What is the treatment for proctitis?

Treatment for Proctitis

The treatment for proctitis depends on its etiology, with infectious proctitis requiring ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 7 days as initial empiric therapy, while ulcerative proctitis is best treated with 1 g mesalamine suppository once daily. 1

Diagnostic Approach

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

• Infectious vs. Inflammatory: Distinguish between infectious causes (sexually transmitted infections) and inflammatory causes (ulcerative proctitis)
• Required Testing:
  • Anoscopic examination
  • Gram-stained smear of anorectal exudate
  • Testing for HSV, N. gonorrhoeae, C. trachomatis, T. pallidum
  • HIV and syphilis testing for all patients with acute proctitis 1

Treatment Algorithm

1. Infectious Proctitis

• Initial Empiric Therapy:

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

• Special Considerations:

  • For patients with bloody discharge, perianal ulcers, mucosal ulcers, positive rectal chlamydia NAAT, or HIV infection: Extend doxycycline to 3 weeks total for presumptive LGV treatment 1
  • For herpes proctitis: Add acyclovir, valacyclovir, or famciclovir (especially important in HIV-positive patients) 1

• Patient Management:

  • Abstain from sexual intercourse until patient and partner(s) complete treatment and symptoms resolve
  • Evaluate, test, and treat sexual partners from the past 60 days
  • Perform retesting 3 months after treatment for gonorrhea or chlamydia 1

2. Ulcerative Proctitis (Inflammatory)

• First-Line Treatment:

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

• For Enhanced Efficacy:

  • Consider combining topical mesalamine with oral mesalamine or topical steroids 1
  • Suppositories are preferred over enemas for better medication delivery to the rectum and improved tolerance 1

• For Refractory Disease:

  • Consider IV steroid therapy, alternative topical therapies, or surgical options 1

Important Clinical Considerations

• Medication Delivery: Address proximal constipation with laxatives if present, as it can affect drug delivery in distal colitis 1

• Adherence Issues: Consider reducing frequency or switching to oral 5-ASA if adherence is a problem 1, 2

• Diagnostic Pitfalls:

  • Infectious proctitis (particularly chlamydial) can mimic inflammatory bowel disease 3
  • Always obtain a thorough sexual history to guide appropriate testing 3
  • Multiple pathogens may be present simultaneously 1

• Treatment Response:

  • Empirical therapy for infectious proctitis results in more rapid resolution of symptoms compared to waiting for specific diagnoses 4
  • However, approximately 25% of patients, primarily those with unrecognized herpes simplex virus proctitis, may not respond to standard empirical therapy 4

• Disease Progression:

  • In ulcerative proctitis, approximately 10% of patients may experience disease extension to involve the colon 5
  • Proper treatment of ulcerative proctitis is important for improving long-term prognosis 2

Treatment Efficacy

• Topical mesalamine acts more effectively and rapidly to induce and maintain remission compared to oral mesalamine or topical steroids for ulcerative proctitis 6

• Mesalamine suppositories are more effective than dose intensification of oral mesalamine for patients who relapse while on maintenance doses of oral mesalamine 2