Urethritis Chlamydiosis, Proctitis Chlamydiosis, and Anal

Condyloma Acuminata in Versatile

Icha Rachmawati Kusmayadi, Syawalika Ulya Isneny, Pati Aji Achdiat,

Rasmia Rowawi

Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital,

Bandung 40161 Indonesia

Keywords: chlamydiosis, urethritis, proctitis, versatile

Abstract: Versatile is a sexual role as both insertive and receptive in men who have sex with men. Versatiles are prone

to be infected to transmit sexual transmitted infections (STIs). On versatiles, we can found concomitant

STIs such as urethritis and rectal condyloma acuminata. A case of chlamydiosis urethritis, proctitis

chlamydiosis, and condyloma acuminata in 24-year old male was reported to unveil multiple STIs in genital

and anal on versatile. Physical examination showed no urethral discharge but solitary vegetative skin

colored tumor with verrucose surface on perianal. Gram staining from urethral meatus displayed 5-6

PMN/high power field (hpf) and 1-4 PMN/hpf from rectum, polymerase chain reaction (PCR) from urethra

and rectum unveiled positive result for Chlamydia trachomatis, and human papilloma virus (HPV) DNA

genotyping examination revealed type 11 HPV. Varying types genital and anal of STIs could be found on

versatiles, thorough examination should be done. High transmission in versatile can become our concern,

both genital and anal examinations should always be performed simultaneously.

1 INTRODUCTION

The increasing number of sexually transmitted

infections (STIs) has increased since 2004, allegedly

due to the increasing number of men who had sex

with men (MSM) (Mayer, 2011). In MSM, there are

sexual role such as top, bottom and versatile

(Peinado et al., 2014). Based on research in New

York in 2013, it is known that there are 63% of

versatile MSM (Tieu et al., 2013). STIs in MSM

may manifest clinically in the form of urethritis,

proctitis, and anogenital warts (Stam, 2008). The

occurrence of urethritis chlamydiosis, proctitis

chlamydiosis, and anogenital warts simultaneously

in one MSM have not been reported. Nevertheless,

in a study in Stockholm, there were 430 MSM with

17 cases (16%) of whom experienced perianal CA

and chlamydiosis at the same time (Bratt et al.,

2009). In a San Francisco study, it was found that

from 452 MSM, there were 28 (6.2%) cases of

whom had chlamydia urethritis with chlamydia

proctitis compared to those who only had infection

in one site (Kent et al., 2003).

2 CASE

A 24 year-old-male, a college student, unmarried,

came with chieft complaint of skin colored nodule

around the anus that feels itch. Patient is an MSM,

unmarried, coitarche with a boyfriend three years

ago. Risk factors in patients are having a same sex

sexual partner, multiple, sex in anus-genital manner,

as top and bottom, without condom. On

venereological examination, there was not urethral

discharge, but were perianal vegetation, solitary

lesion, irregular shape, size of 4x3x2 cm, clear

border, raised, dry, in the form of a tumor with a

skin colored verrucous surface (Fig. 1A). Anoscopic

examination found erythema rectal wall, no papules,

vesicles, ulcers or erosions, no discharge (Fig. 1B).

Kusmayadi, I., Isneny, S., Achdiat, P. and Rowawi, R.

Urethritis Chlamydiosis, Proctitis Chlamydiosis, and Anal Condyloma Acuminata in Versatile.

DOI: 10.5220/0008159204370441

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 437-441

ISBN: 978-989-758-494-7

437

Gram stain smear examination from external

urethral meatus revealed epithelial cells in 1-2 /hpf,

PMN in 5-6 /hpf, no Gram negative bacteria, intra

and extracellular (Fig. 2A). Result of Gram stain

smear examination from rectal discharge found

epithelial cells in 3-4 /hpf, PMN cell in 1-4 /hpf, no

Gram negative bacteria, intra and extracellular (Fig.

2B). PCR on urethral and rectal positive Chlamydial

infection, HIV test negative and DNA genotyping

HPV found HPV type 11. Patients was treated with

1 gram of single doses of azithromycin followed by

doxycycline 100 mg twice daily for seven days

because infection was still present. Condyloma

acuminata therapy performed by electrocautery.

therapy gives effective results, with no infection

found and no relapse of the condyloma acuminata

Figure 1. A. Condyloma accuminata on perianal; B. Anoscopic examination found erythema rectal wall; C. Perianal region

2 weeks after electrocautery; D. Anoscopic examination after 2 weeks therapy, there is no erythema rectal wall.

Figure 2. A. Gram stain smear examination from external urethral meatus revealed PMN cell; B. Gram stain smear

examination from rectal discharge found PMN cell.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

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3 DISCUSSION

Based on a study in San Francisco in 2004, STIs in

MSM are increasing (APCOM, 2008). In an

Indonesian epidemiological study in 2012, it is

estimated that there are about three million MSM in

which 60,000-80,000 of them are in Jakarta

(Anonim, 2017). Based on research in the United

States in 2011 on 21,000 MSM aged 18-24 years, it

was found that 74% of them did orogenital sexual

intercourse, 42% were anal receptive, and 30% were

anal insertive (Bratt et al., 2009). Based on these

studies, it is known that the transmission of STIs in

MSM can be an infection of the mouth, genitals, and

anus. The incidence of urethritis, proctitis, and

anogenital warts in STIs are generally transmitted

through anogenital sexual intercourse, especially on

versatile (Tieu et al., 2013). Versatile is a pattern of

sexual behavior in an MSM that acts as both

insertive and receptive (Peinado et al., 2014). In a

Dominican Republic study in 2013, it was found that

out of 100 MSM, 39 of them were versatile, of

which 22 (56%) of them had STIs, while those who

were not versatile only 19 (31%) out of a total of 61

(Brito et al., 2015). In another study, in New York in

2013, it was found that 48% versatile did not use

condom while doing sex, compared to 31.2% of

insertive sexual partners, and 19.9% had receptive

sexual intercourse without using condom (Tieu et

al., 2013). At a research in Peru in 2007, the

versatile’s occupation observed in the study is

known to be mostly an employee and only 10%

versatile are commercial sex workers (CSWs).

Characteristics of sexual behavior as versatile are

more often found in whom with higher education

(Peinado et al., 2014). The incidence of urethritis

chlamydiosis, proctitis chlamydiosis, and condyloma

acuminata of the anus occurring simultaneously in

one MSM have not been reported. Nevertheless,

based on research in Stockholm there were 430

MSM with 17 cases (16%) with rectal condyloma

acuminata and chlamydiosis occurring

simultaneously (Bratt et al., 2009). In another study,

reported from 452 MSM, there were 28 patients with

chlamydia urethritis and chlamydia proctitis

occurred simultaneously (Kent et al., 2005). Factors

that increase the risk of multiple STIs in this case

report are versatile MSM, 24 years of age, rarely use

of condom, high level of education (undergraduate

student), and history of multiple partner.

The most common causes of urethritis in MSM

are N. gonorrhoeae and C. trachomatis. Clinical

manifestation of urethritis chlamydiosis is generally

asymptomatic in about 90% (Rompalo and Quinn,

2008). Clinical manifestations may be in the form of

urethral discharge with a clear to murky mucus,

frequently in the morning/morning drops, or in the

form of spotting inside the underwear and may

accompanied with dysuria, and nocturia. Diagnosis

of urethritis is done to determine the cause of

urethritis. The easiest examination is by direct

examination. In direct microscopic examination of

urethritis chlamydiosis can be found PMN > 5/hpf.

Adjunct examination for the diagnosis of urethritis

are confirmed by polymerase chain reaction (PCR)

examination against Chlamydial DNA. Sensitivity of

PCR examination to detect urethritis is 96% and the

specificity is ≥ 99% (Takahashi et al., 2008).

Proctitis can be distinguished into ulcerative and

non-ulcerative. Non-ulcerative proctitis in MSM can

be caused by N. gonorrhoeae and C. trachomatis.

Clinical manifestations of chlamydia proctitis are

generally asymptomatic. In one study, it was found

that 91% of proctitis patients did not give any

symptoms. In symptomatic proctitis, common

symptoms found were a frequent need to defecate

(Rompalo and Quinn, 2008). Adjunct examination

on proctitis include anuscopic examination to

evaluate the presence of ulcer, inflammation,

discharge, or bleeding on the anorectal mucosa.

Based on several studies it is known that diagnosis

of proctitis can be established when PMN cells are

obtained ≥1/hpf. Adjunct examination for the

diagnosis of urethritis and proctitis chlamydiosis is

established through the examination of PCR. On

proctitis chlamydiosis PCR, the sensitivity is 92%

while the specificity is 99%. In this patient, no

symptoms of urethritis or proctitis were found. The

result of adjunct examination in this case was PMN

5-6/hpf from urethral smear and 3-4/hpf from rectal

smear, and PCR examination result on both showed

positive Chlamydia (Rompalo and Quinn, 2008;

Takahashi et al., 2008).

According to the National Guidelines for STI

Treatment in 2015, first-line treatment options for

urethritis chlamydiosis are a single dose of one gram

azithromycin per oral or doxycycline 2x100 mg/day

per oral for seven days (Takahashi et al., 2008).

First-line and second-line treatment options in

chlamydia proctitis are similar to chlamydia

urethritis. Follow-up of urethritis and proctitis are

always performed and when infection is present,

treatment may be replaced (Rompalo and Quinn,

2008). Based on a 2008 study in Japan, it is known

that in the treatment of urethritis chlamydiosis, the

cure rate of patients treated with azithromycin was

86% (Takahashi et al., 2008). In a study at

Birmingham in 2004, the cure rate of patients with

Urethritis Chlamydiosis, Proctitis Chlamydiosis, and Anal Condyloma Acuminata in Versatile

439

chlamydia proctitis treated with azithromycin was

97.5% (Habib and Fernando, 2004). Single dose of

one gram Azithromycin was administered to the

patient as an initial therapy, at the time of control on

one week later, PMN are still present as much as >

30 /hpf in the urethra and 2 /hpf in rectal, so that the

patient were given 100 mg doxycycline therapy

twice per day for seven days and gave good results.

Based on England study in 2013 it was found that

doxycycline administration had a failure rate of <

5% compared to azithromycin. Antibiotic resistance

testing of azithromycin was not done because of lack

of facility availability. Patient experiences

improvement on the observation day 16 in the form

of no PMN cells found on the Gram smears

examination in the urethra and rectal.

Anogenital type CA warts in the form of

exophytic lesion, multiple, flat or raised, skin

colored, brown or white. Site of predilection of CA

wart are on the external or internal genitalia,

perianal, anal canal, perineum, mons pubis, and

groin.

Most of CA wart patients do not complain of

skin disorders, although symptoms may include

itching, burning sensation, or bleeding (Lacey et al.,

2013). The diagnosis of anogenital warts can

generally be established based on anamnesis and

physical examination. One of the adjunct

examination for anogenital warts is genotyping

examination of HPV DNA (KalGen



). This

examination aims to determine the type of HPV

(Anonim, 2012). The diagnosis of CA type of

anogenital warts in this patient was confirmed based

on anamnesis and physical examination of a skin-

colored tumor with uneven verrucous surface, itchy,

neither pain nor bleed easily, perianal, supported by

the result of KalGen



examination which shows the

HPV DNA type 11.

The choice of treatment for anogenital warts

should pay attention to various factor such as:

patient’s choice, availability of treatment, and

experience of the health provider. Various treatment

options can be used for the treatment of warts

anogenital, divided into: the treatment applied by the

health provider (provider-administered modalities),

such as cryotherapy, surgery, electrocautery,

trichloroacetic acid (TCA) and CO

lasers.

Treatments that can be applied by the patient

(patient-applied modalities), such as podofilotoxins,

sinecatechin, and imiquimod. The choice of

treatment using surgery such as electrosurgery

performed when the planned visit will be in one

time, patient’s choice, and the size of the wart is

large. Based on a study, it is known that the

clearance rate of the electrosurgery use on the

anogenital warts is 95-100% with a recurrence rate

of 22% (Patel et al., 2013). In this patient, the

electrosurgery treatment is choosen based on

patient’s choice who want to quickly removed the

wart.

4 CONCLUSION

Varying types genital and anal of STIs could be

found on versatiles such as urethritis, proctitis,

and/or genital warts, thorough examination should

be done. High transmission in versatile can become

our concern, appropiate treatment shoud provide an

effective result.

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