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colorectal & or prostate care in gay HIV+ male vs nongay males
Dec 4, 2000

I need your opinion as to my concerns with my colorectal surgeon, my circumstances, long-term prognosis, and how best to proceed. I FEEL IT WOULD BE MORE BENEFICIAL IF I COULD SEE A GAY COLORECTAL SURGEON AND / OR ONE WHO TREATS A LARGE NUMBER OF GAY MALE PATIENTS IN HIS PRACTICE AND OR STUDIES. DO YOU THINK THIS IS A LEGITIMATE CONCERN. DO YOU FEEL THAT GAY MALES HAVE SPECIAL OR DIFFERENT CIRCUMSTANCES RELATED TO THE EXAMINATION, TREATMENT, CARE--PREVENTION, FOLLOW-UP, DIAGNOSIS, PROGNOSIS, RECOVERY INSTRUCTIONS, Etc., IN REGARDS TO ANAL/COLORECTAL DISEASE, INFECTIONS, CONDITIONS (PATHOLOGY) THAN NON-GAY PATIENTS, DUE TO THE INTRICATE PART OF ANAL STIMULATION/INVOLVEMENT/PLEASURE IN A GAY MAN'S SEX LIFE??? It is my belief that it is different, and a Colorectal surgeon who is not gay or does not treat a large number of gay patients may not be best suited for treating a gay patient. My colorectal surgeon, Dr. H, has been an excellent surgeon, a great concerned and generous man. In 1993 after 3 surgeries (beginning in early 1990), close followup and office and suppository treatments effectively removed my carcinoma in situ of the rectum which developed as a result of a botched hemorrhoidectomy and removal of anal warts by a proctologist in NC 1989. As of the last visit 03/29/00 there has been no reoccurrence of either the carcinoma in situ or anal warts. History briefly summarized below: Oct. 1988-- became infected with HIV (tested negative but 99% sure that is when I was infected.) Dec. 1988--tested positive for HIV April 1989--treated by a urologist for external anal warts May/June 1989--returned to urologist for additional anal warts, he referred me to a Proctologist to surgically remove all warts internal and external. June 1989-- Proctologist also advised removing some hemorrhoids that he found on examination. Did surgery. June 1989 - June 1990-- continued to bleed from the rectum regularly after bowel movements. June 1990-1993-- Dr. H, Board certified colorectal surgeon, treated my carcinoma in situ of the rectum and anal warts (condyloma) February 1998-- During a routine followup exam Dr. H found a suspicious area, did a biopsy and found CMV proctitis (fortunately, which allowed me to begin immediate and aggressive treatment by HIV specialist/primary care physician). 1993-March 2000 Dr. H has followed up with me regularly and as anal/rectal concerns/complications occur. My concern is that possibly although Dr. H, is a great surgeon and effectively cured my carcinoma in situ of the rectum and condyloma, He has advised me that the best thing for my long term health is complete abstinence from anal stimulation of any kind (digital, penile, or dildo) or I may face a colostomy in the future. I feel, this seems drastic and perhaps unrealistic. Ever since the final surgery in 1993 I have had only occasional bleeding due to difficult bowel movements, anal sex (self or partnered) but I have had continuous prostate problems ... every 3-4 weeks (or more frequently if my IBS is causing diarrhea)--with pain in my penis and prostate area, the only relief is with 1-2 ejaculations with or without anal stimulation. Could the skin flap procedure that Dr. H performed after removing all suspicious tissue have caused my prostate to be more than normally susceptible to infection, irritation, congestion and chronic pain??? Could this be corrected or improved by another procedure performed by a Colorectal Surgeon who is either gay or more gay empathetic in regards to the use of the anus/rectum in a gay man's sex life??? I Would greatly appreciate any and all advice and or referral you may be able to offer. Thank you for your time. Warmest regards, Irvine, CA

Response from Dr. Pavia

Dear Jerry,

I have edited your email to remove your last name and that of your surgeon. Your general questions are excellent ones.

First -- do gay men with or without HIV have different issues regarding anal health? Absolutely. The key issues relate to sexually transmitted infections involving the anus and rectum, including herpes, gonorrhea, and anal warts. Anal warts are caused by papilloma virus, and it is papilloma virus that is an important cause of anal dysplasia, precancerous changes, and anal cancer. Actually, the strains which cause the big ugly warts are not the ones most likely to cause cancer. At the very least, men with anal warts in the past should be followed with regular anal exams, perhaps as often as once a year. There is increasing evidence that an anal pap smear may be helpful. This is not yet a done deal, however, and visual exams may be as good. Other problems include fissures, hemorrhoids, tears, problems with anal tone, and others.

Second question -- are you likely to be better off with a colorectal surgeon who is gay or sees lots of gay men? I think the answer is yes to the question the way you asked it. I think a surgeon who takes care of and is comfortable with gay men, is sensitive to their issues, and is up to date on the issues that are involved, especially around HIV, is what you need. I am not sure that his or her orientation per se matters EXCEPT, that one hopes all gay doctors are gay-friendly, and that is not guaranteed with a heterosexual doctor (hold the hate mail please. I have known enough homophobic gay men to know that this is dangerous territory).

Clearly we have dealt with colorectal surgeons who are great with our patients and their health maintenance issues, as well as those that are great for big surgeries, but not sympathetic to annual followup, wart removal, and the other day to day stuff. It sounds like your physician has been thorough and thoughtful and sees you regularly. It is always reasonable to get a second opinion when dealing with complicated issues, though. It is also important to realize that if after getting a second opinion you are still comfortable with the first doc, they are not going to throw you out for "being unfaithful." In fact, most of us are tickled when the second opinion either matches ours, or helps solve a difficult problem. Your HIV provider probably has a lot of experience with colorectal surgeons. If not, and you know of a general internist with a large gay practice, ask them for a name.

Good luck,and thanks for the questions.

ATP

Andrew T. Pavia, M.D.



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