What is the treatment for proctitis?

Treatment of Proctitis

For acute sexually transmitted proctitis, immediately initiate empiric treatment with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days while awaiting diagnostic results. 1

Initial Diagnostic Evaluation

Perform anoscopy on all patients presenting with acute proctitis symptoms (anorectal pain, tenesmus, rectal discharge, or bleeding). 1

• Obtain a Gram-stained smear of anorectal exudate to identify polymorphonuclear leukocytes. 1
• Test all patients for N. gonorrhoeae using NAAT or culture. 1
• Test for C. trachomatis on rectal swab. 1
• If C. trachomatis is positive, perform molecular PCR testing specifically for lymphogranuloma venereum (LGV) serovars. 1
• Evaluate for T. pallidum and HSV, as these are among the most common sexually transmitted pathogens causing proctitis. 2, 1
• Test all patients for HIV and syphilis regardless of initial findings. 1

Treatment Algorithm

Standard Acute Proctitis (No LGV Features)

Initiate empiric therapy immediately without waiting for test results:

• Ceftriaxone 250 mg IM as a single dose 1
• PLUS Doxycycline 100 mg orally twice daily for 7 days 1

This regimen covers the most common pathogens (N. gonorrhoeae and C. trachomatis) and should be started in any patient with anorectal pus on examination or polymorphonuclear leukocytes on Gram stain. 2

LGV Proctitis (Extended Treatment Required)

If the patient presents with bloody discharge, perianal ulcers, or mucosal ulcers, extend doxycycline treatment:

• Doxycycline 100 mg orally twice daily for a total of 3 weeks 1

LGV serovars of C. trachomatis require this extended course and can cause severe proctocolitis extending beyond the rectum. 2, 1

Herpes Proctitis

• For confirmed HSV proctitis, refer to genital herpes treatment guidelines. 2
• HIV-positive patients with herpes proctitis require particularly close monitoring, as the disease can be especially severe in this population. 2, 1

Radiation-Induced (Actinic) Proctitis

This is a distinct entity occurring after pelvic radiation therapy and requires different management:

• Grade 1/2 proctitis: Topical anti-inflammatory agents such as sulfasalazine or mesalazine, alone or combined with steroids. 2
• Chronic bleeding proctitis: Argon plasma coagulation resolves 80-90% of cases with repeated applications. 2
• Refractory cases: Hyperbaric oxygen therapy induces neo-vascularization and may improve outcomes, though patient selection criteria require further study. 2
• Prevention: Hyaluronic acid suppositories as prophylaxis significantly reduce rectal toxicity in patients receiving neoadjuvant radiochemotherapy. 3

Partner Management

All sexual partners who had contact with the patient within 60 days before symptom onset must be evaluated, tested, and treated presumptively. 4, 1

• Both patient and partners must abstain from sexual intercourse until treatment completion (full 7-day regimen) and complete symptom resolution. 4, 1
• Verify that all partners have been notified and treated to prevent reinfection cycles. 4

Follow-Up Protocol

Retesting Schedule

• For gonorrhea or chlamydia-associated proctitis, retest for the specific pathogen 3 months after treatment completion. 4, 1
• For LGV proctitis, longer follow-up may be needed after completing the 3-week doxycycline course to ensure complete symptom resolution. 4

Clinical Monitoring

• Monitor for resolution of rectal pain, discharge, bleeding, and tenesmus. 4
• Repeat anoscopy or sigmoidoscopy if symptoms persist after treatment. 4
• Patients with severe initial presentation require closer follow-up to ensure complete resolution. 4

Special Populations

HIV-positive patients require more vigilant follow-up due to risk of more severe disease and opportunistic infections. 4

• Consider more frequent monitoring for those with low CD4 counts. 4
• Herpes proctitis recurrence patterns should be tracked, as they can be particularly problematic in this population. 4

Common Pitfalls to Avoid

• Failing to distinguish between reinfection and treatment failure leads to inadequate treatment and prolonged symptoms. 4
• Inadequate partner notification and treatment creates reinfection cycles—thorough contact tracing is essential. 4
• Missing LGV diagnosis results in undertreatment with only 7 days of doxycycline when 3 weeks is required. 1
• Assuming inflammatory bowel disease without obtaining sexual history can lead to unnecessary endoscopic procedures and immunosuppressive therapy when the cause is actually an STI. 5, 6

Prevention Counseling

• Counsel all patients about consistent condom use for anal intercourse to prevent recurrence. 4
• Consider more frequent STI screening intervals for individuals with ongoing risk factors, particularly men who have sex with men. 4, 7