Proctitis

The term proctitis describes inflammation of the lining of the rectum, the lower end of the large intestine or colon. The rectum functions as a reservoir for fecal matter and inflammation in this area can create the continual sensation of having to have a bowel movement ("tenesmus").

What causes proctitis?

Proctitis has many different causes, including acute/short-term and chronic/long-lasting conditions. Among the causes are the following:

• Inflammatory bowel disease (IBD): Ulcerative colitis and Crohn’s disease, two types of IBD, can cause either proctitis alone, or they may lead to inflammation that affects a longer stretch of colon or (in the case of Crohn's disease) even the small bowel.

• Radiation therapy. People who have had radiation therapy that targets the pelvic area also may develop proctitis. Examples of those at risk are people with rectal, ovarian, or prostate cancer who have received radiation treatment directed to those areas.

• Use of antibiotics may be associated with proctitis in some people. While meant to kill infection-causing bacteria, antibiotics can also kill non-harmful, or "commensal", bacteria in the GI tract. The loss of commensal bacteria can then allow other harmful bacteria known as Clostridium difficile to cause an infection in the colon and rectum.

• Sexually transmitted diseases (STDs). Some STDs can be passed on when a person is receiving anal sex and may then cause proctitis. Those STD infections include gonorrhea, chlamydia, syphilis, and herpes. Herpes-induced proctitis may be particularly severe in people who are also infected with the HIV virus.

• Non-STD infections. Infections that are not sexually transmitted also can cause proctitis. Salmonella and Shigella are examples of foodborne bacteria that can cause proctitis. Streptococcal proctitis sometimes occurs in children who have strep throat.

• Anorectal trauma. Proctitis can be caused by trauma to the anorectal area from anal sex or the insertion of objects or harmful substances into the rectum,including the chemicals in some enemas.

What are the symptoms of proctitis?

Proctitis often causes tenesmus, an uncomfortable urge to have frequent bowel movements. When more severe, proctitis may lead to pain in the rectal area. Some patients also experience non-bloody diarrhea, or sometimes bleeding or mucous discharge.

How is proctitis diagnosed?

To diagnose proctitis, your doctor will take a complete medical history, asking about symptoms, current and past medical conditions, family history, and sexual behavior that increases the risk of STD-induced proctitis. The physical exam will include an abdominal exam and a rectal exam. Sometimes an endoscopy may be done to diagnose proctitis.  Anoscopy is a similar, more limited procedure that can also be helpful in this situation. During anoscopy, a small rigid tube, rather than a flexible endoscope, is inserted into the anus to view the anal canal and the lower rectum. Based on a patient's history and risk factors, other tests may be done including blood or stool tests to evaluate for certain types of infections or the extent of blood loss. 

What are complications of proctitis?

If proctitis is not treated or does not respond to treatment, complications may occur. These can include severe bleeding and anemia (low levels of red blood cells), ulcers (breaks and defects in the lining of the rectum), abscesses (painful, pus-filled areas caused by infection), and fistulae (abnormal connections between the inside of the rectum and other structures around the rectum). Prompt recognition and treatment of proctitis reduces the risk of developing complications.

How is proctitis treated?

With proper medical attention, proctitis can be treated and usually resolved. Because of the many different types of proctitis, the treatment depends on the underlying cause. In general terms, the goal of treatment is to reduce inflammation, control symptoms, and eliminate infection, if it is present.

If testing confirmed an infection as the cause of proctitis, antibiotics are prescribed based on the type of infection found. Antibiotics are prescribed to kill bacteria; antiviral medications are prescribed to treat viruses.

If antibiotic use triggered proctitis, the doctor may prescribe a different antibiotic designed to destroy the harmful bacteria that have developed in the intestines.

If proctitis is caused by anorectal trauma, the activity causing the inflammation should be stopped. Healing usually occurs in 4 to 6 weeks. The doctor may recommend over-the-counter medications such as an antidiarrheal and those used for pain relief, such as aspirin and ibuprofen.

Treatment of radiation proctitis is based on symptoms. Radiation proctitis causing only mild symptoms such as occasional bleeding or tenesmus may heal without treatment. For people with persistent or severe bleeding, endoscopic therapy may be used to treat the bleeding spots in the rectum.

When IBD such as ulcerative colitis or Crohn’s disease causes proctitis, treatment aims to reduce inflammation, control symptoms, and induce and maintain remission. If proctitis is the only manifestation of IBD, and if it is relatively mild, local therapies with enemas and/or suppositories may be used to control the inflammation.

Topical mesalamine is often used in this situation. Some people with IBD and proctitis cannot tolerate—or may have an incomplete response to—rectal therapy with 5-ASA suppositories or enemas. For these people, the doctor may prescribe oral medications alone or in combination with rectal therapy.

Corticosteroids for proctitis may be taken in pill, suppository, or enema form. When symptoms are at their worst, corticosteroids are usually prescribed in a large dose. The dosage is then gradually lowered once symptoms are controlled.

Nutrition and dietary issues are also important in the management of proctitis. Drinking plenty of fluids is important when diarrhea or frequent passage of loose or liquid stools occurs. Avoiding caffeine and foods that are greasy, high in fiber, or sweet may lessen diarrhea symptoms. Some people also have problems digesting lactose—the sugar found in milk and milk products—during or after about of diarrhea. Yogurt, which has less lactose than milk, is often better tolerated. Yogurt with active, live bacterial cultures may even help people recover from diarrhea more quickly. If diarrhea symptoms improve, soft, bland foods can be added to the diet, including bananas, plain rice, boiled potatoes, toast, crackers, cooked carrots, and baked chicken without the skin or fat. If the diarrhea stops, a normal diet may be resumed if tolerated.