From the Guidelines
Treatment for proctitis should prioritize mesalamine suppositories (1g daily) as the first-line therapy, as they have been shown to be effective in inducing and maintaining remission in patients with mild-moderate ulcerative proctitis 1.
Key Considerations
- The choice of treatment depends on the underlying cause of proctitis, with antibiotics prescribed for infectious proctitis and mesalamine suppositories or enemas for inflammatory bowel disease-related proctitis.
- Corticosteroid suppositories or enemas may be used for flare-ups, but their use should be limited due to potential long-term safety concerns.
- Supportive care, including increasing dietary fiber, adequate hydration, sitz baths, and avoiding irritants, is also essential in managing proctitis.
Treatment Options
- Mesalamine suppositories (1g daily) are the preferred treatment for mild-moderate ulcerative proctitis, with a strong recommendation and moderate quality evidence 1.
- Rectal corticosteroid therapy may be considered for patients who are intolerant of or refractory to mesalamine suppositories, but with a conditional recommendation and low quality evidence 1.
- Oral prednisone or budesonide MMX may be added for patients with refractory symptoms, but with a conditional recommendation and low quality evidence 1.
Evidence Summary
- A meta-analysis of 38 clinical trials confirmed the superiority of topical mesalamine over placebo for inducing symptomatic, endoscopic, and histological remission in proctitis and left-sided colitis 1.
- The AGA recommends using mesalamine suppositories in patients with mild-moderate ulcerative proctitis who opt for rectal therapy, with a strong recommendation and moderate quality evidence 1.
From the FDA Drug Label
The mechanism of action of mesalamine is not fully understood, but it appears to have a topical anti-inflammatory effect on the colonic epithelial cells
- Treatment for proctitis: Mesalamine is used to treat ulcerative colitis, and its topical anti-inflammatory effect on the colonic epithelial cells may be beneficial for proctitis.
- Key points:
- Mesalamine has a topical anti-inflammatory effect on the colonic epithelial cells.
- The exact mechanism of action is not fully understood.
- Mesalamine may be used to treat proctitis due to its anti-inflammatory properties 2
From the Research
Treatment for Proctitis
- The treatment for proctitis depends on the underlying cause, which can be determined through a comprehensive history, clinical evaluation, including anoscopy, and rectal nucleic amplification STI testing 3.
- For infectious proctitis, treatment should be based on specific diagnosis, and empirical therapy for acute proctitis in persons who have recently practiced receptive anal intercourse should be chosen to treat Neisseria gonorrhoeae and Chlamydia trachomatis infections 4.
- Topically administered 5-aminosalicylates (5-ASA) and corticosteroids are effective in the treatment of proctitis, although they seem to be underused in everyday practice 5.
- The combination of topical and oral 5-ASA and steroids should be considered for escalation of treatment, and refractory patients may require immunomodulators or biological therapy 5.
- Alternative medicine can be used complementarily, while experimental approaches are reserved for patients failing conventional medication, and proctocolectomy may be the last resort of treatment 5.
Specific Treatments
- For ulcerative proctitis, the short-term goal of treatment is to induce remission, whereas long-term goals are to maintain remission and prevent disease progression 5.
- For sexually acquired proctitis and proctocolitis, treatment should be based on specific diagnosis, and empirical therapy should be chosen to treat Neisseria gonorrhoeae and Chlamydia trachomatis infections 4.
- For proctitis caused by other pathogens, such as Herpes Simplex virus and Treponema pallidum, treatment should be specific to the underlying cause 6, 7.
Considerations
- The risk of proctitis appears to be higher in individuals participating in anal intercourse, especially men having sex with men (MSM) or subjects who use sex toys and participate in sex parties, dark rooms, and so on 6, 7.
- The involvement of experts in infectious diseases and in sexual health is crucial for the diagnostic and therapeutic management of proctitis 7.
- Simultaneous infections by multiple organisms should be considered, and particular emphasis should be given to this possibility in the diagnosis and treatment of proctitis 7.