(See also Evaluation of Anorectal Disorders Evaluation of Anorectal Disorders The anal canal begins at the anal verge and ends at the anorectal junction (pectinate line, mucocutaneous junction, dentate line), where there are 8 to 12 anal crypts and 5 to 8 papillae. The... read more .)
Proctitis may be a manifestation of
Sexually transmitted infections Overview of Sexually Transmitted Infections Sexually transmitted infections (STIs), also termed sexually transmitted diseases or STDs, can be caused by a number of microorganisms that vary widely in size, life cycle, the diseases and... read more (eg, Neisseria gonorrhoeae, Chlamydia species)
Certain enteric infections (eg, Campylobacter, Shigella, Salmonella—see Introduction to Gram-Negative Bacilli Introduction to Gram-Negative Bacilli Gram-negative bacilli are responsible for numerous diseases. Some are commensal organisms present among normal intestinal flora. These commensal organisms plus others from animal or environmental... read more )
Proctitis associated with prior antibiotic use may be due to Clostridioides difficile Clostridioides (formerly Clostridium) difficile–Induced Diarrhea Toxins produced by Clostridioides difficile strains in the gastrointestinal tract cause pseudomembranous colitis, typically after antibiotic use. Symptoms are diarrhea, sometimes bloody... read more (formerly Clostridium difficile).
Sexually transmitted pathogens cause proctitis more commonly among men who have sex with men. Immunocompromised patients are at particular risk of infections with herpes simplex and cytomegalovirus.
Symptoms and Signs of Proctitis
Typically, patients report tenesmus (a strong feeling of need to defecate when stool is not present), rectal bleeding, or passage of mucus. Proctitis resulting from gonorrhea, herpes simplex, or cytomegalovirus may cause intense anorectal pain.
Diagnosis of Proctitis
Proctoscopy or sigmoidoscopy
Tests for sexually transmitted infections and C. difficile
Diagnosis of proctitis requires proctoscopy or sigmoidoscopy, which may reveal an inflamed rectal mucosa. Small discrete ulcers and vesicles suggest herpes infection. Rectal swabs should be tested for Neisseria gonorrhoeae and Chlamydia species (by culture or ligase chain reaction), enteric pathogens (by culture), and viral pathogens (by culture or immunoassay).
Serologic tests for syphilis Diagnosis Syphilis is caused by the spirochete Treponema pallidum and is characterized by 3 sequential clinical, symptomatic stages separated by periods of asymptomatic latent infection. Common... read more and stool tests for C. difficile toxin are done. Sometimes mucosal biopsy is needed.
Colonoscopy may be valuable in some patients to rule out inflammatory bowel disease.
Treatment of Proctitis
Various treatments depending on cause
Infective proctitis can be treated with antibiotics. Patients who engage in anal-receptive intercourse who have nonspecific proctitis may be treated empirically with ceftriaxone 250 mg IM once, plus doxycycline 100 mg orally 2 times a day for 7 days. Antibiotic-associated proctitis due to C. difficile is treated with vancomycin (125 mg orally 4 times a day) or fidaxomicin (200 mg orally 2 times a day) for 10 days.
Radiation proctitis that is bleeding is usually treated initially with a topical drug; however, evidence of efficacy from well-done studies is lacking. Topical treatments include corticosteroids as foam (hydrocortisone 90 mg) or enemas (hydrocortisone 100 mg or methylprednisolone 40 mg) 2 times a day for 3 weeks, or sucralfate retention enemas (2 g in 20 mL water 2 times a day) may also be effective. Patients unresponsive to these forms of therapy may benefit from topical application of formalin, or from hyperbaric oxygen therapy Recompression Therapy Recompression therapy is administration of 100% oxygen for several hours in a sealed chamber pressurized to > 1 atmosphere, gradually lowered to atmospheric pressure. In divers, this therapy... read more .
Endoscopic therapies may be used. Argon plasma coagulation seems effective in reducing symptoms at least in the short term (≤ 6 weeks). Other methods of coagulation include lasers, electrocoagulation, and heater probes. (See also the American Society of Colon and Rectal Surgeons' clinical practice guidelines for the treatment of chronic radiation proctitis.)
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
American Society of Colon and Rectal Surgeons: Clinical practice guidelines for the treatment of chronic radiation proctitis
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