Treatment of Proctitis
The recommended treatment for acute proctitis of recent onset in patients who have practiced receptive anal intercourse is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 7 days. 1
Diagnostic Approach
- Patients presenting with symptoms of acute proctitis (anorectal pain, tenesmus, rectal discharge) should undergo anoscopy examination 1
- A Gram-stained smear of anorectal exudate should be examined for polymorphonuclear leukocytes 1
- All patients should be evaluated for:
- HSV (by PCR or culture)
- N. gonorrhoeae (NAAT or culture)
- C. trachomatis (NAAT)
- T. pallidum (darkfield if available and serologic testing) 1
- If C. trachomatis test is positive on a rectal swab, a molecular PCR test for LGV should be performed to confirm LGV diagnosis 1
Treatment Algorithm
1. Initial Presumptive Therapy
- Initiate treatment while awaiting laboratory results for patients with:
- Anorectal exudate detected on examination
- Polymorphonuclear leukocytes detected on Gram-stained smear
- Clinical presentation consistent with acute proctitis in persons reporting receptive anal intercourse 1
2. Standard Treatment Regimen
- Ceftriaxone 250 mg IM in a single dose
- PLUS
- Doxycycline 100 mg orally twice a day for 7 days 1
3. Special Considerations Based on Clinical Presentation
For patients with bloody discharge, perianal ulcers, or mucosal ulcers among MSM with acute proctitis AND either:
- Positive rectal chlamydia NAAT, or
- HIV infection
- Provide extended treatment for LGV with doxycycline 100 mg twice daily orally for a total of 3 weeks 1
If painful perianal ulcers are present or mucosal ulcers are detected on anoscopy:
- Add presumptive therapy for genital herpes 1
Follow-Up Recommendations
- Patients should abstain from sexual intercourse until they and their partner(s) have been adequately treated (completion of 7-day regimen and resolution of symptoms) 1
- All persons with acute proctitis should be tested for HIV and syphilis 1
- For proctitis associated with gonorrhea or chlamydia, retesting for the respective pathogen should be performed 3 months after treatment 1, 2
- Follow-up should be based on specific etiology and severity of clinical symptoms 1, 2
Partner Management
- Partners who had sexual contact with persons treated for gonorrhea, chlamydia, or LGV within 60 days before symptom onset should be evaluated, tested, and treated presumptively 1, 2
- Verification that all partners have been notified and treated is important to prevent reinfection cycles 2
Common Pitfalls and Considerations
- Failing to distinguish between infectious proctitis and inflammatory bowel disease can lead to misdiagnosis and inappropriate treatment 3
- The most common sexually transmitted pathogens causing proctitis are N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV 1, 4
- In persons with HIV infection, herpes proctitis can be especially severe and may require closer monitoring 1, 2
- Inadequate partner notification and treatment can lead to reinfection cycles 2