What is the management approach for proctitis?

Management Approach for Proctitis

The management of proctitis depends on its etiology, with topical mesalamine 1g suppositories once daily being the preferred initial treatment for mild to moderate ulcerative proctitis, while sexually transmitted proctitis requires antibiotic therapy with ceftriaxone 250mg IM plus doxycycline 100mg twice daily for 7 days. 1

Diagnostic Approach

• First, determine the etiology of proctitis through clinical history, physical examination, and appropriate diagnostic tests 1
• For suspected ulcerative proctitis, perform endoscopy with biopsy 1
• For suspected infectious proctitis, especially in those with history of receptive anal intercourse, perform anoscopy and collect samples for:
  • Gram stain of anorectal exudate for polymorphonuclear leukocytes 1
  • Testing for HSV (PCR or culture), N. gonorrhoeae (NAAT or culture), C. trachomatis (NAAT), and T. pallidum (darkfield if available and serologic testing) 1
  • If C. trachomatis test is positive, perform PCR for LGV if available 1
• Rule out other potential causes such as irritable bowel syndrome, Crohn's disease, mucosal prolapse, or cancer 1

Management of Ulcerative Proctitis

First-line Treatment

• Topical mesalamine (5-ASA) 1g suppository once daily is the preferred initial treatment for mild to moderate ulcerative proctitis 1
• Suppositories are more appropriate than enemas for proctitis as they better target the site of inflammation and are better tolerated 1
• There is no dose response for topical therapy above 1g 5-ASA daily 1
• Once-daily topical therapy is as effective as divided doses 1

Alternative or Adjunctive Treatments

• Mesalamine foam or enemas are alternatives to suppositories 1
• Topical mesalamine is more effective than topical steroids 1
• Combining topical mesalamine with oral mesalamine or topical steroids is more effective than monotherapy 1
• For patients with visible fecal loading, consider a laxative as abnormal intestinal motility can induce proximal colonic stasis and affect drug delivery 1

Management of Refractory Ulcerative Proctitis

• Refractory proctitis may require treatment with systemic steroids, immunosuppressants, and/or biologics 1
• Consider IV steroid therapy for patients who fail oral corticosteroids combined with oral and rectal 5-ASA therapy 1
• Alternative salvage therapies include oral or rectal cyclosporine, oral or rectal tacrolimus, or infliximab 1
• If disease persists despite medical therapy, surgery may be necessary 1

Management of Infectious Proctitis

Empiric Treatment

• For patients with symptoms of acute proctitis who recently practiced receptive anal intercourse, or when anorectal exudate or polymorphonuclear leukocytes are detected on Gram stain, initiate presumptive therapy: 1
  • Ceftriaxone 250mg IM in a single dose PLUS
  • Doxycycline 100mg orally twice a day for 7 days

Special Considerations

• For MSM with acute proctitis and either a positive rectal chlamydia NAAT or HIV infection who present with bloody discharge, perianal ulcers, or mucosal ulcers:
  • Offer presumptive treatment for LGV with doxycycline 100mg twice daily for a total of 3 weeks 1
  • If painful perianal ulcers are present or mucosal ulcers are detected on anoscopy, add treatment for genital herpes 1
• Patients with HIV infection and acute proctitis may present with bloody discharge, painful perianal ulcers, or mucosal ulcers and should receive presumptive treatment for both genital herpes and LGV 1

Follow-up and Partner Management

• Instruct patients to abstain from sexual intercourse until they and their partner(s) have been adequately treated 1
• Test all persons with acute proctitis for HIV and syphilis 1
• For proctitis associated with gonorrhea or chlamydia, retest for the respective pathogen 3 months after treatment 1
• Evaluate, test, and presumptively treat partners who had sexual contact with the patient within 60 days before symptom onset 1

Common Pitfalls and Caveats

• Failure to recognize infectious causes of proctitis, especially in patients with risk factors for sexually transmitted infections, can lead to misdiagnosis as inflammatory bowel disease and inappropriate treatment 2, 3
• Poor adherence to prescribed therapy is a common cause of treatment failure in ulcerative proctitis 1
• Always consider alternative explanations for refractory proctitis, including:
  • Inadequate concentration of the active drug reaching the inflamed mucosa 1
  • Unrecognized complications such as proximal constipation or infection 1
  • Inappropriate diagnosis 1
• For patients with allergic reactions to penicillin, especially IgE-mediated reactions (anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis), ceftriaxone is contraindicated 1