What is the recommended treatment approach for a patient with proctocolitis?

Treatment of Proctocolitis

For sexually transmitted proctocolitis in patients with recent receptive anal intercourse, initiate empirical treatment immediately with ceftriaxone 250 mg IM plus doxycycline 100 mg orally twice daily for 7 days while awaiting diagnostic results. 1, 2

Diagnostic Evaluation

Before initiating treatment, perform the following assessments:

• Anoscopy or sigmoidoscopy to visualize inflammation extending up to 12 cm above the anus and obtain samples for diagnostic testing 1, 2
• Stool examination for fecal leukocytes and enteric pathogens including Campylobacter, Shigella, Entamoeba histolytica, and C. difficile toxin 1
• Testing for sexually transmitted pathogens: N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV 1, 3
• HIV testing for all patients, as HIV infection significantly affects disease severity and treatment approach 1, 2

Treatment Based on Etiology

Sexually Transmitted Proctocolitis

Empirical therapy should cover gonorrhea, chlamydia (including LGV), and syphilis while awaiting culture results:

• Ceftriaxone 250 mg IM as a single dose 1, 2
• Plus doxycycline 100 mg orally twice daily for 7 days 1, 2

For MSM with acute proctocolitis and either positive rectal chlamydia NAAT or HIV infection, extend doxycycline to 3 weeks total to cover potential LGV. 2, 3

In HIV-infected patients, herpes proctitis may be especially severe and requires specific antiviral treatment. 1

Ulcerative Proctocolitis (Inflammatory Bowel Disease)

When inflammatory bowel disease is confirmed as the cause:

First-line treatment:

• Mesalamine 1 g suppository once daily for disease limited to the rectum 4, 5, 2
• Mesalamine enemas (at least 1 g daily) for disease extending into the sigmoid colon 4, 5

Combination therapy for enhanced efficacy:

• Add oral mesalamine 2.4-4.8 g once daily to topical therapy for more extensive or refractory disease 1, 4, 6
• Topical mesalamine combined with oral mesalamine is more effective than either agent alone 1, 4

Second-line options for inadequate response:

• Rectal corticosteroids (budesonide or hydrocortisone foam) if mesalamine is not tolerated or ineffective 4, 5
• Oral prednisone 40 mg daily for patients failing optimized oral and rectal 5-ASA therapy 1

Enteric Pathogens

For Campylobacter, Shigella, or Entamoeba histolytica identified on stool culture, treat based on specific pathogen sensitivities. 1

For C. difficile coinfection (more prevalent in UC patients):

• Oral vancomycin is the preferred treatment 1
• Stop immunosuppressive therapy if possible, though this may not always be warranted 1
• Consider fecal microbiota transplant for refractory cases 1

Special Populations

HIV-Infected Patients

• Herpes proctitis is particularly severe and requires aggressive antiviral therapy 1
• CMV and other opportunistic pathogens (Mycobacterium avium-intracellulare, Cryptosporidium, Microsporidium, Isospora) may be involved in immunosuppressed patients 1
• Multiple stool examinations with special preparations may be necessary to identify opportunistic pathogens 1

Pregnancy

• Pregnancy is not a contraindication to mesalamine or corticosteroid therapy 6

Refractory Disease Management

Before declaring treatment failure, systematically evaluate:

• Medication adherence and proper administration technique 1, 5
• Proximal constipation with abdominal X-ray, as fecal loading impairs drug delivery 1, 5
• Unrecognized complications such as infection, irritable bowel syndrome, Crohn's disease, mucosal prolapse, or cancer 1, 2

For confirmed refractory ulcerative proctocolitis:

• Intravenous corticosteroids (methylprednisolone 60 mg daily or hydrocortisone 100 mg four times daily) 1
• Biologic therapy (infliximab, adalimumab, golimumab, or vedolizumab) for steroid-dependent or steroid-refractory disease 1
• Surgical consultation for colectomy if medical therapy fails 1

Critical Pitfalls to Avoid

• Do not delay empirical antibiotic treatment in sexually transmitted proctocolitis while awaiting stool microbiology results 1
• Do not use rectal corticosteroids as first-line therapy instead of mesalamine for ulcerative proctocolitis 4, 5
• Do not switch between different oral 5-ASA formulations when initial therapy fails; instead, optimize dosing or add topical therapy 4
• Do not overlook C. difficile testing, as it is associated with increased morbidity and mortality in UC patients 1
• Do not continue ineffective corticosteroid therapy beyond 7-10 days, as this increases morbidity without additional benefit 1

Monitoring and Follow-Up

• Evaluate response to therapy within 4-8 weeks to determine if treatment modification is needed 4
• Instruct patients to abstain from sexual intercourse until they and their partners have been adequately treated for sexually transmitted infections 2
• Test all persons with acute proctitis for HIV and syphilis 2