From the Guidelines
Proctitis should be treated with mesalamine suppositories (1g daily) as the preferred initial treatment for mild or moderately active proctitis. This recommendation is based on the strongest and most recent evidence from the AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis, which suggests that mesalamine suppositories are the first-line therapy for proctitis 1. The guidelines also recommend using mesalamine suppositories over oral therapy for patients with mild-moderate ulcerative proctitis who choose rectal therapy, with a strong recommendation and moderate quality evidence.
The treatment of proctitis depends on the underlying cause, and the following options are available:
- For infectious proctitis, antibiotics are prescribed based on the pathogen
- For inflammatory bowel disease-related proctitis, mesalamine suppositories (1g daily) or enemas are first-line treatments, with hydrocortisone suppositories (25mg twice daily) added for more severe cases
- Radiation proctitis may require sucralfate enemas (2g in 20ml water twice daily) or oral sulfasalazine (1g four times daily)
Supportive care includes:
- Sitz baths
- Increased fiber intake
- Pain management
- Avoiding spicy foods, alcohol, and caffeine during treatment
If symptoms persist beyond 2-3 weeks of appropriate therapy, further evaluation with colonoscopy may be necessary to rule out other conditions. Prompt treatment is essential to prevent complications like strictures, fistulas, or abscesses. The European evidence-based consensus on diagnosis and management of ulcerative colitis also supports the use of mesalamine suppositories as the first-line therapy for proctitis, with a Cochrane systematic review of 38 clinical trials confirming its superiority over placebo for inducing symptomatic, endoscopic, histological response and remission 1.
From the Research
Definition and Symptoms of Proctitis
- Proctitis refers to inflammation of the rectum, which can be diagnosed through endoscopic evaluation 2
- Symptoms of proctitis include rectal bleeding, urgency, tenesmus, diarrhea or constipation, and occasionally rectal pain 2
Causes of Proctitis
- The causes of proctitis include infection, medication, ischemia, radiation, and ulcerative proctitis 2
- Ulcerative proctitis is an important and increasingly common subcategory of ulcerative colitis (UC) in which inflammation is limited to the rectum 2
- Sexually transmitted infections (STIs) such as gonorrhea, chlamydia, and syphilis can also cause proctitis 3
Treatment of Ulcerative Proctitis
- Mesalazine suppository has been the first-line therapy for patients with ulcerative proctitis due to its high effectiveness and safety 4
- Topical aminosalicylates are effective first-line agents in ulcerative proctitis and distal UC, acting more effectively and rapidly to induce and maintain remission compared to oral counterparts or topical steroids 2
- Topically administered 5-aminosalicylates (5-ASA) and corticosteroids are effective in the treatment of proctitis, although they seem to be underused in everyday practice 5
- The combination of topical and oral 5-ASA and steroids should be considered for escalation of treatment 5
Diagnosis and Management
- Differential diagnosis from other chronic proctitis is important and should be performed based on the clinical history and endoscopical and histological features 4
- A comprehensive history, clinical evaluation including anoscopy, and rectal nucleic amplification STI testing may be useful in identifying the cause of proctitis and targeting treatment 3
- Prevention of aggravation of ulcerative proctitis is important for improving the prognosis of ulcerative colitis 4
Treatment Efficacy
- Topical 5-ASA was significantly superior to placebo for induction and maintenance of clinical remission in patients with ulcerative proctitis 6
- Subgroup analysis of 5-ASA suppositories also showed superiority over placebo for induction of clinical and endoscopic remission 6
- The efficacy of corticosteroids, thiopurines, and anti-TNFα has been insufficiently studied in patients with UP 6