What is Proctitis?
Proctitis is an inflammatory syndrome of the rectum (the distal 10-15 cm of the anal canal), which can be caused by inflammatory bowel disease (most commonly ulcerative colitis), sexually transmitted infections, radiation exposure, or other etiologies 1, 2.
Two Main Categories
1. Ulcerative Proctitis (Inflammatory Bowel Disease)
- Disease confined to within 15 cm of the anal verge, confirmed by endoscopy and histopathology 3
- Accounts for approximately 37% of all ulcerative colitis cases 3
- Characterized by persistent mucosal inflammation limited to the rectum 4
- Treated primarily with topical 5-ASA suppositories as first-line therapy 5, 4
- For refractory cases, add oral 5-ASA, topical corticosteroids, or escalate to systemic corticosteroids, JAK inhibitors, S1P agonists, or biologic therapy 4
2. Infectious Proctitis (Sexually Transmitted)
- Transmitted via genital-anal mucosal contact, digital contact, or toys 1
- Most common pathogens include:
- Shigellosis can be transferred via oral-anal contact and may cause proctocolitis or enteritis 1
- Increasingly found in HIV-negative men who have sex with men (MSM), though women having anal intercourse are also at risk 1
- The majority of rectal chlamydia and gonococcal infections are asymptomatic and only detected by laboratory testing 1, 2
Clinical Presentation
Symptomatic Proctitis
- Anorectal itching, pain, and tenesmus (cramping)
- Rectal bleeding and mucous discharge
- Constipation
- Discharge in and around the anal canal 1, 2
- Occasionally: aphthous ulcers, generalized lymphadenopathy, and fever 8, 6
Asymptomatic Proctitis
- Frequently occurs with sexually transmitted infections 2
- Can only be detected by laboratory tests
- Screening is indicated when there is a history of receptive anal contact, even with condom use, as condoms do not guarantee protection from all STIs 1, 2
Important Clinical Pitfalls
Condom use does not prevent all sexually transmitted proctitis because many infections spread without penile penetration 1, 2. Therefore, a history of "protected" anal contact does not exclude infectious proctitis.
Syphilitic proctitis can mimic rectal cancer, malignant lymphoma, or inflammatory bowel disease, making diagnosis difficult 9. Intestinal spirochetosis found incidentally on colonic biopsies should not be confused with syphilis 1.
Mycoplasma genitalium should be considered in symptomatic proctitis after excluding the common pathogens listed above 1.
Radiation proctitis is a known complication after radiotherapy for pelvic malignancies and can become chronic, affecting quality of life 10.
Diagnostic Approach
For suspected infectious proctitis:
- Careful sexual history (receptive anal contact, number of partners, HIV status)
- Physical examination for ulcers, discharge, lymphadenopathy
- Laboratory testing: PCR, culture, serology for common STI pathogens 1, 8, 6
- Endoscopy and histology when diagnosis unclear 8, 6
- Always consider co-infections, HIV testing, and treatment of sexual partners 8, 6
For suspected ulcerative proctitis:
- Endoscopic confirmation of inflammation confined to rectum
- Histopathological confirmation
- Exclusion of infectious and other etiologies 3