EVIDENCE-TO-DECISION TABLE: ANORECTAL DISCHARGE

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Guidelines for the management of symptomatic sexually transmitted infections [Internet]. Geneva: World Health Organization; 2021 Jun.

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Guidelines for the management of symptomatic sexually transmitted infections [Internet].

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ANNEX 7EVIDENCE-TO-DECISION TABLE: ANORECTAL DISCHARGE

Should the current WHO syndromic management approach be recommended versus laboratory diagnosis, no treatment and treat all to identify sexually transmitted infections among people with anorectal discharge?

Population

Men and women (cis-men, cis-women, trans-women and transmen) presenting with anorectal discharge

Intervention and comparator

Intervention: current WHO syndromic approach versus comparison: laboratory diagnosis (or no treatment or treat all)

Purpose of the test

To detect Neisseria gonorrhoeae and/or Chlamydia trachomatis; herpes simplex virus (HSV); C. trachomatis (serovars L1, L2 and L3) causing lymphogranuloma venereum and Mycoplasma genitalium

Linked treatments

Treatments for anorectal infections (see above)

Anticipated outcomes

Number of people identified correctly as having or not having STI; number of people identified incorrectly as having or not having STI; consequences of appropriate or inappropriate treatment; patient and provider acceptability, feasibility, equity and resource use

Setting

Outpatient

Perspective

Population level

Subgroups

High- or low-prevalence settings; settings with limited versus established laboratory capacity; key populations: sex workers, men who have sex with men, transgender people, people living with HIV

Background

Syndromic management refers to a strategy to identify and treat people with STIs based on specific symptoms identified by a patient and signs (clinically observed signs of infection) associated with clearly defined causes. Although etiological diagnosis is preferred, it is not always accessible or affordable.

Fig. A7.1 shows clinical guidelines for the syndromic management of anorectal syndrome in the 2003 WHO guidelines for the management of sexually transmitted infections.

Assessment

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Summary of judgements

	Judgement
Problem	No	Probably no	Probably yes	Yes		Varies	Don’t know
Test accuracy	Very inaccurate	Inaccurate	Accurate	Very accurate		Varies	Don’t know
Desirable effects	Trivial	Small	Moderate	Large		Varies	Don’t know
Undesirable effects	Large	Moderate	Small	Trivial		Varies	Don’t know
Certainty of the evidence of test accuracy	Very low	Low	Moderate	High			No included studies
Certainty of the evidence of the effects of management	Very low	Low	Moderate	High			No included studies
Certainty of effects	Very low	Low	Moderate	High			No included studies
Values	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
Balance of effects	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	Varies	Don’t know
Resources required	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Varies	Don’t know
Certainty of evidence of required resources	Very low	Low	Moderate	High			No included studies
Cost–effectiveness	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	Varies	No included studies
Equity	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Varies	Don’t know
Acceptability	No	Probably no	Probably yes	Yes		Varies	Don’t know
Feasibility	No	Probably no	Probably yes	Yes		Varies	Don’t know

Conclusions

Should the current WHO syndromic management approach be recommended versus laboratory diagnosis, no treatment and treat all to identify sexually transmitted infections among people with anorectal discharge?

Type of recommendation

●

Strong recommendation against the intervention

○

Conditional recommendation against the intervention

○

Conditional recommendation for either the intervention or the comparison

○

Conditional recommendation for the intervention

○

Strong recommendation for the intervention

Recommendation

Recommendations for management of anorectal discharge

For people with symptom of anorectal discharge and report receptive anal sex, we recommend management based on the results of quality-assured molecular assays. However, in settings with limited or no molecular tests or laboratory capacity, we recommend syndromic treatment to ensure treatment on the same day of the visit.

Good practice includes:

taking a medical and sexual history and assessing the risk of STIs;
performing a physical examination of the genital and perianal areas and a digital rectal examination, if acceptable (and anoscopy, if available and acceptable);
offering HIV and syphilis testing and other preventive services as recommended in other guidelines; and
referring for other investigations when anorectal discharge is unrelated to a sexually transmitted infection, such as other gastrointestinal conditions.

Settings with quality-assured molecular testing in a laboratory with a fully operational quality management system and results available on the same day of the visit

We recommend the following.

Perform molecular assays (nucleic acid amplification test (NAAT)) using a self-collected or clinician-collected anorectal swab to confirm or exclude infection with N. gonorrhoeae and/or C. trachomatis and treat the individual infections detected.
Treat, additionally, for herpes simplex virus if there is anorectal pain.
Follow the genital ulcer guidelines if ulceration is present.

Settings in which same-day treatment is not feasible with molecular testing or with limited or no molecular testing

We suggest the following.

Treat for N. gonorrhoeae and C. trachomatis if discharge is present.
Treat, additionally, for herpes simplex virus if there is anorectal pain.

Good practice includes.

Following the genital ulcer guidelines if ulceration is present.
Referring people with persistent anorectal discharge to a centre with laboratory capacity to diagnose N. gonorrhoeae, C. trachomatis (including lymphogranuloma venereum serovars) and M. genitalium and determine antimicrobial resistance for N. gonorrhoeae and M. genitalium.

Justification

Managing people presenting with anorectal discharge based on a syndromic approach results in small benefits and moderate harm compared with molecular testing or treating all. Molecular testing may not be feasible in all settings and, alternatively, treating all would be feasible and the costs would be negligible. Treating all or conducting molecular testing would be acceptable to all and would not negatively affect equity (in some settings, it may increase equity).

References

1.: Mugundu PR, Narayanan P, Das A, Morineau G. Assessing syndromic management algorithms for the diagnosis of rectal chlamydia and gonorrhoeae among men who have sex with men clinic attendees from two cities in India. Sex Transm Infect. 2013;89(Suppl. 1).
2.: Quilter LAS, Obondi E, Kunzweiler C, Okall D, Bailey RC, Djomand G et al. Prevalence and correlates of and a risk score to identify asymptomatic anorectal gonorrhoea and chlamydia infection among men who have sex with men in Kisumu, Kenya. Sex Transm Infect. 2019;95:201–11. [PMC free article: PMC6428609] [PubMed: 30242143]
3.: Rebe K, Lewis D, Myer L, de Swardt G, Struthers H, Kamkuemah M et al. A cross sectional analysis of gonococcal and chlamydial infections among men-who-have-sex-with-men in Cape Town, South Africa. PLoS One. 2015;10:e0138315. [PMC free article: PMC4587970] [PubMed: 26418464]
4.: Sanders EJ, Wahome E, Okuku HS, Thiong’o AN, Smith AD, Duncan S et al. Evaluation of WHO screening algorithm for the presumptive treatment of asymptomatic rectal gonorrhoea and chlamydia infections in at-risk men who have sex with men in Kenya. Sex Transm Infect. 2014;90:94–9. [PMC free article: PMC3932748] [PubMed: 24327758]
5.: Caracas C, Jalil EM, Garcia ACF, Nazer SC, De Oliveira LP, Veloso V et al. High chlamydia and gonorrhea prevalences and low performance of syndromic management among Brazilian trans-women. AIDS Res Hum Retrovirus. 2018;34(Suppl. 1):240.
6.: Passaro RC, Segura ER, Perez-Brumer A, Cabeza J, Montano SM, Lake JE et al. Body parts matter: social, behavioral, and biological considerations for urethral, pharyngeal, and rectal gonorrhea and chlamydia screening among men who have sex with men in Lima, Peru. Sex Transm Infect. 2018;45:607–14. [PMC free article: PMC6092933] [PubMed: 30102262]
7.: Van der Bij AK, Spaargaren J, Morre SA, Fennema HS, Mindel A, Coutinho RA et al. Diagnostic and clinical implications of anorectal lymphogranuloma venereum in men who have sex with men: a retrospective case-control study. Clin Infect Dis. 2006;42:186–94. [PubMed: 16355328]
8.: Chan PA, Robinette A, Montgomery M, Almonte A, Cu-Uvin S, Lonks JR et al. Extragenital infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae: a review of the literature. Infect Dis Obstet Gynecol. 2016;2016:5758387. [PMC free article: PMC4913006] [PubMed: 27366021]
9.: 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. [PubMed: 15937765]
10.: Soni S, White JA. Self-screening for Neisseria gonorrhoeae and Chlamydia trachomatis in the human immunodeficiency virus clinic – high yields and high acceptability. Sex Transm Dis. 2011;38:1107–9. [PubMed: 22082720]
11.: Turner AN, Reese PC, Ervin M, Davis JA, Fields KS, Bazan JA. HIV, rectal chlamydia, and rectal gonorrhea in men who have sex with men attending a sexually transmitted disease clinic in a midwestern US city. Sex Transm Dis. 2013;40:433–8. [PMC free article: PMC3815564] [PubMed: 23677015]
12.: Ross MW, Nyoni J, Ahaneku HO, Mbwambo J, McClelland RS, McCurdy SA. High HIV seroprevalence, rectal STIs and risky sexual behaviour in men who have sex with men in Dar es Salaam and Tanga, Tanzania. BMJ Open. 2014;4:e006175. [PMC free article: PMC4156794] [PubMed: 25168042]
13.: Kim EJ, Hladik W, Barker J, Lubwama G, Sendagala S, Ssenkusu JM et al. Sexually transmitted infections associated with alcohol use and HIV infection among men who have sex with men in Kampala, Uganda. Sex Transm Infect. 2016;92:240–5. [PMC free article: PMC4814355] [PubMed: 26424713]
14.: Muraguri N, Tun W, Okal J, Broz D, Raymond HF, Kellogg T et al. HIV and STI prevalence and risk factors among male sex workers and other men who have sex with men in Nairobi, Kenya. J Acquir Immune Defic Syndr. 2015;68:91–6. [PMC free article: PMC4973514] [PubMed: 25501346]
15.: Katz DA, Dombrowski JC, Bell TR, Kerani RP, Golden MR. HIV incidence among men who have sex with men after diagnosis with sexually transmitted infections. Sex Transm Dis. 2016;43:249–54. [PMC free article: PMC4789769] [PubMed: 26967302]
16.: Rowley J, Vander Hoorn S, Korenromp E, Low N, Unemo M, Abu-Raddad LJ et al. Chlamydia, gonorrhoea, trichomoniasis and syphilis: global prevalence and incidence estimates, 2016. Bull World Health Organ. 2019;97:548–62. [PMC free article: PMC6653813] [PubMed: 31384073]
17.: Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA et al. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis. 2014;14:742–50. [PubMed: 25022435]
18.: Korenromp EL, Wi T, Resch S, Stover J, Broutet N. Costing of national STI program implementation for the global STI control strategy for the health sector, 2016–2021. PLoS One. 2017;12:e0170773. [PMC free article: PMC5271339] [PubMed: 28129372]
19.: Okuku HS, Wahome E, Duncan S, Thiongo A, Mwambi J, Sahfi J et al. Evaluation of presumptive treatment recommendation for asymptomatic anorectal gonorrhoea and chlamydia infections in at-risk men who have sex with men in Kenya. J Int AIDS Soc. 2012;15:99.

Fig. A7.1Current WHO syndromic approach to the management of anorectal syndrome

*History of GI conditions? Suggestive of GI

** Risk: unprotected anal intercourse last 6 months, plus

–: Partner with STI; or
–: Multiple partners

Follow up after 1 week. If symptoms persist:

–: Treat for LGV;
–: Treat for HSV;
–: Refer

Table A7.1Detection of any STI for anorectal syndrome

Study	Year of study	Country	Country income level	Sample size	Where recruited	Subpopulation	How a positive case is defined	Pathogens and test	True positive	False negative	False positive	True negative
Mugundu et al. (1)	2008–2009	India	Lower middle	868	Sexual health clinic	100% men who have sex with men	Receptive anal sex and/or anal discharge + subsequent proctoscopy ± smear findings	C. trachomatis and N. gonorrhoeae NAAT – Roche Amplicor	53	74	250	491
Mugundu et al. (1)	2008–2009	India	Lower middle	868	Sexual health clinic	100% men who have sex with men	Adding “risk assessment” to above		104	23	592	149
Quilter et al. (2)	Unclear	Kenya	Lower middle	698	Community settings	99% men who have sex with men	Anal symptoms + “risk assessment” (model-derived risk score)	C. trachomatis and N. gonorrhoeae NAAT – Abbott Realtime	15	21	151	511
Rebe et al. (3)	2012	South Africa	Upper middle	200	Sexual health clinic	100% men who have sex with men	Symptoms only	C. trachomatis and N. gonorrhoeae, Aptima Combo 2	9	38	13	140
Sanders et al. (4)	2011–2012	Kenya	Lower middle	244	Unclear	100% men who have sex with men	Symptoms + “risk assessment”	C. trachomatis and N. gonorrhoeae Aptima Combo 2	3	28	1	212

Table A7.2Detection of anal gonorrhoea for anorectal syndrome

Study	Year of study	Country	Country income level	Sample size	Where recruited	Subpopulation	How a positive case is defined	Diagnostic	True positive	False negative	False positive	True negative
Caracas et al. (5)	2015–2016	Brazil	Upper middle	345	Unclear	100% trans-women	Symptoms only	Not reported	4	43	26	272
Passaro et al. (6)	2012–2014	Peru	Upper middle	787	Unclear	100% men who have sex with men	Symptoms only	NAAT	3	62	16	706
Quilter et al. (2)	Unclear	Kenya	Lower middle	698	Community settings	99% men who have sex with men	Anal symptoms + “risk assessment” (model-derived risk score)		12	15	154	517
Rebe et al. (3)	2012	South Africa	Upper middle	200	Sexual health clinic	100% men who have sex with men	Symptoms only		3	14	19	164
Sanders et al. (4)	2011–2012	Kenya	Lower middle	19	Unclear	100% men who have sex with men	Symptoms + “risk assessment”		4	3	11	1

Table A7.3Detection of anal chlamydia for anorectal syndrome

Study	Year of study	Country	Country income level	Sample size	Where recruited	Subpopulation	How a positive case is defined	Diagnostic	True positive	False negative	False positive	True negative
Caracas et al. (5)	2015–2016	Brazil	Upper middle	345	Unclear	100% trans-women	Symptoms only	Not reported	22	28	8	287
Passaro et al. (6)	2012–2014	Peru	Upper middle	787	Unclear	100% men who have sex with men	Symptoms only	NAAT	3	122	16	646
Quilter et al. (2)	Unclear	Kenya	Lower middle	698	Community settings	99% men who have sex with men	Anal symptoms + “risk assessment” (model-derived risk score)		8	11	158	521
Rebe et al. (3)	2012	South Africa	Upper middle	200	Sexual health clinic	100% men who have sex with men	Symptoms only		2	14	20	164
Sanders et al. (4)	2011–2012	Kenya	Lower middle	244	Unclear	100% men who have sex with men	Symptoms + “risk assessment”		0	20	4	220

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Guidelines for the management of symptomatic sexually transmitted infections [Internet]. Geneva: World Health Organization; 2021 Jun. ANNEX 7, EVIDENCE-TO-DECISION TABLE: ANORECTAL DISCHARGE.
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Should the current WHO syndromic management approach be recommended versus laboratory diagnosis, no treatment and treat all to identify sexually transmitted infections among people with anorectal discharge?
Assessment
Summary of judgements
Conclusions

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Guidelines for the management of symptomatic sexually transmitted infections [Internet].

ANNEX 7EVIDENCE-TO-DECISION TABLE: ANORECTAL DISCHARGE

Should the current WHO syndromic management approach be recommended versus laboratory diagnosis, no treatment and treat all to identify sexually transmitted infections among people with anorectal discharge?

Population

Intervention and comparator

Purpose of the test

Linked treatments

Anticipated outcomes

Setting

Perspective

Subgroups

Background

Assessment

Summary of judgements

Conclusions

Should the current WHO syndromic management approach be recommended versus laboratory diagnosis, no treatment and treat all to identify sexually transmitted infections among people with anorectal discharge?

References

Fig. A7.1Current WHO syndromic approach to the management of anorectal syndrome

Table A7.1Detection of any STI for anorectal syndrome

Table A7.2Detection of anal gonorrhoea for anorectal syndrome

Table A7.3Detection of anal chlamydia for anorectal syndrome

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