What is the treatment for proctitis?

Treatment of Proctitis

For acute sexually transmitted proctitis, 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, 2

Diagnostic Workup

Patients presenting with symptoms of acute proctitis require immediate anoscopy examination to visualize the rectal mucosa and identify anorectal exudate. 1, 2 The diagnostic approach should include:

• Gram stain of anorectal exudate to detect polymorphonuclear leukocytes, which indicates active inflammation requiring presumptive treatment 1, 2
• NAAT or culture for N. gonorrhoeae as this is one of the most common sexually transmitted pathogens 1, 2
• NAAT for C. trachomatis on rectal swab, followed by PCR testing for LGV if positive 1, 2
• HSV testing by PCR or culture to identify herpetic proctitis 1
• T. pallidum testing including darkfield microscopy if available and serologic testing 1

The most common sexually transmitted pathogens causing proctitis are N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV. 2

Treatment Algorithm

Standard Acute Proctitis (Presumptive Treatment)

Initiate empiric therapy immediately for patients with:

• Anorectal exudate detected on examination, OR
• Polymorphonuclear leukocytes on Gram stain, OR
• Clinical presentation consistent with acute proctitis in persons reporting receptive anal intercourse when anoscopy/Gram stain unavailable 1

Recommended regimen:

• Ceftriaxone 250 mg IM single dose 1, 2
• PLUS Doxycycline 100 mg orally twice daily for 7 days 1, 2

Extended Treatment for Suspected LGV

Extend doxycycline to 100 mg twice daily for 3 weeks total for patients with: 1, 2

• Bloody discharge, OR
• Perianal ulcers, OR
• Mucosal ulcers on anoscopy

AND either:

• Positive rectal chlamydia NAAT, OR
• HIV infection 1, 2

This extended regimen is critical because LGV requires longer treatment duration than non-LGV chlamydial infections. 1

Herpes Proctitis

If painful perianal ulcers or mucosal ulcers are present on anoscopy, add presumptive therapy for genital herpes to the standard regimen. 1 This is particularly important in HIV-infected patients, where herpes proctitis can be especially severe. 2, 3

Management Considerations

Sexual Abstinence

Patients must abstain from sexual intercourse until both they and their partner(s) complete the full 7-day treatment regimen and symptoms have resolved. 1, 2 This prevents transmission and reinfection cycles. 3

HIV and Syphilis Testing

All persons with acute proctitis should be tested for HIV and syphilis regardless of the identified pathogen. 1, 2 This is a critical step that should not be omitted.

Follow-Up Protocol

Timing of Retesting

For gonorrhea or chlamydia-associated proctitis, retest for the respective pathogen 3 months after treatment completion. 1, 2, 3 This detects both treatment failures and reinfections.

Symptom-Based Follow-Up

Follow-up intensity should be based on the specific etiology and severity of clinical symptoms at presentation. 1 Patients with severe initial presentations require closer monitoring to ensure complete resolution. 3

Partner Management

All partners who had sexual contact within 60 days before symptom onset must be evaluated, tested, and presumptively treated for the identified pathogen. 1, 2, 3 This is non-negotiable for breaking transmission chains. Inadequate partner notification and treatment leads to reinfection cycles, which is a common pitfall in proctitis management. 3

Common Pitfalls to Avoid

• Delaying empiric treatment while awaiting test results in patients with anorectal exudate or positive Gram stain—this allows disease progression and continued transmission 1
• Failing to extend doxycycline to 3 weeks when LGV is suspected based on clinical presentation (bloody discharge, ulcers) in high-risk patients 1, 2
• Inadequate partner tracing and treatment, which perpetuates reinfection cycles 3
• Failing to distinguish between reinfection and treatment failure at follow-up, which can lead to inappropriate management 3

Special Population: Non-Sexually Transmitted Proctitis

For radiation-induced proctitis (actinic proctitis), the treatment approach differs entirely. This occurs in patients with history of pelvic radiation therapy and requires endoscopic confirmation. 4 Hyaluronic acid suppositories can be used prophylactically to reduce rectal toxicity. 4 For ulcerative proctitis (idiopathic inflammatory bowel disease limited to rectum), topical 5-aminosalicylic acid or corticosteroids are first-line treatments. 5, 6, 7