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Proctitis is inflammation of the rectal mucosa, which may result from infection, inflammatory bowel disease, or radiation. Symptoms are rectal discomfort and bleeding. Diagnosis is by sigmoidoscopy, usually with cultures and biopsy. Treatment depends on etiology.
Proctitis may be a manifestation of sexually transmitted disease, certain enteric infections (eg, Campylobacter, Shigella, Salmonella), inflammatory bowel disease, or radiation treatments; it may be associated with prior antibiotic use. Sexually transmitted pathogens cause proctitis more commonly among homosexual men. Immunocompromised patients are at particular risk of infections with herpes simplex and cytomegalovirus.
Symptoms and Signs
Typically, patients report rectal bleeding or passage of mucus. Proctitis resulting from gonorrhea, herpes simplex, or cytomegalovirus may cause intense anorectal pain.
Diagnosis
Diagnosis requires proctoscopy or sigmoidoscopy, which may reveal an inflamed rectal mucosa. Small discrete ulcers and vesicles suggest herpes infection. Smears should be sent for culture of Neisseria gonorrhoeae
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Chlamydia sp, enteric pathogens, and viral pathogens. Serologic tests for syphilis and stool tests for C. difficile toxin are done. Sometimes mucosal biopsy is needed. Colonoscopy may be valuable in some patients.
Treatment
Infective proctitis can be treated with antibiotics. Homosexual men with nonspecific proctitis may be treated empirically with ceftriaxone 125 mg IM once (or ciprofloxacin 500 mg po bid for 7 days), plus doxycycline 100 mg po bid for 7 days. Antibiotic-associated proctitis is treated with metronidazole (250 mg po qid) or vancomycin (125 mg po qid) for 7 to 10 days.
Radiation proctitis is usually effectively treated with topical formalin carefully applied to the affected mucosa. Alternative treatments include topical corticosteroids as foam (hydrocortisone 90 mg) or enemas (hydrocortisone 100 mg or methylprednisolone 40 mg) bid for 3 wk, or mesalamine (4 g) enema at bedtime for 3 to 6 wk. Mesalamine suppositories 500 mg once/day or bid, mesalamine 800 mg po tid, or sulfasalazine 500 to 1000 mg po qid for ≥ 3 wk alone or in combination with topical therapy may also be effective. Patients unresponsive to these forms of therapy may benefit from a course of systemic corticosteroids.
Last full review/revision October 2007 by Parswa Ansari, MD
Content last modified October 2007
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