Introduction

Digestive conditions can be a hassle to deal with. Some of these conditions come with more discomforting symptoms than others. Have you ever had the urge to go to the bathroom and then pass little or no stool? This bothersome sensation, referred to as tenesmus, is hard to ignore, especially when recurrent. Furthermore, this inability to completely pass stool is associated with various gastrointestinal conditions such as Crohn’s disease and ulcerative colitis, and surprisingly, sexually transmitted infections (STIs). Therefore, this article uncovers the intricacies of tenesmus in sexually transmitted infections. 

What is tenesmus?

Tenesmus is a spurious feeling of incomplete evacuation of the bowels and is usually accompanied by cramping and involuntary straining efforts.¹ In this condition, your body keeps urging you to defecate with symptoms such as pain, pressure, and some digestive tract symptoms such as nausea and vomiting. The prevalence of this symptom is low, which is why it is vastly understudied.¹ Tenesmus can come in the form of having the urge to defecate or urinate. The persistent feeling of needing to defecate is called rectal tenesmus. The most common ailment that can result in tenesmus is rectal carcinoma. However, malignancies in the pelvic region can trigger the symptoms associated with tenesmus. Radiation proctitis can elicit some side effects, which can include tenesmus.² Similarly, tenesmus can also affect your bladder and result in vesical tenesmus. This type makes you feel like you need to urinate even after emptying your bladder, and can cause pain in the bladder area.³ It is commonly associated with urinary frequency, urgency, and dysuria, and can be a clinical feature of conditions such as endometriosis or pelvic organ prolapse.³

Why does tenesmus occur? 

The most common trigger of tenesmus is inflammatory bowel disease (IBD), such as Crohn’s disease and ulcerative colitis.⁴ However, tenesmus affects people with ulcerative colitis (UC) more often than those with Crohn’s disease. This is because UC causes more hypersensitivity of the rectum and can affect any part of the gastrointestinal tract. Also, according to the International Foundation for Gastrointestinal Disorders, if inflammation involves only the rectum (i.e., proctitis), then urgency and tenesmus may be the hallmark signs of rectal inflammation. Approximately 30% of people with ulcerative colitis begin with proctitis. 

Generally, IBD can cause inflammation and ulceration of the gastrointestinal tract, leading to narrowing or blocking of the gut. Consequently, this leads to the perforation or scarring of the bowel wall.⁴ These changes make it more difficult to pass stool and contribute to the development of tenesmus. The main characteristic symptom of tenesmus is the urge to defecate or urinate. Other symptoms include: abdominal pain or cramping, straining to pass stool or urine, and bladder and rectal pressure. 

Causes of tenesmus 

Apart from IBD, other causes of tenesmus include; 

• Surgical procedure that affects the bowels, including scars
• Enteritis 
• Infectious colitis
• Constipation 
• Chronic intestinal pseudo-obstruction⁵ 
• Cancer
• Urinary tract infections
• Interstitial cystitis 
• Anorectal abscess 
• Pregnancy and sometimes, premenstrual dysphoric disorder (PMDD)
• Infections that can lead to pelvic inflammation, such as sexually transmitted infections, such as chlamydia⁶ 

 Chronic stress may trigger tenesmus in people who are susceptible to digestive problems such as IBD. However, normal amounts of daily stress alone should not cause tenesmus. Stress significantly impacts digestion because the gut is closely connected to the brain. The two communicate constantly via a large nerve called the vagus nerve. This nerve sends signals from your central nervous system to your gastrointestinal tract(GIT). ⁷ 

The connection between tenesmus and sexually transmitted infections

Sexually transmitted infections(STIs) are those diseases that are spread via several routes, such as sexual intercourse, mother-to-child, blood transfusion, and sharing of sharp objects such as syringes or needles.⁷ However, the re-emergence of STIs is due to the increase in STIs in the rectum and anus. This is referred to as anorectal STI and occurs due to the insidious spread of the genital infection. ⁷ Anorectal STIs are more common among homosexuals but are not exclusively seen in this population, as they can also affect heterosexuals.⁸ In homosexuals, these infections occur mainly due to anal sex and other sexual methods such as oro-anal sexual contact.⁷

Anorectal STIs can trigger tenesmus as these infections can cause inflammation and irritation of the rectum's lining(i.e., Rectal mucosa). This results in the sensation of an urgent and irresistible need to defecate even when the bowel is empty. This is often accompanied by discomfort, pain, and straining during bowel movements. General symptoms of anorectal STIs include anal pain, tenesmus, purulent drainage, and bleeding.⁷ Proctitis, or inflammation of the rectum, has infectious and non‐infectious causes, typically being sexually acquired. Enteric pathogens causing proctocolitis, such as Campylobacter, Shigella, Salmonella, Giardia, and Entamoeba histolytica, do not typically cause sexually transmitted infections, yet can be transmitted by oro‐anal sex, and sexual transmission is more common in homosexual men.⁸

The most commonly diagnosed bacterial STI in the UK is genital chlamydial infection caused by the bacterium C. trachomatis.⁹ There were approximately 240,000 diagnosed cases in the UK in 2012.⁹ Young adults below 25 years are mostly affected, with an estimated prevalence ranging between 2 and 3% in the general population.⁹ Furthermore, lymphogranuloma venereum (LGV) which is a systemic disease caused by C. trachomatis can cause anorectal symptoms such anal discharge, which can be mucous, purulent, or bloody, tenesmus, and constipation. There are case reports of LGV causing severe rectal diseases in heterosexual women.¹⁰ Herpes simplex virus (HSV), which is highly prevalent in the US and UK, can also induce proctitis. HSV proctitis is more commonly associated with the symptoms of anorectal pain, constipation, tenesmus, anal pruritus, difficulty in initiating micturition, sacral paresthesias, pain, and fever.¹⁰

Other STIs associated with tenesmus

Other STIs that can cause tenesmus as one of the symptoms include; 

• Gonorrhea (rectal gonorrhea)
• Syphilis
• HIV/AIDS
• Human papillomavirus 
• Giardiasis 
• Amoebiasis 

Most sexually transmitted infections and inflammatory bowel disease present with proctitis and proctocolitis, which is why they can trigger the onset of tenesmus.¹¹ However, distal proctitis occurs in the following organisms: Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and Herpes simplex virus. In proctocolitis, the organisms associated with food or waterborne diseases are more common. These include Entamoeba histolytica, Campylobacter spp., Salmonella spp., Shigella spp., Cryptosporidium spp., and Cytomegalovirus (CMV).¹¹

Management and treatment of tenesmus in STIs

The management and treatment of tenesmus stems from addressing the underlying medical condition. An expert on sexual health and associated infections should see patients diagnosed with an STI in a gastroenterology clinic. When precise information regarding their diagnosis and severity is provided to these patients, their partners should be notified, and screening should be undertaken. This may assist in identifying sexual networks with a high risk of future transmission, which can create a vicious cascade of continuous spread of anorectal STIs.¹² 

As tenesmus is a symptom of a variety of health conditions, the following treatment is recommended for tenesmus in STIs and IBD;

• Use of antibiotics and antiviral medications for STI treatment
• Use of probiotics and anti-inflammatory medications 
• Consuming cranberry juice (unsweetened), pills, or extract to reduce the recurrence of UTIs
• Practice stress management techniques
• Limit intake of caffeine, alcohol, and cessation of smoking 
• Make dietary changes and include more anti-inflammatory foods¹³

Prevention of tenesmus in STIs and IBD

To prevent tenesmus caused by an anorectal STI, the most effective method is to practice safe sex by consistently using condoms during anal intercourse and limiting sexual partners. It is also essential to get tested regularly for STIs, especially if you repeatedly have symptoms. If diagnosed with an STI, completing the full course of prescribed treatment by a medical professional is recommended before engaging in sexual activity again. 

Also, to prevent IBD, it is advised to keep a journal of your daily foods and activities. This is especially true if you get bloated or experience acid reflux after eating. This will help you identify what could be worsening symptoms like tenesmus. People with IBS may need to limit their intake of spicy or greasy foods. This depends on the digestive symptoms they experience after consuming such foods.¹³

FAQs

How can tenesmus in STIs be diagnosed?

Tenesmus in STI can be diagnosed by a gastroenterologist who will perform a physical examination and ask about your symptoms and medical history. A digital rectal exam may also be performed to check for rectal abnormalities. Other tests that can be done include: STI testing and urinalysis, stool studies, and imaging tests. 

What are the risk factors of tenesmus?

The risk factors of tenesmus include: colonoscopy, rectal trauma, infections that affect the gut or digestive system, radiation of the rectum (radiation proctitis), motility disorders, colon cancer, etc. 

What are the complications of tenesmus in STIs? 

If left unresolved, tenesmus can cause complications such as fecal impaction, hemorrhoids, anal fissures, and sepsis as a result of uncontrolled dissemination of the bacteria (in the case of tenesmus in STIs) and worsening of underlying conditions such as inflammatory bowel disease and colon cancer. 

Summary 

• Tenesmus is a symptom that involves the persistent urge to evacuate the bowels even though they are empty
• It is commonly triggered by digestive conditions such as inflammatory bowel disease, and infections that lead to inflammation of the rectum (proctitis)
• Sexually transmitted infections with anal and rectal involvement can cause tenesmus such as gonorrhea, syphilis, etc
• The mechanism involves the irritation and inflammation of the rectal mucosa, which triggers the irresistible urge to empty the bowels
• The management of tenesmus involves identifying the culprit behind the pain and straining when trying to defecate
• The use of antibiotics, probiotics, and adherence to dietary changes are the most recommended techniques to manage and treat tenesmus in STIs
• Practising abstinence, safe sex, and avoiding triggers assist in the prevention of tenesmus in STIs