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 proctoscopy or sigmoidoscopy, usually with cultures and biopsy. Treatment depends on etiology.
(See also Evaluation of Anorectal Disorders.)
Proctitis may be a manifestation of
Sexually transmitted infections (eg, Neisseria gonorrhoeae, Chlamydia species)
Certain enteric infections (eg, Campylobacter, Shigella, Salmonella—see Introduction to Gram-Negative Bacilli)
Radiation treatments
Proctitis associated with prior antibiotic use may be due to Clostridioides difficile (formerly Clostridium difficile).
Sexually transmitted pathogens cause proctitis more commonly among men who have sex with men. For example, Mpox has been found to cause significant infectious proctitis in men who have sex with men.
Patients with immunocompromise 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, cytomegalovirus, or monkeypox 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 nucleic acid amplification test, such as polymerase chain reaction (PCR), enteric pathogens (by culture), and viral pathogens (by culture or immunoassay).
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 to rule out inflammatory bowel disease.
Treatment of Proctitis
Various treatments depending on cause
Infective proctitiscan 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 toC. difficileis treated with vancomycin or fidaxomicin for 10 days.
Radiation proctitis that is bleeding is usually treated initially with a topical medication; however, evidence of efficacy from well-done studies is lacking (1). Topical treatments include corticosteroids as foam (hydrocortisone) or enemas (hydrocortisone or methylprednisolone), 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 fromhyperbaric oxygen therapy (2).
Endoscopic therapies may be used for radiation proctitis. Argon plasma coagulation seems effective in reducing symptoms at least in the short term (≤ 6 weeks) (2). Other methods of coagulation include lasers, electrocoagulation, and heater probes.
Treatment references
1. van de Wetering FT, Verleye L, Andreyev HJ, et al. Non-surgical interventions for late rectal problems (proctopathy) of radiotherapy in people who have received radiotherapy to the pelvis. Cochrane Database Syst Rev. 2016;4(4):CD003455. Published 2016 Apr 25. doi:10.1002/14651858.CD003455.pub2
2. Paquette IM, Vogel JD, Abbas MA, Feingold DL, Steele SR. Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Chronic Radiation Proctitis. Dis Colon Rectum. 2018;61(10):1135-1140. doi:10.1097/DCR.0000000000001209
