What is the primary treatment for proctitis?

Treatment of Proctitis

The primary treatment for proctitis is ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 7 days, as recommended by the Centers for Disease Control and Prevention. 1

Diagnostic Approach Before Treatment

• Patients presenting with symptoms of proctitis (anorectal pain, tenesmus, rectal discharge, bleeding) should undergo anoscopy examination 1, 2
• A Gram-stained smear of anorectal exudate should be examined for polymorphonuclear leukocytes 1
• Testing should include evaluation for:
  • N. gonorrhoeae (NAAT or culture) 1
  • C. trachomatis (NAAT) 1
  • HSV (PCR or culture) 2
  • T. pallidum (darkfield if available and serologic testing) 2
• All patients should also be tested for HIV and syphilis 1

Treatment Algorithm

First-Line Treatment

• For patients with acute proctitis who recently practiced receptive anal intercourse and have anorectal exudate or polymorphonuclear leukocytes on Gram stain:
  • Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 7 days 1, 2

Special Considerations

• For patients with bloody discharge, perianal ulcers, or mucosal ulcers:
  • Extended treatment for LGV with doxycycline 100 mg twice daily orally for a total of 3 weeks 1
• For herpes proctitis:
  • Specific antiviral therapy should be initiated, especially important in HIV-positive patients where herpes proctitis can be particularly severe 3, 1

Follow-Up Management

• 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
• For proctitis associated with gonorrhea or chlamydia, retesting for the respective pathogen should be performed 3 months after treatment 4, 1
• Patients with persistent symptoms after treatment should be evaluated for:
  • Possible reinfection 4
  • Treatment failure 4
  • Alternative diagnoses such as inflammatory bowel disease 5, 6

Partner Management

• Sex partners who had contact with the patient 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

Common Pitfalls and Considerations

• Failing to distinguish between infectious proctitis and inflammatory bowel disease can lead to inappropriate treatment 5, 6
• The most common sexually transmitted pathogens causing proctitis are N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV 1
• In persons with HIV infection, herpes proctitis can be especially severe and may require closer monitoring 3, 1
• Inadequate partner notification and treatment can lead to reinfection cycles 4
• Not all cases of proctitis are sexually transmitted; other causes include radiation, ischemia, medication, and inflammatory bowel disease 5, 7

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