What is the appropriate evaluation and treatment approach for proctitis?

Proctitis: Evaluation and Treatment

Immediate Diagnostic Approach

For any patient presenting with proctitis symptoms (anorectal pain, tenesmus, rectal discharge, bleeding, constipation), obtain a detailed sexual history specifically asking about receptive anal intercourse and oral-anal contact, as sexually transmitted infections are the primary cause requiring immediate empiric antimicrobial therapy. 1

Essential History Components

• Document receptive anal intercourse history, as this is the primary risk factor for sexually transmitted proctitis 1
• Ask about oral-anal contact to identify potential enteric pathogen exposure 1
• Assess HIV status in all patients, as this affects disease severity and treatment approach 1
• Obtain radiation therapy history to distinguish actinic proctitis from infectious causes 2

Physical Examination and Endoscopy

• Perform anoscopy immediately to visualize rectal mucosa and confirm inflammation limited to the distal 10-12 cm of rectum 1
• Examine Gram-stained smear of anorectal exudate for polymorphonuclear leukocytes—this finding indicates acute inflammation requiring immediate empiric treatment 1
• Identify high-risk features: bloody discharge, perianal ulcers, or mucosal ulcers suggest lymphogranuloma venereum (LGV) requiring extended 3-week treatment 1

Laboratory Testing Protocol

• Test all patients for four primary sexually transmitted pathogens: N. gonorrhoeae (NAAT or culture), C. trachomatis, T. pallidum, and HSV 1, 3
• Perform HIV and syphilis testing universally in all persons with acute proctitis 1
• If C. trachomatis is positive on rectal swab, perform molecular PCR testing specifically for LGV serovars, as this determines whether 7-day versus 3-week treatment is needed 1
• Consider Mycoplasma genitalium testing in symptomatic patients after excluding common pathogens 3

Treatment Algorithm

Empiric Treatment (Start Immediately)

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

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

Extended Treatment for LGV

For patients presenting with bloody discharge, perianal ulcers, or mucosal ulcers, extend doxycycline to 100 mg twice daily for a total of 3 weeks to adequately treat LGV proctitis 1

Pathogen-Specific Considerations

• N. gonorrhoeae and C. trachomatis (including LGV serovars) are the most common sexually transmitted pathogens causing proctitis 1, 3
• HSV proctitis can be especially severe in HIV-infected individuals and requires antiviral therapy 1
• In HIV-positive patients with severe disease, consider CMV as a cause of proctitis in immunosuppressed patients 1

Partner Management (Mandatory)

• Partners who had sexual contact within 60 days before symptom onset must be evaluated, tested, and treated presumptively 1, 4
• Both patient and partners must abstain from sexual intercourse until treatment completion (7-day regimen) and complete symptom resolution 1, 4

Follow-Up Protocol

Retesting Schedule

• For proctitis associated with gonorrhea or chlamydia, retest for the respective pathogen 3 months after treatment to detect both treatment failure and reinfection 1, 4
• For LGV proctitis, longer follow-up may be needed after completing the extended 3-week doxycycline course 4

Persistent Symptoms

• Patients with persistent symptoms after treatment require evaluation for reinfection, treatment failure, or alternative diagnoses 1, 4
• Consider repeat anoscopy or sigmoidoscopy for patients with persistent symptoms 4

Special Population Monitoring

• HIV-positive patients require more vigilant follow-up due to risk of severe disease and opportunistic infections 1, 4
• Consider more frequent monitoring for those with low immune cell counts 4

Critical Pitfalls to Avoid

• Do not confuse sexually transmitted proctitis with inflammatory bowel disease—the endoscopic appearance can be identical, but treatment differs completely (antibiotics versus immunosuppression) 2, 5, 6
• Do not wait for culture results before starting empiric treatment if polymorphonuclear leukocytes are present on Gram stain 1
• Do not use standard 7-day treatment for LGV—this requires 3 weeks of doxycycline 1
• Failing to distinguish between reinfection and treatment failure can lead to inadequate treatment and prolonged symptoms 4
• Inadequate partner notification and treatment leads to reinfection cycles 4
• Condom use does not guarantee complete protection, as infections often spread without penile penetration 1, 3

Prevention Counseling

• Counsel patients about safer sex practices including consistent condom use for anal intercourse 1, 4
• Consider more frequent STI screening for individuals with ongoing risk factors 4