What care is needed for a 24‑year‑old patient with proctitis?

Management of Proctitis in a 24-Year-Old Patient

For a 24-year-old with acute proctitis, immediately initiate empiric treatment with ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days while awaiting diagnostic test results. 1, 2, 3

Immediate Diagnostic Evaluation

Sexual History and Risk Assessment

• Obtain detailed sexual history specifically asking about receptive anal intercourse, as this is the primary transmission route for sexually transmitted proctitis 2, 4
• Document any oral-anal contact, which may indicate enteric pathogen exposure 2
• Ask about symptoms including anorectal pain, tenesmus (painful straining), rectal discharge, bleeding, and constipation 2, 4

Physical Examination

• Perform anoscopy to visualize the rectal mucosa and identify inflammation limited to the distal 10-12 cm of rectum 1, 2, 3
• Examine a Gram-stained smear of any anorectal exudate for polymorphonuclear leukocytes—if present, this confirms acute inflammation requiring immediate empiric treatment 1, 2, 3
• Look for bloody discharge, perianal ulcers, or mucosal ulcers, as these findings suggest lymphogranuloma venereum (LGV) and require extended 3-week treatment 1, 2, 3

Laboratory Testing

• Test for all four primary sexually transmitted pathogens: N. gonorrhoeae (NAAT or culture), C. trachomatis (NAAT), T. pallidum (serologic testing), and HSV (PCR or culture) 1, 2, 3
• If C. trachomatis is positive on rectal swab, perform molecular PCR testing specifically for LGV serovars, as this determines whether 7-day or 3-week treatment is needed 1, 2, 3
• Perform HIV and syphilis testing in all persons with acute proctitis 2, 3

Treatment Algorithm

Standard Empiric Treatment

Initiate treatment immediately if anorectal pus is present on examination OR polymorphonuclear leukocytes are found on Gram stain 1, 2, 3:

• Ceftriaxone 250 mg IM single dose 1, 2, 3
• PLUS Doxycycline 100 mg orally twice daily for 7 days 1, 2, 3

Extended Treatment for LGV

If the patient presents with bloody discharge, perianal ulcers, or mucosal ulcers on anoscopy, extend doxycycline to 100 mg twice daily for a total of 3 weeks to adequately treat LGV proctitis 1, 2, 3. This extended regimen is also indicated for MSM with acute proctitis who have either a positive rectal chlamydia NAAT or HIV infection 1.

Herpes Proctitis

If painful perianal ulcers are present or mucosal ulcers are detected on anoscopy, add antiviral therapy for genital herpes 1. Note that HSV proctitis can be especially severe in HIV-infected individuals and requires closer monitoring 1, 2, 3.

Partner Management

Partners who had sexual contact within 60 days before symptom onset must be evaluated, tested, and treated presumptively 2, 3, 4. Both patient and partners should abstain from sexual intercourse until treatment completion (7-day regimen) and symptom resolution 2, 3.

Follow-Up Protocol

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

Critical Pitfalls to Avoid

Don't Wait for Test Results

The most common error is delaying treatment while awaiting laboratory results. If clinical findings suggest acute proctitis (anorectal exudate or PMNs on Gram stain), start empiric treatment immediately 1, 2, 3. The combination of ceftriaxone plus doxycycline covers the most common pathogens (N. gonorrhoeae, C. trachomatis, T. pallidum) 1, 2, 3.

Don't Undertreat LGV

Missing LGV is a critical error because it requires 3 weeks of doxycycline, not 7 days 1, 2, 3. Any patient with bloody discharge, perianal ulcers, or mucosal ulcers should receive the extended regimen 1, 2.

Don't Forget HIV Testing

HIV status affects both disease severity and prognosis—herpes proctitis can be especially severe in HIV-infected individuals, and opportunistic infections like CMV can cause proctitis in immunosuppressed patients 1, 2, 3.

Don't Neglect Partner Treatment

Failure to treat partners leads to reinfection. Partners must be evaluated and treated presumptively, not just tested 2, 3, 4.

Special Considerations for Young Adults

At age 24, this patient is in a high-risk demographic for sexually transmitted proctitis 5, 6. The majority of rectal chlamydia and gonococcal infections are asymptomatic, so even if symptoms resolve, complete the full treatment course and ensure 3-month retesting 2, 7, 8. Counsel about safer sex practices including consistent condom use, though emphasize that condom use does not guarantee complete protection as infections often spread without penile penetration 2, 7, 8.