What is the management for proctitis?

Management of Proctitis

For ulcerative proctitis, start with 1 gram mesalamine suppositories once daily as first-line therapy, which is superior to oral therapy alone and achieves faster remission. 1

Initial Assessment and Differential Diagnosis

Before initiating treatment, determine the underlying etiology through:

• Sexual history: Specifically ask about receptive anal intercourse, number of partners, and use of sex toys, as sexually transmitted infections (STIs) are increasingly common causes, particularly in men who have sex with men 2, 3, 4
• Endoscopic evaluation: Perform anoscopy or sigmoidoscopy with biopsy to distinguish ulcerative proctitis from infectious causes 2
• Infectious workup: Collect samples for Gram stain, HSV, N. gonorrhoeae, C. trachomatis, T. pallidum, and consider Mycoplasma genitalium in symptomatic cases after excluding common pathogens 2, 5, 4
• Rule out mimics: Exclude proximal constipation (obtain abdominal X-ray), irritable bowel syndrome, Crohn's disease, solitary rectal ulcer, rectal prolapse, radiation proctitis, and ischemia 1

Management of Ulcerative Proctitis

Mild to Moderate Disease

Step 1: Initiate topical therapy

• Start mesalamine 1 gram suppository once daily (typically at night) 1, 2
• Suppositories are preferred over enemas because they deliver drug specifically to the rectum, are better tolerated, and achieve higher mucosal concentrations 1, 2
• No dose-response benefit exists above 1 gram daily 2

Step 2: If incomplete response after adequate trial

• Add oral mesalamine 2-3 grams daily to the suppository regimen 1
• Combination topical plus oral therapy is more effective than either alone 1

Step 3: If still inadequate response

• Switch to or add corticosteroid suppository (e.g., prednisolone 5 mg) while continuing oral mesalamine 1
• Optimize oral mesalamine dose to 4-4.8 grams daily 1
• Alternatively, consider budesonide foam or hydrocortisone foam, which show comparable efficacy (53% vs 52% remission rates) and may be better tolerated 2

Step 4: For refractory disease

• Initiate oral prednisolone 40 mg once daily, weaning over 6-8 weeks 1
• For patients failing conventional therapy, consider immunomodulators and/or biological therapy 1
• Tacrolimus, clinical trials, or surgery may be considered for non-responsive cases 1

Maintenance Therapy

• Continue mesalamine 1 gram suppository daily for long-term remission 1
• For adherence issues, reduce frequency to every 2nd or 3rd day, or switch to oral mesalamine alone 1
• Alternatively, use twice-weekly enemas or enemas one week per month when using 4 grams/day dose 2
• Patients with infrequent flares may use suppositories on-demand rather than continuous maintenance, as colorectal cancer risk in proctitis equals the general population 1

Management of Infectious Proctitis

Presumptive Therapy for Acute Proctitis

For patients with acute proctitis symptoms who recently practiced receptive anal intercourse:

• Ceftriaxone 250 mg IM plus doxycycline 100 mg twice daily for 7 days 2
• For MSM with acute proctitis and either positive rectal chlamydia or HIV infection, extend doxycycline to 100 mg twice daily for 3 weeks total to cover lymphogranuloma venereum 2, 4
• Test all patients for HIV and syphilis 2

Pathogen-Specific Considerations

• Herpes proctitis: May require longer follow-up, especially in HIV-positive patients where disease can be severe 6
• Mycoplasma genitalium: Consider in symptomatic proctitis after excluding N. gonorrhoeae, C. trachomatis, syphilis, and herpes 4
• Shigellosis: Can cause proctocolitis or enteritis via oral-anal contact 4

Partner Management and Follow-Up

• Evaluate, test, and treat presumptively all sex partners with contact within 60 days before symptom onset 6
• Instruct patients and partners to abstain from sexual intercourse until treatment completion and symptom resolution 2, 6
• Retest for gonorrhea or chlamydia 3 months after treatment 6

Management of Radiation (Actinic) Proctitis

• Distinguish from other causes in patients with history of pelvic radiation therapy through endoscopic evaluation 7
• Hyaluronic acid suppositories as prophylaxis significantly reduce rectal toxicity during neoadjuvant radiochemotherapy 7

Critical Pitfalls to Avoid

• Assess adherence and proper administration technique before declaring treatment failure 1, 2
• Check for proximal constipation with abdominal X-ray, as fecal loading impairs drug delivery and causes treatment failure 1, 2
• Obtain sexual history even when IBD seems likely, as STIs can mimic ulcerative colitis and inappropriate IBD therapy may worsen infectious proctitis 3
• Distinguish reinfection from treatment failure in infectious cases to avoid inadequate treatment 6
• Use rectal corticosteroids only short-term for induction, not maintenance, as they have not been studied for long-term use 2
• Verify complete partner notification and treatment to prevent reinfection cycles 6