What is the appropriate evaluation and management of proctitis?

Evaluation and Management of Proctitis

Initial Evaluation: Distinguish Infectious from Inflammatory Causes

The first critical step is obtaining a detailed sexual history, specifically asking about receptive anal intercourse, as this determines whether you're dealing with sexually transmitted proctitis requiring immediate empiric antibiotics versus inflammatory bowel disease requiring different management. 1, 2

Essential History Components

• Ask directly about receptive anal intercourse – this is the primary risk factor for sexually transmitted proctitis and cannot be assumed based on stated sexual orientation 2, 3
• Document oral-anal contact – indicates potential enteric pathogen exposure (Shigella, Entamoeba) 2, 4
• Assess HIV status immediately – affects disease severity, treatment approach, and risk of opportunistic infections like CMV 2, 4, 5
• Characterize symptoms: anorectal pain, tenesmus, rectal discharge (bloody vs. purulent), bleeding, and constipation 2, 6

Physical Examination and Endoscopy

• Perform anoscopy to visualize the distal 10-12 cm of rectum – proctitis is defined by inflammation limited to this region 2, 3, 6
• Examine Gram-stained smear of anorectal exudate for polymorphonuclear leukocytes – presence indicates acute inflammation requiring immediate empiric treatment 1, 2, 5
• Look for specific high-risk findings: bloody discharge, perianal ulcers, or mucosal ulcers suggest lymphogranuloma venereum (LGV) requiring extended 3-week treatment 1, 2, 5

Laboratory Testing for Infectious Proctitis

• Test all patients for the four primary sexually transmitted pathogens: N. gonorrhoeae (NAAT or culture), C. trachomatis (NAAT), T. pallidum (serology), and HSV 1, 2, 4
• If C. trachomatis is positive on rectal swab, perform molecular PCR specifically for LGV serovars – this determines whether you treat for 7 days versus 3 weeks 1, 2, 5
• Perform HIV and syphilis testing in all persons with acute proctitis 1, 2, 5
• Consider Mycoplasma genitalium in symptomatic proctitis after excluding common pathogens 6

Treatment Algorithm for Infectious Proctitis

Immediate Empiric Treatment Indications

If anorectal pus is present on examination OR polymorphonuclear leukocytes are found on Gram stain, initiate empiric treatment immediately without waiting for culture results: 1, 2, 5

Standard regimen:

• Ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days 1, 2, 5

Extended Treatment for LGV

For patients with bloody discharge, perianal ulcers, or mucosal ulcers (especially MSM with positive rectal chlamydia or HIV infection), extend doxycycline to 100 mg twice daily for a total of 3 weeks to adequately treat LGV proctitis 1, 2, 5

Additional Considerations

• If painful perianal ulcers or mucosal ulcers are present, add presumptive therapy for genital herpes – HSV proctitis can be especially severe in HIV-infected individuals 1, 4, 5
• In HIV-positive patients presenting with bloody discharge or ulcers, presume both LGV and herpes and treat both empirically 1

Management of Ulcerative Proctitis (IBD)

For proctitis confirmed as ulcerative colitis (continuous mucosal inflammation from rectum, no infectious cause), topical aminosalicylates are first-line therapy and more effective than oral preparations. 1, 7, 8

Classification and Surveillance

• Proctitis alone carries colorectal cancer risk similar to general population and does not require surveillance colonoscopy – unlike left-sided or extensive colitis 1
• Note that 20-50% of patients with proctitis may develop proximal extension over time – requires monitoring 1

Treatment Approach for Ulcerative Proctitis

• Topical 5-aminosalicylates (suppositories) are first-line for inducing and maintaining remission – more effective and rapid than oral aminosalicylates or topical steroids 7, 8
• Combination of topical and oral 5-ASA should be considered for escalation 8
• For refractory cases, re-evaluate for compliance failures, infections (including C. difficile and CMV), or proximal disease extent before escalating to immunomodulators 1, 8

Partner Management and Follow-Up

Partner Notification and Treatment

• Partners who had sexual contact within 60 days before symptom onset must be evaluated, tested, and treated presumptively 1, 2, 5
• Both patient and partners should abstain from sexual intercourse until treatment completion (7-day regimen) and symptom resolution 1, 2, 5

Follow-Up Protocol

• For proctitis associated with gonorrhea or chlamydia, retest for the respective pathogen 3 months after treatment to detect treatment failure and reinfection 1, 2, 5
• Patients with persistent symptoms after treatment require evaluation for reinfection, treatment failure, or alternative diagnoses 2, 4, 5

Common Pitfalls to Avoid

• Do not assume sexual history based on stated orientation – significant proportion of women engage in anal intercourse and are at risk 3, 6
• Do not rely on condom use history to exclude STI proctitis – infections often spread without penile penetration via digital contact or toys 2, 3, 6
• Do not miss LGV in HIV-negative MSM – increasingly common and requires extended treatment 6
• Do not confuse intestinal spirochetosis (incidental finding in colonic biopsies) with syphilis 6
• In HIV-positive patients, consider opportunistic infections (CMV, Cryptosporidium, Microsporidium) as causes of severe proctitis 4, 5
• Confirm active colitis by flexible sigmoidoscopy and biopsy before starting IBD treatment – may identify unexpected causes like CMV colitis, rectal mucosal prolapse, Crohn's disease, or malignancy 1