American Journal of Obstetrics & Gynecology
Volume 198, Issue 3 , Pages 260.e1-260.e2, March 2008

Rectovaginal examinations and human papillomavirus: can we decrease the risk of colorectal infection?

  • William W. Hurd, MD

      Affiliations

    • Corresponding Author InformationReprints: William W. Hurd, MD, 128 East Apple St, CHE 3800, Dayton, OH 45409

Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, OH.

published online 01 October 2007.

Article Outline

Rectovaginal examination with gloves contaminated with vaginal secretions might increase the risk of human papillomavirus (HPV) inoculation of the rectum in women with genital HPV infections. Because of the high prevalence of asymptomatic genital HPV infections, and the association between HPV and colorectal malignancy, examination gloves should be changed between vaginal and rectal examinations.

Key words: colorectal neoplasms, digital rectal examination, human papillomavirus, physical examination, vaginal diseases

 

Gynecologists have long been leaders in application of screening test to maintain patients’ health. The periodic use of screening Papanicolaou smears has been shown to reduce the incidence of invasive cervical cancer by at least 80%.1 In recent years, it has become clear that the cervical dysplasia and cancers detected by Papanicolaou smears are almost always the manifestation of genital human papillomavirus (HPV) infections.

The pelvic examination has long been considered to be an important part of our periodic screening assessment, and the majority of gynecologists believe that the rectovaginal examination is an integral and important part of this assessment.2 Techniques used for pelvic examinations are designed to avoid contamination of the vagina with colonic bacteria. However, it is clear that commonly used techniques are not designed to avoid the spread of HPV infections from the vagina to the rectum.

Genital HPV infections have become the most commonly diagnosed sexually transmitted infections in the United States.3 It has been estimated that more than 75% of sexually active adults will be infected with genital HPV at some time during their lives, and young women are the most likely to both become infected and have clinical complications.4, 5 At any given time, 10% of women will have an active genital HPV infection, but most will be subclinical. Only 1% of infected women will develop genital condyloma and only 4% will ever have cytological abnormalities.4 Although HPV vaccines are likely to reduce the risk of HPV-related malignancies, their benefits remain in the future.

It is well appreciated that HPV infections are association with gynecologic malignancies. High-risk HPV infections have been causally related to both adeno- and squamous carcinomas of the cervical.6 More than half of high-grade cervical intraepithelial neoplasia biopsies will be infected with high-risk HPV types, and HPV DNA can be demonstrated in the majority of cervical carcinoma specimens.7, 8

It might be less widely recognized that HPV infections are also associated with colorectal dysplasia and malignancies.9, 10 Colorectal cancer is the fourth most common cancer in women (after skin, breast, and lung cancer) and the second leading cause of cancer-related deaths in the United States.11 Approximately 10% of colorectal malignancies in women are located in the rectum.12 HPV DNA has been detected in 74% of colorectal malignancies, and it is more commonly found in rectal lesions than in those located in the colon.9, 10

The mode of spread of HPV infections is multifactorial. Genital HPV infections are most commonly spread by skin-to-skin sexual contact.13, 14 However, it is believed that nonsexual transmission also occurs. Among children, anogenital HPV infections resulting from nonsexual horizontal transmission via fomites, such as shared towels, are believed to be relatively common.15

Nonsexual transmission of HPV is possible because of the hardiness of the virus.15, 16 In the laboratory, papillomavirus has been shown to relatively heat resistant and remains viable for at least a week despite desiccation.13 This makes it very likely that HPV remains viable in residual vaginal secretions on an examination glove after vaginal digital examination.

The mode of spread of HPV to colorectal mucosa is also likely to be multifactorial. It is not surprising that anal intercourse is strongly associated with HPV infections of the anal canal in women.17 In patients with no history of anal intercourse, colorectal HPV infections are hypothesized to result from retrograde transmission of HPV from the perineum to the lower gastrointestinal tract.10 It is well established that the vaginal discharge of women with genital HPV infections contains HPV-infected cells.18 The obvious concern is that routine rectovaginal examination with a glove contaminated with vaginal secretions in women with genital HPV infections may increase the risk of colorectal HPV infection, and ultimately malignancy. Following a bimanual pelvic examination with the index and middle fingers placed in the vagina, a rectovaginal examination is routinely performed by removing the middle finger from the vagina and immediately placing it in the rectum. The rationale for this approach is evaluation of the posterior portion of the pelvis and the rectovaginal septum compared to bimanual examination using only vaginal digital assessment. In addition, in women over 50 years of age, a digital rectal examination allows for occult blood testing for screening and detection of colorectal cancer.19

The clinical implications are obvious. Given the association of HPV infection and colorectal malignancy and the high prevalence of asymptomatic genital HPV infections in women, every effort should be made to minimize the risk of spread of HPV infection from the genital tract to the rectum and colon. Based on these factors, it appears prudent to change examination gloves between a vaginal digital examination and a digital rectal examination.

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References 

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 Cite this article as: Hurd WW. Rectovaginal examinations and human papillomavirus: can we decrease the risk of colorectal infection? Am J Obstet Gynecol 2008;198:260.e1-260.e2.

PII: S0002-9378(07)00554-6

doi:10.1016/j.ajog.2007.04.034

American Journal of Obstetrics & Gynecology
Volume 198, Issue 3 , Pages 260.e1-260.e2, March 2008

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