What is the management of proctitis?

Management of Proctitis

For proctitis, the first-line treatment is a 1 g mesalamine (5-ASA) suppository once daily, which is the most effective therapy for mild to moderate ulcerative proctitis. 1 This approach is strongly recommended based on high-quality evidence and achieves higher mucosal drug concentrations than oral therapy alone.

Diagnosis and Initial Assessment

Before initiating treatment, it's crucial to determine the etiology of proctitis:

• Inflammatory Bowel Disease (IBD) Proctitis: Typically presents with rectal bleeding, urgency, tenesmus, and mucous discharge
• Infectious Proctitis: Often associated with receptive anal intercourse; common pathogens include:
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
  • Treponema pallidum
  • Herpes simplex virus 2

Diagnostic Workup

• Anoscopy with Gram-stained smear of anorectal exudate
• Testing for STIs: HSV (PCR/culture), N. gonorrhoeae (NAAT/culture), C. trachomatis (NAAT), T. pallidum (serology)
• HIV testing is recommended for all patients with proctitis 1

Treatment Algorithm for Ulcerative Proctitis

Mild to Moderate Disease

1. First-line: 1 g 5-ASA suppository once daily (preferably at night) 1
2. If incomplete response: Add oral 5-ASA 2-3 g daily to suppository regimen
3. If still incomplete response: Switch to or add corticosteroid suppository (e.g., 5 mg prednisolone) and continue oral 5-ASA (dose-optimize to 4-4.8 g daily)

Maintenance Therapy

• 1 g 5-ASA suppository daily
• Can reduce frequency to every 2nd or 3rd day or switch to oral 5-ASA to improve adherence 1

Refractory Disease

• Oral prednisolone 40 mg once daily, weaning over 6-8 weeks
• Consider immunomodulators or biologic therapy for induction/maintenance of remission 1

Treatment for Infectious Proctitis

For acute proctitis of recent onset in persons who have practiced receptive anal intercourse:

Recommended Regimen

• Ceftriaxone 250 mg IM in a single dose
• PLUS
• Doxycycline 100 mg orally twice a day for 7 days 1

Special Considerations

• For MSM with bloody discharge, perianal ulcers, or mucosal ulcers and positive rectal chlamydia NAAT or HIV infection: Consider extending doxycycline to 3 weeks for presumptive LGV treatment
• If painful perianal ulcers are present: Add treatment for genital herpes 1
• Advise patients to abstain from sexual intercourse until they and their partner(s) have completed treatment and symptoms have resolved

Important Clinical Pearls

1. Suppositories vs. Enemas: Suppositories are preferred for proctitis as they deliver medication more effectively to the rectum and are better tolerated than enemas 1

2. Combination Therapy: Combining topical mesalamine with oral mesalamine or topical steroids is more effective than monotherapy 1

3. Common Pitfalls to Avoid:

   • Failing to distinguish between infectious and inflammatory causes of proctitis
   • Not considering proximal constipation, which may contribute to symptoms and poor treatment response
   • Overlooking co-existing irritable bowel syndrome
   • Missing other conditions that may cause symptoms (solitary rectal ulcer, psoriatic colitis, chemical colitis, rectal prolapse) 1

4. Partner Management: For infectious proctitis, sexual partners within 60 days before symptom onset should be evaluated, tested, and presumptively treated 1

5. Follow-up: For proctitis associated with gonorrhea or chlamydia, retesting should be performed 3 months after treatment 1

By following this evidence-based approach to proctitis management, clinicians can effectively treat this condition while minimizing morbidity and improving quality of life for affected patients.