Introduction: Receptive anal intercourse (RAI) is a common practice both among men and women. For patients with medically refractory ulcerative colitis (UC) or UC with dysplasia who practice RAI,, it has been cited anecdotally as a reason not to pursue IPAA surgery. There remains a lack of formal studies investigating the true extent of and impact of RAI on IBD patients who have anorectal disease.
Case Description/Methods: A 40-year-old man with a 15-year history of pancolonic UC presented with worsening abdominal pain and hematochezia. Flexible sigmoidoscopy revealed Mayo 3 inflammation. Stool infectious studies were negative and he was started on 40 mg of prednisone tapered over eight weeks. Due to a history of treatment failure with infliximab, vedolizumab was started as an outpatient. He had clinical response but his symptoms worsened when prednisone was decreased below 20 mg. Despite two consultative visits with colorectal surgery, he refused an elective total colectomy with IPAA.
He presented a year later with a UC flare despite being on continuous prednisone. After a week of intravenous steroids, inpatient flexible sigmoidoscopy still showed Mayo 3 inflammation. Urgent colectomy with IPAA was recommended. Despite being known to our health system for over one year, he admitted to regularly practicing RAI for the first time and state that was the reason he declined IPAA surgery. Biopsies from his flexible sigmoidoscopy revealed CMV infection, and he has treated with valacyclovir. His symptoms eventually remitted and he was successfully weaned off prednisone. He continues to be on maintenance vedolizumab.
Discussion: Our case presents several major challenges in caring for IBD patients who practice RAI. Due to the social stigma associated with it, some patients may be reluctant to discuss with their providers how RAI impacts their overall health. In some instances, the patients instead rely on non-medical sources of information. There is lack of consensus in the surgical literature and anecdotally on whether RAI is permissible after IPAA surgery. Conceivably, a hand-sewn anastomosis may be the technique of choice compared to stapled anastomosis to allow for continued RAI practice after IPAA surgery. Additional considerations and discussion may be needed when deciding the pouch length.
Overall, IBD patients who practice RAI represent an under-studied population with likely specialized medical and surgical needs.
