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. Recently, monkeypox 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 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 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.
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' 2018 clinical practice guidelines for the treatment of chronic radiation proctitis.)
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The following English-language resource 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 (2018)
