A good sexual history can catch secondary STIs

When screening patients for sexually transmitted infections (STIs), physicians typically only screen the genitals, but STIs can also infect anal tissue. A comprehensive sexual health history is crucial to catching these secondary infections, says Jack Springer, M.D., assistant professor of emergency medicine at the Zucker School of Medicine at Hofstra/Northwell, in Manhasset, N.Y.

Part of the problem diagnosing anal STIs is that they often do not present any symptoms, Springer says. To determine if a patient is at risk for anal STIs, he says it’s necessary to take a comprehensive sexual history.

He describes an ER patient who presented with no rectal symptoms at all. “He had a very interesting rash,” Springer says. “It turns out this gentleman had anal receptive intercourse, unprotected. We made the diagnosis of secondary syphilis.”

Occasionally, he says, anal STIs may present with symptoms such as proctitis-inflammation of the rectum, which may cause itching and irritation-or discomfort on receptive intercourse, or pain moving the bowels. “Those would be obvious signs,” he says, but most of the time, there are no symptoms.

If he had not taken that patient’s sexual history, they might never have caught the infection.

As an ER doctor, he says he doesn’t have time to worry about a patient’s discomfort in addressing this sensitive issue. “I’m very matter of fact.” He asks if a person is sexually active, what their preference is-men, women, or both-whether they use protection, birth control, if they have ever had an STI, and if they have ever been pregnant.

“I ask these questions as I would ask you about chest pain. A doctor is not doing his job if he lets discomfort come between him and doing what is in the patient’s best interest,” he says. “This is about health and taking care of people. It’s not about niceties.”

Any STI left untreated can have complications. While genital STIs present greater risks for cisgender women, such as infertility and pelvic inflammatory disease, anal STIs can also cause scarring, discomfort and pain in anyone, and should not be left untreated, Springer says.

“The skin of the anus is not like the vaginal wall that’s made to resist trauma. The rectum’s skin bleeds easily and is thinner. That’s why HIV is so easily transmitted anally, even compared to vaginally or orally,” he says.

The most common cause of anal STIs is penetrative sex, without a physical prophylactic barrier, by someone with a penis who has an infection, Springer says. “Now, one could make the argument that if there were toys used, and that toy was used immediately before being placed in someone’s bottom, that theoretically could transmit an infection.”

However, he says, viruses tend to die very quickly out of the body so risk of being infected from a sexual toy is much lower.

He says sexually active people should use condoms until they have both had STI screening, and even after, to be safe. “People feel that because HIV is so treatable now, I think STIs are diminishing importance in people’s minds. I don’t think they really understand how much [STIs] can affect your life and your health.”

He urges physicians to remind patients who are not in a long term monogamous relationship to take the approach, “No condom, no sex.”