What is the treatment for proctitis?

Treatment for 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. 1

Diagnosis and Etiology

Proctitis refers to inflammation of the rectum and can be caused by:

• Sexually transmitted infections (most common in those with receptive anal intercourse):

  • Neisseria gonorrhoeae
  • Chlamydia trachomatis (including LGV serovars)
  • Treponema pallidum (syphilis)
  • Herpes simplex virus (HSV) 2, 1

• Non-infectious causes:

  • Inflammatory bowel disease (ulcerative proctitis)
  • Radiation
  • Ischemia
  • Medication-induced 3

Diagnostic Approach

All patients with suspected proctitis should undergo:

1. Anoscopic examination
2. Gram-stained smear of anorectal exudate to check for polymorphonuclear leukocytes
3. Testing for:
   • HSV (PCR or culture)
   • N. gonorrhoeae (NAAT or culture)
   • C. trachomatis (NAAT)
   • T. pallidum (darkfield if available and serologic testing)
   • HIV and syphilis testing 2, 1

Treatment Algorithm

1. Infectious Proctitis (Sexually Transmitted)

• Initial empiric therapy (while awaiting test results):

  • Ceftriaxone 250 mg IM in a single dose PLUS
  • Doxycycline 100 mg orally twice a day for 7 days 2, 1

• Special considerations:

  • If bloody discharge, perianal ulcers, or mucosal ulcers are present with positive rectal chlamydia NAAT or HIV infection: extend doxycycline to 3 weeks total (for presumptive LGV) 2, 1
  • If painful perianal ulcers are present: add treatment for genital herpes (acyclovir, valacyclovir, or famciclovir) 1

2. Ulcerative Proctitis (Inflammatory)

• First-line treatment:

  • Mesalamine (5-ASA) suppository 1 g once daily 1, 4

• For inadequate response:

  • Combine topical mesalamine with oral mesalamine or topical steroids 1
  • Suppositories are preferred over enemas for proctitis as they deliver medication more effectively to the rectum 1

Follow-up and Partner Management

• Patients should abstain from sexual intercourse until they and their partner(s) have completed treatment and symptoms have resolved 2, 1
• For proctitis associated with gonorrhea or chlamydia, perform retesting 3 months after treatment 2
• Sexual partners from the past 60 days should be evaluated, tested, and treated presumptively 1

Common Pitfalls to Avoid

1. Missing co-infections: Multiple pathogens may be present simultaneously; comprehensive testing is essential 1, 5

2. Misdiagnosis: Distinguishing between infectious proctitis and inflammatory bowel disease can be challenging due to overlapping symptoms and endoscopic findings 6, 5

3. Undertreatment: Herpes proctitis can be especially severe in patients with HIV infection and may require more aggressive therapy 2, 1

4. Poor adherence: Low adherence to rectal mesalamine therapy can hinder remission in patients with ulcerative proctitis 4

5. Overlooking proximal constipation: This can affect drug delivery in distal colitis and should be addressed with laxatives if present 1

6. Inadequate follow-up: Reinfection may be difficult to distinguish from treatment failure, making proper follow-up essential 1