What is the management of proctitis?

From the Guidelines

The management of proctitis should prioritize the use of topical mesalamine suppositories (1g daily) as first-line therapy, as recommended by the AGA guidelines 1. For inflammatory bowel disease-related proctitis, this approach is supported by the guidelines, which suggest that mesalamine suppositories are more effective than oral mesalamine alone for proctitis 1. The use of oral mesalamine (2-4g daily) may be considered for more extensive disease, but topical therapy is preferred for proctitis due to its targeted delivery and better patient acceptance 1. Corticosteroid suppositories or enemas may be added for flares, but their use should be balanced against the potential for side effects and the availability of alternative therapies 1. Symptomatic management, including sitz baths, adequate hydration, stool softeners, and pain control, should be continued until symptoms resolve completely to prevent recurrence and complications 1. It is essential to note that the diagnosis of ulcerative proctitis should be made by ileocolonoscopy and confirmed by histopathology, with the exclusion of infections, drug-induced causes, radiation, trauma, and Crohn’s disease, as recommended by the IOIBD consensus 1. In terms of specific treatment regimens, the AGA guidelines recommend the use of mesalamine suppositories (1g daily) for patients with mild-moderate ulcerative proctitis, with the option to add oral mesalamine (2-4g daily) for more extensive disease 1. The guidelines also suggest that rectal corticosteroid therapy may be considered for patients who are intolerant of or refractory to mesalamine suppositories, but this should be done with caution and under close monitoring 1. Overall, the management of proctitis requires a tailored approach that takes into account the underlying cause, disease extent, and patient preferences, with a focus on minimizing morbidity, mortality, and improving quality of life. Some key points to consider in the management of proctitis include:

• The use of topical mesalamine suppositories (1g daily) as first-line therapy for inflammatory bowel disease-related proctitis
• The consideration of oral mesalamine (2-4g daily) for more extensive disease
• The addition of corticosteroid suppositories or enemas for flares
• The importance of symptomatic management, including sitz baths, adequate hydration, stool softeners, and pain control
• The need for a tailored approach that takes into account the underlying cause, disease extent, and patient preferences.

From the Research

Management of Proctitis

The management of proctitis involves a combination of medical therapies, lifestyle modifications, and in some cases, surgical interventions. The approach to management depends on the underlying cause of proctitis, which can include inflammatory bowel diseases (IBD), infectious causes, radiation, ischemia, diversion, and traumatisms 2.

Medical Therapies

• 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 3.
• Systemic corticosteroids, antibiotics, immunomodulators, or surgery may be required in cases of refractory ulcerative proctitis 3.
• For infectious proctitis, empirically initiated or specific therapies can guarantee a good prognosis and prevent relapses, with particular emphasis on simultaneous infections by multiple organisms 2.
• Broad-spectrum antibiotics may be used in patients with Crohn's disease (CD) who present with localized peritonitis or complicated perineal disease, and as primary therapy in active uncomplicated CD 4.

Diagnostic Approach

• 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 5.
• The diagnosis of proctitis is supported by the combination of clinical history and physical examination, and secondly, by endoscopic, serologic, and microbiologic findings 2.

Lifestyle Modifications

• Patients with proctitis should be advised on lifestyle modifications, such as avoiding anal intercourse or using protective measures to reduce the risk of sexually transmitted infections 2, 5.

Surgical Interventions

• Proctocolectomy may be considered as a last resort of treatment for refractory cases of ulcerative proctitis 6.

Multidisciplinary Approach

• The involvement of experts in infectious diseases and sexual health is crucial for the diagnostic and therapeutic management of proctitis 2.