What is the treatment for proctitis?

From the Guidelines

The treatment for proctitis should prioritize mesalamine suppositories (1g daily) as first-line therapy to induce symptomatic remission, as recommended by the Toronto Consensus guidelines 1. The choice of treatment for proctitis depends on its underlying cause, with different approaches for infectious, inflammatory bowel disease-related, and radiation-induced proctitis.

• For infectious proctitis, antibiotics are prescribed based on the specific pathogen.
• For inflammatory bowel disease-related proctitis, mesalamine suppositories (1g daily) or enemas are first-line treatments, often combined with oral mesalamine (2-4g daily) 1.
• Corticosteroid suppositories or enemas may be added for moderate cases, as suggested by the AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis 1.
• Severe or refractory cases might require immunomodulators like azathioprine or biologics such as infliximab.
• Radiation proctitis is managed with sucralfate enemas, metronidazole, or hyperbaric oxygen therapy. Regardless of cause, lifestyle modifications are important, including increased fluid intake, high-fiber diet, sitz baths for comfort, and avoiding irritants like spicy foods and alcohol.
• Treatment should continue until symptoms resolve completely, which may take several weeks, and follow-up is essential to ensure the condition has been adequately treated and to prevent recurrence. The AGA suggests using mesalamine suppositories in patients with mild-moderate ulcerative proctitis who opt for rectal therapy, with pooled analysis of 4 RCTs showing that mesalamine suppositories (1–1.5 grams per day) are more effective than placebo in inducing remission (RR 0.44,95%CI 0.34–0.56) 1.
• Maintenance therapy with mesalamine suppositories (0.5–1 gram administered once per day to three times per week) is also superior to placebo (RR 0.50,95%CI 0.32–0.79) 1. The quality of evidence comparing rectal 5-ASA to placebo for induction was moderate due to imprecision from low event rates, while evidence for rectal corticosteroids vs placebo for induction was rated as high 1.
• The evidence supporting rectal 5-ASA over corticosteroids for induction was moderate, and was rated down for heterogeneity in the effect size 1. The overall quality of evidence for the recommendation to use mesalamine suppositories was rated as moderate, and was rated down for imprecision due to low event rates in the available studies 1.
• The evidence for mesalamine suppositories for maintenance of remission was rated as low quality due to imprecision and risk of bias 1. In patients with mild to moderate active ulcerative proctitis, the Toronto Consensus guidelines recommend rectal 5-ASA, at a dosage of 1 g daily, as first-line therapy to induce symptomatic remission, with a strong recommendation and high-quality evidence 1.
• The guidelines also recommend that patients with UC be evaluated for lack of symptomatic response to oral/rectal 5-ASA induction therapy in 4 to 8 weeks to determine the need to modify therapy, with a strong recommendation and very low-quality evidence 1. The AGA makes no recommendation for use of probiotics in patients with mild-moderate UC, with seven RCTs enrolling 585 patients showing no significant difference in remission rates between probiotics and placebo (RR 0.88,95%CI 0.69–1.12) 1.
• The evidence for curcumin in induction of remission was rated as very low quality due to high risk of bias, inconsistency, and imprecision due to low event rates and wide confidence intervals for the effect estimates 1. The AGA recommends that fecal microbiota transplantation (FMT) be performed only in the context of a clinical trial for patients with mild-moderate UC who do not have Clostridium difficile infection, with pooled analysis of four RCTs showing that FMT was more effective in inducing clinical remission (RR 0.80,95%CI 0.71–0.89) and endoscopic remission (RR 0.77,95%CI 0.63–0.93) 1.

From the Research

Treatment for Proctitis

The treatment for proctitis depends on the underlying cause of the condition.

• For infectious proctitis, treatment with antibiotics or antivirals is usually initiated, either empirically or after establishing a diagnosis 2, 3.
• In cases of ulcerative proctitis, topical aminosalicylates are effective first-line agents, and they act more effectively and rapidly to induce and maintain remission compared to their oral counterparts or topical steroids 4.
• Rarely, ulcerative proctitis is refractory to topical therapy, and in these instances, systemic corticosteroids, antibiotics, immunomodulators, or surgery may be required 4.
• For proctitis caused by sexually transmitted pathogens, treatment recommendations include antibiotics or antivirals, and other sexually transmitted infections should always be ruled out 5, 3.
• A comprehensive history, clinical evaluation, and rectal nucleic amplification STI testing may be useful in identifying the cause of proctitis and targeting treatment 6.

Considerations for Treatment

• Co-infections, HIV testing, and treatment of sexual partners should always be considered 2.
• Condom use does not guarantee protection from STIs, which are often spread without penile penetration 5.
• Traumatic causes of proctitis should be considered in sexually active patients 5.
• Evolving data support a role for Mycoplasma genitalium in proctitis, and anorectal Mycoplasma genitalium infection should be considered in patients with symptomatic proctitis after exclusion of other common causations 5, 6.