Initial Approach to Managing Proctitis in a Female Patient
The initial approach to managing proctitis in a female patient should include anoscopy, evaluation for sexually transmitted infections (STIs), and empiric treatment with ceftriaxone 125-250 mg IM plus doxycycline 100 mg orally twice daily for 7 days while awaiting test results. 1
Understanding Proctitis
Proctitis is an inflammation limited to the rectum (distal 10-12 cm) characterized by:
- Anorectal pain
- Tenesmus (painful straining)
- Rectal discharge
- Possible bleeding
- Itching and discomfort
Diagnostic Evaluation
Step 1: Thorough History
- Sexual practices (especially receptive anal intercourse)
- Onset and duration of symptoms
- Recent antibiotic use
- Previous STIs
- HIV status
Step 2: Physical Examination and Initial Testing
- Anoscopy is essential for all patients with suspected proctitis 1
- Collect specimens for:
- Gram stain of anorectal exudate to check for polymorphonuclear leukocytes
- NAAT or culture for Neisseria gonorrhoeae
- NAAT for Chlamydia trachomatis (including LGV testing if C. trachomatis positive)
- PCR or culture for Herpes simplex virus
- Testing for Treponema pallidum (syphilis serology)
- HIV testing
Step 3: Empiric Treatment
If anorectal exudate is present or polymorphonuclear leukocytes are detected on Gram stain, initiate empiric treatment immediately while awaiting test results:
Recommended Regimen:
- Ceftriaxone 250 mg IM in a single dose, PLUS
- Doxycycline 100 mg orally twice daily for 7 days 1
If painful perianal or mucosal ulcers are present, add treatment for genital herpes.
Etiology-Specific Considerations
Sexually Transmitted Proctitis
The most common sexually transmitted pathogens causing proctitis include:
- Neisseria gonorrhoeae
- Chlamydia trachomatis (including LGV serovars)
- Treponema pallidum (syphilis)
- Herpes simplex virus 1
Non-Sexually Transmitted Causes
Consider other causes if STI testing is negative:
- Inflammatory bowel disease
- Radiation proctitis
- Chemical irritation
- Trauma
- Proximal constipation 1
Special Considerations
Refractory Proctitis
If symptoms persist despite appropriate treatment:
- Reassess diagnosis with repeat cultures
- Check for treatment adherence
- Evaluate for proximal constipation (abdominal X-ray may be helpful)
- Consider alternative therapies or specialist referral 1
Emerging Pathogens
Recent evidence suggests Mycoplasma genitalium may play a role in proctitis and should be considered if testing for common pathogens is negative 2.
Management of Sexual Partners
- Partners who had sexual contact within 60 days before symptom onset should be evaluated and treated
- Both patient and partners should abstain from sexual activity until treatment is completed and symptoms have resolved 1
Follow-Up
- Follow-up should be based on specific etiology and symptom severity
- For proctitis associated with gonorrhea or chlamydia, repeat testing 3 months after treatment 1
- Persistent symptoms warrant reassessment and consideration of alternative diagnoses
Common Pitfalls to Avoid
- Failing to perform anoscopy, which is essential for proper evaluation
- Not testing for all potential STI pathogens
- Treating only the identified pathogen without considering co-infections
- Neglecting to test for HIV in patients with STI-related proctitis
- Overlooking non-sexually transmitted causes in patients without identified pathogens
By following this structured approach to diagnosis and management, clinicians can effectively address proctitis in female patients and prevent complications associated with delayed or inadequate treatment.