From the Guidelines
Proctitis should be treated with mesalamine suppositories (1g daily) as first-line therapy for mild-moderate ulcerative proctitis, according to the AGA clinical practice guidelines 1. This recommendation is based on moderate quality evidence and is a strong recommendation. The treatment of proctitis depends on the underlying cause, and for inflammatory bowel disease-related proctitis, mesalamine suppositories or enemas are the preferred treatment options. Some key points to consider in the treatment of proctitis include:
- Mesalamine suppositories are recommended for patients with mild-moderate ulcerative proctitis who choose rectal therapy over oral therapy 1.
- Rectal corticosteroid therapy may be considered for patients who are intolerant of or refractory to mesalamine suppositories 1.
- Supportive care, such as sitz baths, increased fiber intake, and pain management, is also important in the treatment of proctitis.
- Persistent symptoms warrant further investigation with sigmoidoscopy or colonoscopy to confirm diagnosis and rule out other conditions. The inflammation in proctitis involves mucosal damage and immune cell infiltration, which explains the characteristic symptoms and guides targeted therapy approaches. It is essential to note that the treatment of proctitis should be individualized based on the underlying cause and severity of the disease, and patients should be closely monitored for response to therapy and potential complications. In addition to mesalamine suppositories, other treatment options may be considered, such as hydrocortisone suppositories (25mg twice daily) as an alternative, or sucralfate enemas (2g in 20ml water twice daily) or oral sulfasalazine (1g three times daily) for radiation proctitis. However, the AGA clinical practice guidelines provide a strong recommendation for the use of mesalamine suppositories as first-line therapy for mild-moderate ulcerative proctitis 1.
From the Research
Definition and Symptoms of Proctitis
- Proctitis refers to inflammation of the rectum, which can be diagnosed through endoscopic evaluation 2
- Symptoms of proctitis include rectal bleeding, urgency, tenesmus, diarrhea or constipation, and occasionally rectal pain 2
- Proctitis can also be characterized by anorectal itching, pain, cramps, and discharge in and around the anal canal 3
Causes of Proctitis
- The causes of proctitis include infection, medication, ischemia, radiation, and ulcerative proctitis 2
- Sexually transmitted infections (STIs) such as gonorrhea, chlamydia, and syphilis can also cause proctitis 3, 4, 5
- Other causes of proctitis include Herpes Simplex Virus, Treponema pallidum, and Mycoplasma genitalium 3, 4, 5
Diagnosis and Treatment of Proctitis
- A presumptive clinical diagnosis of proctitis can be made when there are symptoms and signs, and a definitive diagnosis when the results of laboratory tests are available 3
- Topical aminosalicylates are effective first-line agents in ulcerative proctitis and distal UC, and can act more effectively and rapidly to induce and maintain remission compared to oral counterparts or topical steroids 2
- In cases of refractory proctitis, systemic corticosteroids, antibiotics, immunomodulators, or surgery may be required 2
- A comprehensive history, clinical evaluation, and rectal nucleic amplification STI testing may be useful in identifying the cause of proctitis and targeting treatment 5
Management of Intractable Proctitis
- Medically refractory proctitis poses particular problems, and unusual therapies, often delivered locally by enema or suppository, have been tested in small case series without definitive outcomes 6
- The management of intractable proctitis is made more challenging by the wide differential diagnosis that must be considered and by the paucity of high-quality clinical trials to support any one therapy 6
- Key strategies to overcoming these limitations include methodical and systematic investigation and review, and a willingness to tailor therapy to the individual patient 6