What is the initial treatment approach for proctitis in the Emergency Department (ED)?

Emergency Department Treatment of Proctitis

The initial treatment for proctitis in the Emergency Department should include ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice daily for 7 days, especially when there is anorectal pus or polymorphonuclear leukocytes on Gram stain. 1, 2

Diagnostic Approach

• Perform anoscopy to visualize rectal mucosa and collect specimens for testing 3
• Obtain a Gram-stained smear of anorectal exudate to examine for polymorphonuclear leukocytes 1
• Collect samples for specific pathogen testing:
  • HSV (PCR or culture) 3
  • N. gonorrhoeae (NAAT or culture) 3
  • C. trachomatis (NAAT) 3
  • T. pallidum (serologic testing) 3
• Test all patients with proctitis for HIV and syphilis 1

Treatment Algorithm

For Acute Proctitis with Recent Receptive Anal Intercourse

• If anorectal pus is found on examination or polymorphonuclear leukocytes are found on Gram stain, initiate empiric therapy while awaiting test results 2:
  • Ceftriaxone 250 mg IM in a single dose (or another agent effective against anal and genital gonorrhea) 2, 1
  • PLUS Doxycycline 100 mg orally twice daily for 7 days 2, 1

For Suspected LGV Proctitis

• If bloody discharge, perianal ulcers, or mucosal ulcers are present, extend doxycycline treatment to 3 weeks (100 mg twice daily) 1
• Consider LGV testing if C. trachomatis test is positive 3

For Herpes Proctitis

• Refer to specific herpes treatment guidelines 2
• Note that herpes proctitis may be especially severe in HIV-infected patients 1, 2

Special Considerations

HIV Co-infection

• Patients with HIV require more vigilant monitoring due to risk of more severe disease 4
• Herpes proctitis can be particularly severe in HIV-positive patients 2, 1

Inflammatory Bowel Disease vs. Infectious Proctitis

• Infectious proctitis can mimic inflammatory bowel disease symptoms 5, 6
• Obtain detailed sexual history to guide diagnosis, as STIs are a common cause of proctitis that can be mistaken for IBD 6, 7
• Common sexually transmitted pathogens causing proctitis include N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV 1

Partner Management

• Sexual contacts within 60 days before symptom onset should be evaluated, tested, and treated presumptively 3, 1
• Both patient and partners should abstain from sexual intercourse until treatment completion and symptom resolution 4
• Verify that all partners have been notified and treated 4

Follow-Up Recommendations

• Patients with proctitis associated with gonorrhea or chlamydia should be retested for the respective pathogen 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, 3

Common Pitfalls

• Failing to distinguish between infectious proctitis and inflammatory bowel disease can lead to unnecessary treatments 6, 7
• Inadequate partner notification and treatment can lead to reinfection cycles 4
• Syphilitic proctitis may mimic rectal cancer or inflammatory bowel disease and requires high clinical suspicion 8