(See also Evaluation of Anorectal Disorders.)
Proctitis may be a manifestation of
Proctitis associated with prior antibiotic use may be due to Clostridium difficile.
Sexually transmitted pathogens cause proctitis more commonly among men who have sex with men. Immunocompromised patients are at particular risk of infections with herpes simplex and cytomegalovirus.
Diagnosis of proctitis requires proctoscopy or sigmoidoscopy, which may reveal an inflamed rectal mucosa. Small discrete ulcers and vesicles suggest herpes infection. Rectal swabs should be tested for Neisseria gonorrhoeae and Chlamydia species (by culture or ligase chain reaction), enteric pathogens (by culture), and viral pathogens (by culture or immunoassay).
Serologic tests for syphilis and stool tests for C. difficile toxin are done. Sometimes mucosal biopsy is needed.
Colonoscopy may be valuable in some patients to rule out inflammatory bowel disease.
Infective proctitis can be treated with antibiotics. Men who have sex with men who have nonspecific proctitis may be treated empirically with ceftriaxone 250 mg IM once, plus doxycycline 100 mg orally 2 times a day for 7 days. Antibiotic-associated proctitis is treated with metronidazole (250 mg orally 4 times a day) or vancomycin (125 mg orally 4 times a day) for 7 to 10 days.
Radiation proctitis that is bleeding is usually treated initially with a topical drug; however, evidence of efficacy from well-done studies is lacking. Topical treatments include corticosteroids as foam (hydrocortisone 90 mg) or enemas (hydrocortisone 100 mg or methylprednisolone 40 mg) 2 times a day for 3 weeks, or sucralfate retention enemas (2 g in 20 mL water 2 times a day) may also be effective. Patients unresponsive to these forms of therapy may benefit from topical application of formalin, or from hyperbaric oxygen therapy.
Endoscopic therapies may be used. Argon plasma coagulation seems effective in reducing symptoms at least in the short term (≤ 6 weeks). Other methods of coagulation include lasers, electrocoagulation, and heater probes. (See also the American Society of Colon and Rectal Surgeons' clinical practice guidelines for the treatment of chronic radiation proctitis.)