What is the treatment for proctitis?

Treatment of Proctitis

The recommended treatment for proctitis is ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice daily for 7 days, which should be initiated while awaiting test results for patients with acute proctitis who recently practiced receptive anal intercourse and have anorectal exudate or polymorphonuclear leukocytes on Gram stain. 1

Diagnostic Approach

• Patients presenting with proctitis symptoms (anorectal pain, tenesmus, rectal discharge, rectal bleeding) should undergo anoscopy examination to visualize the rectal mucosa and collect specimens 2
• A Gram-stained smear of anorectal exudate should be examined for polymorphonuclear leukocytes 1
• Specific pathogen testing should include:
  • HSV (PCR or culture) 2
  • N. gonorrhoeae (NAAT or culture) 2, 1
  • C. trachomatis (NAAT) 2
  • T. pallidum (darkfield if available and serologic testing) 2
• If C. trachomatis test is positive, a molecular PCR test for LGV should be performed 1
• All patients with proctitis should be tested for HIV and syphilis 1

Treatment Algorithm

Empiric Treatment

• For patients with acute proctitis of recent onset who have practiced receptive anal intercourse:
  • Ceftriaxone 250 mg IM in a single dose PLUS 1
  • Doxycycline 100 mg orally twice a day for 7 days 1

Pathogen-Specific Treatment

• For patients with bloody discharge, perianal ulcers, or mucosal ulcers suggestive of LGV:
  • Extended treatment with doxycycline 100 mg twice daily orally for a total of 3 weeks 1
• For herpes proctitis:
  • Refer to herpes simplex treatment guidelines 3
  • Note that herpes proctitis may be especially severe in HIV-infected individuals 3, 1

Follow-Up Recommendations

• Patients should abstain from sexual intercourse until they and their partner(s) have completed treatment and symptoms have resolved 1
• For proctitis associated with gonorrhea or chlamydia, retesting should be performed 3 months after treatment 4, 1
• Monitor for resolution of symptoms including rectal pain, discharge, bleeding, and tenesmus 4
• For persistent symptoms after treatment, evaluate for possible reinfection or treatment failure 4, 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 4, 1
• Both patient and partners should abstain from sexual intercourse until treatment completion and symptom resolution 4
• Follow-up should include verification that all partners have been notified and treated 4

Special Considerations

HIV Co-infection

• Patients with HIV and proctitis require more vigilant follow-up due to risk of more severe disease 4
• Herpes proctitis can be especially severe in HIV-positive patients 3, 1
• Consider more frequent monitoring for those with low immune cell counts 4

Prevention of Recurrence

• Counsel patients about safer sex practices, including consistent condom use for anal intercourse 4
• Consider more frequent STI screening for individuals with ongoing risk factors 4

Common Pitfalls

• Failing to distinguish between infectious proctitis and inflammatory bowel disease can lead to inappropriate treatment 5, 6
• Inadequate partner notification and treatment can lead to reinfection cycles 4
• Overlooking the possibility of multiple concurrent infections 7
• Not considering non-sexually transmitted causes of proctitis such as radiation, ischemia, or inflammatory bowel disease when standard therapy is ineffective 7, 8