Treatment of Proctitis
Treatment depends on etiology: for infectious proctitis in patients with recent receptive anal intercourse, start ceftriaxone 250mg IM plus doxycycline 100mg twice daily for 7 days immediately; for ulcerative proctitis, use topical mesalamine 1g suppository once daily as first-line therapy. 1, 2
Initial Diagnostic Workup
Before initiating treatment, determine the underlying cause through:
- Anoscopy with collection of anorectal exudate for Gram stain to identify polymorphonuclear leukocytes 1, 2
- Testing for sexually transmitted pathogens: N. gonorrhoeae, C. trachomatis, HSV, and T. pallidum using NAAT or culture 1, 2
- Endoscopy with biopsy if ulcerative proctitis is suspected to rule out inflammatory bowel disease 1
- HIV and syphilis testing for all patients presenting with acute proctitis 2
A common pitfall is failing to obtain a complete sexual history, which can lead to misdiagnosis as inflammatory bowel disease when the true cause is infectious 3.
Treatment Algorithm for Infectious Proctitis
Standard Empirical Therapy
Initiate immediately for patients with acute proctitis who recently practiced receptive anal intercourse:
- Ceftriaxone 250mg IM single dose PLUS doxycycline 100mg orally twice daily for 7 days 1, 2
- This regimen covers the most common sexually transmitted pathogens (N. gonorrhoeae and C. trachomatis) 2
Extended Therapy for Lymphogranuloma Venereum (LGV)
Escalate to extended treatment if:
- Bloody discharge is present 2
- Perianal or mucosal ulcers are identified 2
- Patient is MSM with HIV infection and positive rectal chlamydia NAAT 1
- Molecular PCR confirms LGV serovars 2
Extended regimen: Doxycycline 100mg orally twice daily for a total of 3 weeks 1, 2
Special Considerations for HIV-Positive Patients
- Herpes proctitis can be especially severe in HIV-infected individuals and may require closer monitoring 2
- Consider more vigilant follow-up due to risk of opportunistic infections 4
Treatment Algorithm for Ulcerative Proctitis
First-Line Therapy
Topical mesalamine 1g suppository once daily is the preferred initial treatment for mild to moderate ulcerative proctitis 1
Key evidence-based principles:
- Suppositories are superior to enemas for proctitis because they better target the site of inflammation and are better tolerated 1
- Once-daily dosing is as effective as divided doses, simplifying the regimen 1
- No dose-response benefit above 1g daily, so higher doses are unnecessary 1
- Topical aminosalicylates act more effectively and rapidly than oral aminosalicylates or topical steroids 5
Refractory Cases
For ulcerative proctitis that fails to respond to topical therapy, consider:
Patient Management During Treatment
Sexual Activity Restrictions
- Patients must abstain from sexual intercourse until both they and their partner(s) complete treatment (7-day regimen) and symptoms resolve 1, 2
- This prevents reinfection cycles, which is a common pitfall when inadequate partner notification occurs 4
Partner Management
- All sex partners within 60 days before symptom onset must be evaluated, tested, and treated presumptively 1, 2
- Verify that all partners have been notified and treated to ensure complete outbreak resolution 4
Follow-Up Protocol
Retesting Schedule
- Retest for gonorrhea or chlamydia 3 months after treatment completion 4, 2
- For LGV proctitis, longer follow-up may be needed after the 3-week doxycycline course 4
Monitoring Parameters
- Resolution of rectal pain, discharge, bleeding, and tenesmus 4
- Repeat anoscopy or sigmoidoscopy for persistent symptoms to evaluate for treatment failure versus reinfection 4
- Patients with severe initial presentation warrant closer follow-up 4
Distinguishing Treatment Failure from Reinfection
A critical pitfall is failing to distinguish between these two scenarios, which can lead to inadequate treatment 4. Consider: