What is the management of proctitis?

Management of Proctitis

The initial treatment for proctitis should be ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 7 days while awaiting diagnostic test results, as this addresses the most common infectious causes and reduces morbidity and mortality. 1

Diagnostic Approach

• Perform anoscopic examination to visualize rectal mucosa and identify:

  • Presence of anorectal exudate
  • Mucosal ulcerations
  • Perianal lesions
  • Signs of inflammation

• Obtain laboratory testing for common infectious causes:

  • Neisseria gonorrhoeae (NAAT and culture)
  • Chlamydia trachomatis (NAAT)
  • Herpes Simplex Virus (PCR)
  • Syphilis serology
  • HIV testing (mandatory for all patients with proctitis) 1, 2
  • Consider testing for Mycoplasma genitalium 2

Treatment Algorithm

1. Infectious Proctitis

Empiric Treatment

• Start empiric therapy if any of the following are present:

  • Anorectal exudate
  • Polymorphonuclear leukocytes on Gram stain
  • Clinical presentation consistent with acute proctitis 1

• First-line empiric regimen:

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

Specific Pathogen Management

• For suspected LGV (bloody discharge, perianal ulcers, mucosal ulcers with positive rectal chlamydia NAAT or HIV infection):

  • Extend doxycycline treatment to 3 weeks total 1

• For suspected/confirmed HSV (painful perianal ulcers):

  • Add one of the following:
    • Acyclovir
    • Valacyclovir
    • Famciclovir 1

2. Inflammatory Proctitis (e.g., Ulcerative Proctitis)

• First-line treatment:

  • Mesalamine (5-ASA) suppository 1g once daily 1

• For inadequate response:

  • Combine topical mesalamine with oral mesalamine OR
  • Combine topical mesalamine with topical steroids 1

• For refractory disease:

  • Consider IV steroid therapy
  • Alternative topical therapies
  • Surgical options in severe cases 1

Partner Management and Follow-up

• Sexual partners from past 60 days should be:

  • Evaluated
  • Tested
  • Treated presumptively 1

• Both patient and partners should abstain from sexual intercourse until:

  • Treatment completion
  • Symptom resolution 1

• Follow-up testing:

  • Retest for gonorrhea or chlamydia 3 months after treatment 1

Important Clinical Considerations

• Multiple pathogens may be present simultaneously, necessitating comprehensive testing 1, 3

• Suppositories are preferred over enemas for proctitis as they:

  • Deliver medication more effectively to the rectum
  • Are better tolerated by patients 1

• Address proximal constipation if present, as it can affect drug delivery in distal colitis 1

• The incidence of infectious proctitis is rising, especially in men who have sex with men 3

• Symptoms of proctitis can overlap between infectious and inflammatory causes, including:

  • Rectal bleeding
  • Mucous discharge
  • Anorectal pain
  • Tenesmus
  • Diarrhea or constipation 3, 4

• Herpes proctitis can be particularly severe in patients with HIV 1

• Distinguishing between infectious proctitis and inflammatory bowel disease is crucial for appropriate management 1, 5