pulmonary: Denies difficulty breathing at rest or with exertion. Cardiovascular: Denies chest pain, shortness of breath, swelling of extremities. No history of hypertension or hyperlipidemia. Gastrointestinal: Reports abdominal pain with bloating, cramping, and aching. History of rectal bleeding. Last episode of rectal bleeding was 1 week ago. Some painful bowel movements. Denies nausea, vomiting, constipation, or diarrhea. Denies difficulty swallowing. Denies history of hemorrhoids.
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C. Pitts / The Journal for Nurse Practitioners 15 (2019) e127ee130
Genitourinary: Denies penile discharge or ulcers. M.J.’s vital signs: blood pressure, 120/83 mm Hg; heart rate, 87 beats/min; respirations, 16 breaths/min; O2 saturation, 95%; oral temperature, 98 F; height, 5 ft 10 in; and weight, 205 lbs. His other physical examination findings are as follows: Constitutional: healthy, well nourished, and well developed. Psychologic: Good judgment, normal mood, and affect. Active and alert. Recent and remote memory normal. Pulmonary: unlabored, clear to auscultation. Cardiovascular: Normal S1 and S2, regular rate and rhythm. Gastrointestinal: No masses or costovertebral angle tenderness. Bowel sounds normal. Positive guarding. Epigastric, right upper quadrant, and right lower quadrant tenderness. Appears distended. Could not palpate due to tenderness of right lower quadrant. Positive inflammation and tenderness of anal canal. No apparent ulcerations or warts. Sphincter tone intact. Fecal blood occult test result positive. The diagnostic and laboratory results from his ED and previous visit are available. Results of complete blood count, lipid panel, comprehensive metabolic panel, and the thyroid stimulating hormone test are within normal limits. Colonoscopy
and esophagogastroduodenoscopy results found no polyps, but several ulcers at the rectum. Abdominal computed tomography was not completed because M.J. did not keep the appointment.
Case Challenge Questions and Answers 1. What differential diagnoses should be considered for M.J. at this time? 2. What diagnostic tests would be helpful to determine a diagnosis? 3. What are the next steps in the management of this patient? 4. Were there potential barriers that possibly influenced M.J.’s diagnosis and management throughout his visits?
If you believe you know the answers to the following questions, then test yourself and refer to page e129 for the answers.
C. Pitts / The Journal for Nurse Practitioners 15 (2019) e127ee130
e129
Case Challenge
Chronic Abdominal Pain and Rectal Bleeding: A Missed Opportunity (continued from page e128) Case Challenge Questions and Answers 1. What differential diagnoses should be considered for M.J. at this time? There are a number of diagnoses to consider. MJ’s clinical presentation of abdominal pain or cramping and bloating mimic the symptoms of IBS. However, the symptoms, physical examination, and results of diagnostic/laboratory testing may lead providers to possibly diagnose M.J. with infectious causes such as Crohn disease, ulcerative colitis, “rectal pain,” hemorrhoids, proctitis, sexually transmitted infections, or rectal cancer. Noninfectious causes may be radiation-associated proctitis/proctopathy, diversion colitis, or ischemia. However, a noninfectious cause is unlikely because M.J. has no history of cancer. M.J.’s anorectal symptoms are consistent with proctitis and anusitis. Complaints of pruritus, pain on defecation, bloody or purulent discharge, and pain on digital rectal examination or anal intercourse are common symptoms of proctitis. There are different types of proctitis. Individuals with chronic proctitis may complain of rectal bleeding, urgency, diarrhea, incontinence, pelvic pain, tenesmus, or a combination of these. Individuals with proctitis related to an inflammatory bowel disease or radiation treatment may present with some of the previously mentioned symptoms. However, diagnostic testing will reveal perianal abscess, fistulae, and fissure. If proctitis is related to a sexually transmitted infection (STI), an individual may present with rectal or perianal ulcers, chancres, condyloma, or inguinal lymphadenopathy. Lymphogranuloma venereum proctitis, caused by Chlamydia, can present asymptomatically clinically. A patient who is symptomatic may experience any or all of anal pain, mucoid or hemorrhagic rectal discharge, tenesmus, constipation, or fever.1 The leading causes of STI-related proctitis include Neisseria gonorrhoeae (30%), C trachomatis (19%), herpes simplex virus (16%), and Treponema pallidum (2%).2,3 More specifically, C trachomatis and N gonorrhoeae are the second and third leading causes of proctitis in men who have sex with men (2%).2,3 Therefore, it is highly likely that M.J. is experiencing proctitis resulting from a sexually transmitted infection. 2. What diagnostic tests would be helpful to determine a diagnosis? With colonoscopy results revealing several rectal ulcers, an unremarkable esophagogastroduodenoscopy, and laboratory results within normal limits, M.J. should be tested for STIs in all
orifices in which sexual penetration occurred. Being that he is also living with HIV and the high rates of primary and secondary syphilis coinfection, it is imperative to include a syphilis serology when testing for the presence of an STI.4 The following tests should be ordered for M.J. based on his personal history:
Syphilis serology Urethral infection of N gonorrhoeae and C trachomatis Rectal infection of N gonorrhoeae and C trachomatis Pharyngeal infection of N gonorrhoeae and C trachomatis Herpes simplex virus-2 infection with type-specific serologic tests
When confirming or ruling out possible differential diagnoses, clinicians may find laboratory results to be within normal limits, with diagnostic tests revealing mucosal nodularities and rectal ulcers. 3. What are the next steps in the management of this patient? Suspicion of an STI as the cause of proctitis should result in STI screening. Confirmation of the causative agent would lend to the appropriate treatment (Table). In addition, a presentation consistent with proctitis, especially in patients with receptive anal intercourse, should result in the initiation of therapy while awaiting laboratory results. Providers should encourage patients to notify their partners so that they can be evaluated for possible treatment. Patients should be discouraged from engaging in sexual intercourse until treatment is completed. During future visits, individuals with a history of risk factors or diagnosis of proctitis related to STI should undergo STI screening at least annually. More frequent screening should be implemented based on each individual’s history and risk factors. Retesting should be performed 3 months after the treatment of any chlamydial or gonococcal infections.2 It is paramount that providers counsel individuals with these risk factors about consistent, safe sex practices. Addressing transmission, risk factors, decision making, and communication surrounding condom use prove beneficial in the prevention and reinfection of STIs related to proctitis.5 4. Were there potential barriers that possibly influenced M.J.’s diagnosis and management throughout his visits? M.J.’s clinical presentation can easily be deemed as “vague” and attributable to his medical history of IBS. In addition, the lack of a
Table Treatment Regimens for Sexually Transmitted Infections of the Rectum Pathogen
Diagnosis
Treatment
Gonorrhea Chlamydia
Gram stain, NAAT, culture LGV: NAAT, immunofluorescence, culture Non-LGV: NAAT, culture NAAT, viral culture VDRL, RPR, Treponemal antibody IgG
Ceftriaxone 250 mg IM or cefixime 400 mg POa LGV: Doxycycline 100 mg PO, 2 times daily for 3 weeks Non-LGV: Doxycycline 100 mg PO, 2 times daily for 1 week Acyclovir 400 mg PO, 3 times daily for 10 days 2.4 million units of Bicillinb IM oncec
HSV-2 Syphilis
HSV-2 ¼ herpes simplex virus-2; IgG, immunoglobulin G; IM ¼ intramuscular; LGV ¼ lymphogranuloma venereum; NAAT ¼ nucleic acid amplification test; PO, by mouth; RPR ¼ rapid plasma reagin/ VDRL ¼ Venereal Disease Research Laboratory. Adapted from Centers and Disease Control and Prevention.2 a Consider treatment of ceftriaxone plus doxycycline for 1 week because there is typically a coinfection of Chlamydia with diagnoses of gonorrhea. b Pfizer Inc, New York, NY. c Frequency changes with exposure of unknown duration.
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C. Pitts / The Journal for Nurse Practitioners 15 (2019) e127ee130
thorough history of his present illness assessment played a critical role in the misdiagnosis of M.J.’s proctitis from the provider’s and patient’s standpoints. It is quite possible that the previous diagnosis of IBS might be erroneous in light of the fact that the clinical presentation of both IBS and proctitis is similar. A nurse practitioner’s prudent approach to care during a visit that involves the disclosure of sensitive information, such as sexual practices, can reduce the likelihood of a missed opportunity for an accurate, timely diagnosis. An increase in knowledge about the common causes of proctitis, especially in men who have sex with men, can reduce office visits, result in appropriate treatment, and improve patient-provider rapport. Conclusion Proctitis is commonly diagnosed in primary and urgent care settings. A thorough history, including sexual history, followed by a thorough examination, will enable the nurse practitioner to differentiate between infectious and noninfectious causes. When evaluating the clinical symptoms of a man who has sex with men, it is important to rule out STIs as a cause, especially in the presence of an HIV infection, to reduce the likelihood of misdiagnosis. It is imperative that the appropriate diagnostic screenings occur during
the clinical visit to ensure that the true cause of proctitis is treated with the appropriate follow-up testing.
References 1. Stoner B, Cohen S. Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment. Clin Infect Dis. 2015;61(S8):S865-S873. 2. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines: Proctitis, Proctocolitis, and Enteritis. https://www. cdc.gov/std/tg2015/proctitis.htm. 2015. Accessed January 15, 2019. 3. Lee K, Kim J, Shin D, et al. Chlamydial proctitis in a young man who has sex with men: misdiagnosed as inflammatory bowel disease. Chonnam Med J. 2015;51: 139-141. 4. Workowski K, Bolan G; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. 5. O’Connor E, Lin J, Burda B, Henderson J, Walsh E, Whitlock E. Behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections: a systematic review for the U.S. Preventative Services Task Force. Ann Intern Med. 2014;161:874-883.
Courtney Pitts, DNP, MPH, FNP-BC, is an assistant professor at Vanderbilt University School of Nursing, Nashville, TN, and can be contacted at courtney.j.pitts@vanderbilt. edu. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.