What are the treatment options for a patient with proctitis?

Treatment of Proctitis

For ulcerative proctitis, start with mesalamine 1 gram suppositories once daily as first-line therapy, which is superior to oral therapy alone and achieves faster remission. 1, 2

Initial Diagnostic Approach

Before initiating treatment, determine the underlying etiology through:

• Sexual history and infectious workup to distinguish ulcerative proctitis from sexually transmitted infections (gonorrhea, chlamydia, syphilis, HSV, lymphogranuloma venereum) 2, 3
• Anoscopy or sigmoidoscopy with biopsy to evaluate the rectum and rule out Crohn's disease, ischemia, radiation injury, or malignancy 4, 2
• Stool testing and rectal swabs for infectious causes, particularly in patients with recent receptive anal intercourse 1

Treatment Algorithm for Ulcerative Proctitis

First-Line Therapy

• Mesalamine 1 gram suppositories once daily are the preferred initial treatment, as suppositories better target rectal inflammation and are better tolerated than enemas 1, 2
• Once-daily dosing is as effective as divided doses, simplifying adherence 1
• No dose-response benefit exists above 1 gram daily for topical therapy 1

Second-Line Therapy for Inadequate Response

If symptoms persist after 2-4 weeks:

• Add oral mesalamine 2-3 grams daily to the suppository regimen 2
• Switch to or add corticosteroid suppositories (budesonide 4 mg or hydrocortisone) while continuing oral mesalamine 4, 2
• Topical corticosteroids are superior to placebo (RR=2.83,95% CI 1.62 to 4.92) with moderate-certainty evidence 4
• Budesonide 4 mg suppository may be marginally superior to 2 mg dose (RR=0.74,95% CI 0.57 to 0.96) 4

Third-Line Therapy for Refractory Disease

For severe or refractory ulcerative proctitis:

• Initiate oral corticosteroids (prednisolone or budesonide MMX), as there is no evidence that either is more effective 4
• Consider biologics, topical tacrolimus, or small molecule therapy if corticosteroids are needed repeatedly or for maintenance 4
• Anti-TNF agents are the preferred first-line advanced therapy after conventional treatment failure (48.4% of physicians surveyed) 5

Treatment Algorithm for Infectious Proctitis

Presumptive Therapy

For patients with acute proctitis and recent receptive anal intercourse:

• Ceftriaxone 250 mg IM plus doxycycline 100 mg twice daily for 7 days as initial presumptive therapy 1, 2
• For MSM with positive rectal chlamydia or HIV infection, extend doxycycline to 3 weeks total to cover lymphogranuloma venereum 1
• Test all patients for HIV and syphilis 1, 2
• Instruct patients to abstain from sexual intercourse until they and their partners are adequately treated 1

Partner Management

• Evaluate, test, and treat all sex partners with contact within 60 days before symptom onset 2
• Retest for gonorrhea or chlamydia 3 months after treatment 6

Maintenance Therapy for Ulcerative Proctitis

Many patients rapidly respond to initial treatment and remain in remission without maintenance therapy. 4

For patients requiring maintenance:

• Continue mesalamine 1 gram suppository daily for long-term remission 2
• Alternate-night or every-third-night suppository dosing does not substantially reduce remission rates 4
• Once remission is achieved, maintenance can be accomplished with twice-weekly enemas or enemas one week per month when using the 4g/day dose 1

Critical Pitfalls to Avoid

• Assess for proximal constipation with abdominal X-ray, as fecal loading impairs drug delivery and causes treatment failure 1, 2
• Verify medication adherence and proper administration technique before declaring treatment failure 1, 2
• Rule out concurrent diagnoses such as irritable bowel syndrome, proximal constipation, infection (lymphogranuloma venereum, gonorrhea, HSV, syphilis, Giardia, amoebiasis), solitary rectal ulcer, Crohn's colitis, psoriatic colitis, chemical colitis, or rectal prolapse 4
• Consider endoscopic re-evaluation to rule out proximal extension of disease if symptoms persist 4
• Do not use rectal corticosteroids for maintenance, as they have not been studied for this indication and should only be used short-term for induction 1

Safety Considerations

• Second-generation corticosteroids like budesonide have very low risk (<1%) of adrenocortical axis suppression compared to conventional corticosteroids 1
• Short-term topical corticosteroid therapy carries low risk of systemic side effects 1
• Topical corticosteroids show no difference in significant adverse events compared with placebo in pooled data from five studies 4