Herpetic proctitis

[BenjiAJ]

Hi Dr Hunter,

I'm a straight man who contracted herpes from a protected encounter with a prostitute in July of 05.

The first outbreak was on the scrotal area and since then I've had outbreaks typically in the perianal area and very close to - in and around - the anus. It is most unusual but I have never had an outbreak on any part of my penis.

The problem is that three weeks back I appeared to come down with a bout of herpes proctitis. I was constipated, feeling a lot of pain around the anus, and was passing out tiny quantities of stool which were covered with blood and mucus.

The big concern I have is this: I've read that it is rather unusual for herpes to reactivate as proctitis except in people who are immunocompromised.

However, in one of your posts you suggested that even people who don't engage in anal sex can get anal herpes - that a significant minority of straight men do still get it - despite the fact that they have never engaged in anal sex.

Furthermore, in another of your posts, you stated:

"Some cases of rectal or anal herpes may have episodic proctitis as the main manifestation of recurrent herpes, but it probably is rare; I have never seen such a case.  Most likely this is even less common with HSV-1 than HSV-2."  

My own case is different from the possibility you are envisaging, because I have only just had one bout of proctitis (the recent one).

I suppose that between the possibility of proctitis recurring consistently as a manifestation of a herpes recurrence and the possibility of such a recurrence just taking place only once, the latter possibility would be likelier than the former one.

What do you think could be going on with me? Underwent colonoscopy given the all-clear, and my symptoms are improving, though I still have difficulty in passing out gas through the anus and stool. Is there reason for me to think that I am immunocompromised in the circumstances?

Ben

[H. Hunter Handsfield, M.D.]

Welcome to the STD forum.

Straight to the key question in the closing paragraph ("What do you think could be going on with me?"):  I'm somewhat skeptical that herpes explains all that you describe.  This depends on information you don't mention.  How was the initial diagnosis made?  Culture of the virus?  Blood test?  Or just doctor's judgment?  And same questions for subsequent recurrent outbreaks and for the recept proctitis episode.  There are many causes of acute proctitis, and if HSV was not identified in your rectum by culture or DNA testing (i.e., PCR test), probably something else was going on.

When a disease or syndrome of any kind -- not only in the STD field -- has a highly atypical clinical course, it most often turns out the diagnosis is wrong, or that more than one problem is present.  In addition to the rarity of proctitis as a manifestation of recurrent herpes, it sounds like your other recurrent outbreaks might have been atypical.  Almost all recurrent outbreaks of herpes -- either oral or genital/anal -- appear in more or less the same spot each time, give or take an inch; but your description seems to imply they were more variable in location than that.  And on top of a very atypical clinical course, you describe highly atypical acquisition of the initial infection.

So please return with some of these details about both the original diagnosis, diagnosis of your recurrent outbreaks over time, and about the proctitis -- then I would be happy to make further judgments about what is "going on".

Regards--  HHH, MD

[H. Hunter Handsfield, M.D.]

With the addtional information, please include the virus type (HSV-1 or 2) iand the evidence for it.  If some of the evidence includes blood tests, provide as much detail as you can about the exact (numerical) test results.

[BenjiAJ]

Thanks.

The doctor's judgment was used to make the initial diagnosis, but I'm sure it was right because I saw a bunch of grouped vesicles sitting on an erythematous base on my left scrotum. They ulcerated subsequently and then all hell broke loose in the form of ulcerations appearing in the perianal area. This was the primary episode.

Recurrent episodes - the ones involving the perianal and anal area in my case but never the penis and scrotum - were characterized by sharp pinpricklike burning and stinging sensations in these areas. At times, red, very thin, fissures could be seen. I believe that in many of the recurrent episodes the sensations I have described - and in some cases the thin small fissures - were present in or were originating from somewhere slightly inside the anus. I can't say for how far they extended into the anus but their presence there suggests that the rectum was atypically involved in these instances. I would say that the sores or 'cuts' in the recurrences varied in location, and that they never occurred on the scrotum or penis. Most of these recurrences involved the anal/perianal area.

The most recent episode of proctitis wasn't diagnostically confirmed using the tests you identify but I had all of the classic symptoms - bloody and mucoid stools, tenesmus, constipation and even impotence. I believed I made matters worse by inserting steroid suppositories into the anus during the episode. I am sure it was caused by herpes because not just because of the symptoms (which are highly characteristic) but also because I am pretty sure that I don't have any of the other candidate causes in the relevant differential diagnosis.

I agree that in a highly atypical clinical course either the diagnosis was wrong or that more than one problem is present. Thus if it wasn't wrong and so if some other problem was present, I was wondering whether the other problem in your opinion might be a defective/malfunctioning immunity? I.e. would it be typical for immunocompromise to mess with the clinical presentation of herpes in the way I have described?

Finally, can people have 'fissures' - not big wide ones, but thin small ones - in a recurrent herpetic outbreak? Is that atypical?

[BenjiAJ]

Hi Dr Hunter,

This was my original account which I shortened for the purposes of putting to you a question. I think it gives you a better picture, so I am now reposting it as a comment. Please forgive me if this is somehow a breach of etiquette.

"I'm a straight man who contracted herpes from a protected encounter with a prostitute in July of 05.

The first outbreak was on the scrotal area and since then I've had outbreaks typically in the perianal area and very close to - in and around - the anus. The symptoms that I've had are burning, tingling and stinging and tiny cracks just in and around the anus. In quite a few of these outbreaks, I've felt fissures extending into the anus, though I don't believe that they would have extended very far into the anus. I suppose that this would mean that in some of these recurrences the rectum was also involved - that is, if we suppose that herpetic fissures that extend, by however small an extent into the anus - are fissures involving the rectum as well.

Now I've had very frequent outbreaks but haven't been on medication for any of them except for the first one, when I took Valtrex.

The problem that I am now facing is that three weeks back - on 12 June 09 - I appeared to come down with a bout of herpes proctitis. I was constipated, feeling a lot of pain around the anus, and was passing out tiny quantities of stool which were covered with blood and mucus.

After getting these symptoms, I saw my doctor and then obtained from him Valtrex as well as a box of corticosteroid suppositories for insertion into the anus. Unfortunately, the use of the suppositories made the herpes infection even worse and the pain worsened - in the sense that I began feeling pinpricklike, burning and stinging sensations of great intensity around and inside the anus.

By the end of the week - i.e. on 19 Jun 09 - I realized that because they were steroid-based they could have made things worse and that I should therefore immediately discontinue them.

I discontinued them, but continued taking the Valtrex, had a full blood count done and then found that the neutrophil level was slightly elevated, suggesting a secondary bacterial infection. I then commenced a course of antibiotics which I finished just yesterday (on 3rd July 09).

THere has been an improvement in the symptoms (in terms of a lessening of pain) but I still feel the rectal/anal area is a bit numb and that I still have to strain to pass out stool. I also find it difficult to pass gas out of the anus and so have to sort of get the gas to be forced out of my mouth. I also had a colonoscopy done two days ago (on 2nd July) which indicated that there were no obstructions or visible signs of inflammation.

I figure that the colonoscopy did not pick up anything because the inflammation is now subsiding (with the twice-daily dose of 500mg of Valtrex that I have been taking) . However the fact that I still have to strain to pass stool out and that I have difficulty passing out gas seems to indicate that the herpetic proctitis that I suffered had some kind of effect on the sacral nerves - which is what the experts say that it would typically have. I read in an article that 'radiculopathy of the sacral nerves' in herpetic proctitis is what causes the constipation (though I believe that the swelling also contributes to the difficulty that one would be faced with in passing out stool). I also noted during this time that I was somewhat impotent.

The big concern I have is this: I've read that it is rather unusual for herpes to reactivate as proctitis except in people who are immunocompromised. For instance, in Famvir's web-site, in an article on HIV and HSV coinfection, it is stated that in HIV-infected people, herpes can affect areas not covered by the skin - for instance, that it can enter the rectum.

However, in one of your posts you suggested that even people who don't engage in anal sex can get anal herpes - that a significant minority of straight men do still get it - despite the fact that they have never engaged in anal sex.

Furthermore, in another of your posts, you stated the following:

"Herpetic proctitis is primarily a problem of first-episode herpes, generally in someone who acquires the infection through receptive anal sex.  Some cases of rectal or anal herpes may have episodic proctitis as the main manifestation of recurrent herpes, but it probably is rare; I have never seen such a case.  Most likely this is even less common with HSV-1 than HSV-2.  However, no data are available on either initial manifestations or recurrence pattern for anorectal (as opposed to genital) HSV-1 infection.  That is,  recurrent outbreaks are uncommon with genital HSV-1, but I am not aware of any available studies or data about anorectal infection."

If I understand you correctly, you are saying that some cases of rectal or anal herpes could consistently recur as proctitis but that you have never yourself seen such a case. You also say that this would be even less common with HSV-1 than with HSV-2.

My own case is different from the possibility you seem to be envisaging. I personally have had 'anal herpes' - with some of the fissures extending slightly into the rectum in the case of some of my recurrences - and it is only just once - i.e. in the most recent episode described above - that there has been a manifestation of proctitis - i.e. with all of the classic symptoms of such a condition.

I suppose that between the possibility of proctitis recurring consistently as a manifestation of a herpes recurrence and the possibility of such a recurrence just taking place only once, the latter possibility would be likelier than the former one.

It is noteworthy that the comment you made seems to indicate that there would be some reason to think that a recurrence of proctitis would be likelier in the case of anal or rectal herpes than in the case of conventional herpes.

Thus I am brought back to my original question, which is: whether my own specific pattern of recurrence could make it more likely that I would suffer from an episode of proctitis (say at a time when my immunity was down) than it would so if I had a more conventional pattern?

I recall that before getting this outbreak of herpetic proctitis I was sleeping poorly and under a lot of stress.

These three weeks have been hell for me, and I'm still not out of the woods. I never expected the herpes to enter my rectum, in the way it did, and cause proctitis.

The shock and distress that I am facing still has not abated.

Any light you throw will be helpful for me.

What do you think could be going on with me?


Ben

[BenjiAJ]

Hi Dr Hunter,

I think I left out some potentially critical information about pre-existing conditions:

I have congenital ichtyosis and congenital atopic dermatitis, which affects (according to my dermatologist) my skin barrier function. I also have a bladder condition - weakened stream, urgency, frequency - that I have been told is likely to have a neurological component.

Would the skin conditions I have (say the impaired barrier function) and the bladder condition's neurological component (if there is one) somehow potentially contribute to the likelihood of my suffering proctitis as a reactivation of HSV? This is against the background of the clinical course I have described - i.e. in terms of the recurrent involvement of the area around and just inside the anus in my outbreaks.

Ben

[H. Hunter Handsfield, M.D.]

With apology, I have neither the time nor the energy to read all this very detailed information.  Online forums are for giving general opinions and direction, not to digest so much detail or to confirm a specific opinion.

Based on your first follow-up reply, I will agree that herpes is a good possibility for the initial infection.  It is not a likely explanation for any of the recurrent outbreaks you describe or the proctitis episode.  You definitely need to see a health care provider who is skilled and experienced in herpes, ideally a specialist in infectious diseases.  Blood tests for HSV would help sort this out; and the same provider could do virus specific tests the next time you have symptoms that you have believed to be due to herpes.  In the meantime, I suggest you go forward on the assumption that something else was the cause of your proctitits.

As for other explanations of your symptoms, this forum does not speculate about non STD problems.  If in week before onset of your proctitis symptoms you had a rectal sexual exposure, i.e. receptive anal sex with another man, I will be happy to discuss other sexually transmitted causes of proctitis.  Other than that, I have no opinion about the causes of your various health problems.  (I use "causes" and "problems" intentionally; I doubt there is a single clinical explanation.)  There is nothing in your story that suggest any sort of immune deficiency.

Please follow through with your own health care provider and, preferably, an infectious diseases or other STD expert, then feel free to post a final follow-up comment when you have had proper diagnostic testing for HSV, or if there has been an anal sexual exposure that could explain the proctitis.  Until then, I won't have any further comments or advice.

[H. Hunter Handsfield, M.D.]

By the way, further evidence against herpes as the cause of your proctitis:  on scanning the long/detailed follow-up comment, you describe failure for the problem to resolve with valacyclovir (Valtrex) therapy.  That is strong evidence against herpes.  The steroids would have made no difference.  It is true that corticosteroid therapy can exacerbate HSV infections, but only in the absence of HSV-specific therapy.  When combined with valacyclovir or related drugs, steroids actually help herpes symptoms, usually quite dramatically.

[BenjiAJ]

Hi Dr,

First, I'd like to thank you for your time and informative comments.

I will be undergoing blood tests to see what type of herpes I have.

However, it is clear that I do have some kind of pre-existing neurological condition. I have an overactive bladder with a weakened stream and a twitching toe which seem to have a neurological cause.

In the circumstances, I would like to ask you the following related question, which I think will be illuminating for others as well:

If a person has a pre-existing neurological condition - say one affecting the sacral nerves - and then acquires herpes, could his pre-existing condition induce herpes to present in an atypical way? Has that been known to occur?

Do you think that pre-existing neurological conditions could mess with the classical presentation of acquired herpes (say, in terms of varying significantly the location of recurrent outbreaks, or in terms of focusing them in and around the anal/perianal area)?

Any light you shed on this would be much appreciated, Doctor. Thanks again.

Ben

[H. Hunter Handsfield, M.D.]

Those symptoms do not particularly suggest a signficant neurological problem to me.  My guess is there would be no interaction between herpes and such a problem, but I doubt there are any data and certainly I do not know with certainty.

Please no more comments on this thread unless/until as described above.

[H. Hunter Handsfield, M.D.]

My offer above was for you to "feel free to post a final follow-up comment when you have had proper diagnostic testing for HSV".  I deleted the inordinately long comment with a bunch of other test results irrelevant to whether or not you have HSV.  Any more such nonsense and I will delete the entire thread without further reply.