Initial Workup for Proctitis
The initial workup for a patient presenting with proctitis should include anoscopy with collection of samples for Gram stain of anorectal exudate to check for polymorphonuclear leukocytes, and testing for HSV, N. gonorrhoeae, C. trachomatis, and T. pallidum. 1
Diagnostic Approach
Clinical Assessment
- Evaluate for symptoms including anorectal pain, tenesmus, rectal discharge, rectal bleeding, constipation, and diarrhea 1
- Obtain detailed sexual history, particularly regarding receptive anal intercourse, which is a major risk factor for sexually transmitted proctitis 1
- Assess for HIV status, as herpes proctitis can be especially severe in HIV-infected individuals 1
Initial Laboratory Testing
- Perform anoscopy to visualize the rectal mucosa and collect specimens 1
- Obtain Gram-stained smear of anorectal exudate to examine for polymorphonuclear leukocytes 1
- Collect samples for specific pathogen testing:
- If C. trachomatis test is positive, perform molecular PCR test for LGV to confirm LGV diagnosis 1
- Test for HIV and syphilis in all patients with acute proctitis 1
Additional Testing Based on Clinical Presentation
- For patients with diarrhea or abdominal cramps suggesting proctocolitis, collect stool samples to test for:
- For patients with enteritis symptoms without proctitis signs, consider testing for:
Differential Diagnosis
Infectious Causes
- Sexually transmitted infections: N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV 1
- Enteric pathogens: Campylobacter, Shigella, Entamoeba histolytica 1
- In HIV-infected patients: CMV, opportunistic infections 1
Non-Infectious Causes
- Inflammatory bowel disease (ulcerative colitis) 1, 2
- Radiation proctitis 3
- Ischemic proctitis 3
- Medication-induced proctitis 3
- Traumatic proctitis 4
Management Considerations
Presumptive Treatment
For patients with acute proctitis who recently practiced receptive anal intercourse and have anorectal exudate or polymorphonuclear leukocytes on Gram stain, initiate presumptive therapy while awaiting test results 1:
- Ceftriaxone 250 mg IM in a single dose PLUS
- Doxycycline 100 mg orally twice a day for 7 days 1
For patients with bloody discharge, perianal ulcers, or mucosal ulcers who are MSM with acute proctitis and either positive rectal chlamydia NAAT or HIV infection, offer presumptive treatment for LGV:
- Doxycycline 100 mg twice daily orally for a total of 3 weeks 1
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, 5
- Instruct patients to abstain from sexual intercourse until they and their partner(s) have been adequately treated (completion of treatment regimen and resolution of symptoms) 1
Follow-Up Recommendations
- For proctitis associated with gonorrhea or chlamydia, perform retesting for the respective pathogen 3 months after treatment 1, 5
- Monitor for resolution of symptoms including rectal pain, discharge, bleeding, and tenesmus 5
- For persistent symptoms after treatment, evaluate for possible reinfection or treatment failure 5
Common Pitfalls
- Failing to consider infectious proctitis in patients with suspected inflammatory bowel disease, leading to misdiagnosis and inappropriate treatment 2, 6
- Inadequate sexual history taking, missing key risk factors for sexually transmitted proctitis 6
- Failing to test for co-infections, particularly HIV in patients with sexually transmitted proctitis 1, 6
- Inadequate partner notification and treatment, leading to reinfection cycles 5