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Anal discharge and/or pain are typical symptoms of proctitis.
- Herpes simplex viruses (HSV Types 1 and 2)
- Chlamydia trachomatis (particularly lymphogranuloma venereum (LGV) strains)
- Neisseria gonorrhoea are the most common causes of proctitis.
- Other organisms include: Treponema pallidum (syphilis), and Mycoplasma genitalium.
- Proctitis may be non-infectious. Assess STI risk and investigate for non-infectious causes in those without risk or whose investigations are negative. Investigations for non-infectious proctitis may include sigmoidoscopy/colonoscopy.
||Mucopurulent or light blood staining. May be subtle.|
||Often accompanied by spasm. May preclude proctoscopy.|
|Perianal ulcers and systemic features
||If present suggest herpes or syphilis|
|Altered bowel habit||Constipation predominates in proctitis. Alternating constipation and diarrhoea occurs in proctocolitis.|
|Tenesmus||Sensation of needing to pass stools indicates inflammation of anal canal.|
Swab of ulcer
NAAT. If NAAT test result is positive, swab for culture, before treatment. Cultures are the preferred test for samples from non-genital sites.
NAAT, LGV testing if reactive.
NAAT – Nucelic acid amplification test
These should always be clinician collected as the patient should be examined. Ideally this should be done via proctoscope. If patients are reluctant to undergo anorectal examination the importance and benefits of physical examination should be explained with respect to achieving an accurate diagnosis and appropriate management plan.
- Symptomatic ano-rectal chlamydia infection is more likely to be caused by lymphogranuloma venereum (LGV) by strains.
- STIs are a neglected cause of proctitis. All patients with proctitis should be assessed for risk of STIs and tested if indicated.
- If syphilis is suspected, consider testing.
- If the patient is a known contact of M. genitalium, or if no other infectious cause for proctitis is found, consider testing for M. genitalium by ano-rectal swab for NAAT.
- Rectal infections are commonly accompanied by concomitant infection at other sites, therefore collect specimens from other sites.
- If patient is a man who has sex with men (MSM), consider additional testing.
|Principal treatment options|
|Lymphogranuloma venereum (LGV)/Chlamydia
||Doxycycline 100mg PO, BD for 21 days.||Alternative regimens are not recommended due to lack of efficacy data. If alternative regimen required, seek specialist advice.
||Ceftriaxone 500mg in 2mL of 1% lignocaine, IMI stat.
Azithromycin 1g PO, stat.
|Seek specialist advice|
Valaciclovir 500mg PO, BD for 5 days.
Episodic therapy: Valaciclovir 500mg PO, BD for 3 days.
Suppressive therapy: Valaciclovir 500mg PO, daily for 6 months.
Aciclovir 400mg PO, TDS for 5 days.
Episodic therapy: Famciclovir 1g PO, BD for 1 day.
Suppressive therapy: Famciclovir 250mg PO, BD for 6 months.
- Distinguishing between the causative agents of proctitis clinically can be difficult. As patients can be or (quickly become) unwell, immediate treatment of LGV/chlamydia, gonorrhoea and herpes is recommended. Do not wait for test results.
- Testing for LGV may not be available in some locations, or turnaround time for results may be lengthy. Single doses of azithromycin are unreliable for treating LGV.
- If chlamydia testing is negative, doxycycline should be ceased.
- For rectal coinfection with gonorrhoea and chlamydia[EW1] , treatment should be given for both infections i.e.: Ceftriaxone 500mg IMI, stat in 2mL 1% lignocaine PLUS Azithromycin 1g PO, stat PLUS Doxycycline 100mg PO, BD 21 days.
- Limited evidence comparing other antiviral agents (aciclovir and famciclovir) with valaciclovir indicate that they are therapeutically equivalent for treating herpes. The ability for the patient to adhere to the recommended dosing frequency should be considered when selecting the appropriate treatment. Initial episodes of herpes may require a longer duration of treatment.
Other immediate management
- Advise no sexual contact for 7 days after treatment is administered
- Advise no sex with partners from the last 6 months until the partners have been tested and treated if necessary
- Contact tracing.
If confirmed STI, follow up provides an opportunity to:
- Confirm patient adherence to treatment and assess for symptom resolution.
- Confirm contact tracing procedures have been undertaken or offer more contact tracing support.
- Provide further sexual health education and prevention counselling.
For test of cure (TOC) and retesting advice see:
- 100% of patients diagnosed with proctitis are treated with an appropriate antibiotic regimen.
- 100% of patients with proctitis have been investigated with appropriate tests to exclude STIs.