Proctitis: Difference between revisions

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==Background==
==Background==
===Causes===
===Causes===
*Radiation treatment
*Radiation treatment
*Autoimmune
*Autoimmune
*Vasculitis
*Vasculitis
*Ischemia
*Ischemia
*Infectious ([[STI]] and enteric organisms)
*Infectious ([[STI|STI]] and enteric organisms)
 


==Clinical Features==
==Clinical Features==
===General===
*Inflammation of the rectal mucosa
*Inflammation of the rectal mucosa
*Pain on defecation
*Pain on defecation
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*Mucoid discharge
*Mucoid discharge
*Inguinal lymphadenopathy (may be seen with [[Syphilis|T. pallidum]])
*Inguinal lymphadenopathy (may be seen with [[Syphilis|T. pallidum]])
===By Causative Agent===
*[[Condyloma Acuminata|Condyloma Acuminata]]
*[[Gonorrhea|Gonorrhea]]
**Symptoms vary from none to severe rectal pain with yellow, bloody discharge
**Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt
*[[Chlamydia|Chlamydia]]
**Infection due to direct anorectal infection or via vaginal seeding to perirectal lymphatics
**Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge
**Lymphogranulomatous variety
***Acutely painful anal ulcerations associated with unilateral lymph node enlargement
***[[Fever|Fever]] and flulike symptoms
***May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas
*[[Syphilis|Syphilis]]
**Primary
***Anal chancres appear ~2-6 weeks after intercourse, are often painful
****May be misdiagnosed as simple fissure
*****Symmetric lesion on opposite side of anal margin is distinguishing feature
*****Inguinal adenopathy is often present
**Secondary
***Condylomata lata (flatter and firmer than condylomata acuminata)
*[[Herpes Simplex Virus-2|Herpes Simplex Virus-2]]
**Itching and soreness in perianal area progressing to severe anorectal pain
***Accompanied by flulike illness, inguinal adenopathy
**Early lesions are small, discrete vesicles on erythematous base
***Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers


==Differential Diagnosis==
==Differential Diagnosis==
{{Anorectal DDX}}
{{Anorectal DDX}}


==Evaluation and Management==
===[[Condyloma Acuminata]]===


===[[Gonorrhea]]===
*Symptoms vary from none to severe rectal pain with yellow, bloody discharge
*Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt
*Diagnosis made by Gram stain and culture
*Also consider dissemination to heart, liver, CNS, and joints
*Treatment: [[ceftriaxone]] 125mg IM + [[azithromyci]]n 2gm PO single dose


===[[Chlamydia]]===
==Evaluation==
*Infection due to direct anorectal infection or via vaginal seeding to perirectal lymphatics
 
*Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge
*Consider Gram stain and culture
*Lymphogranulomatous variety
 
**Acutely painful anal ulcerations associated with unilateral lymph node enlargement
 
**[[Fever]] and flulike symptoms
==Management==
**May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas
 
*Treatment
 
**Non-LGV: [[Azithromycin]] 2gm PO x1 or [[doxycycline]] 100mg PO BID x7d
{{Presumed GC chlamydia of cervix, urethra, or rectum}}
**LGV: [[Doxycyline]] 100mg PO BID x21d
 
===[[Syphilis]]===
 
*Primary
 
**Anal chancres appear ~2-6 wks after intercourse, are often painful
===[[Syphilis|Syphilis]]===
***May be misdiagnosed as simple fissure
 
****Symmetric lesion on opposite side of anal margin is distinguishing feature
*[[Penicillin|Penicillin]] G 2.4mil IM x1
****Inguinal adenopathy is often present
 
*Secondary
 
**Condylomata lata (flatter and firmer than condylomata acuminata)
===[[Herpes Simplex Virus-2|Herpes Simplex Virus-2]]===
*Treatment
 
**[[Penicillin]] G 2.4mil IM x1
*[[Acyclovir|Acyclovir]] 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes
 
 
===[[Lymphogranuloma Venereum|Lymphogranuloma Venereum]]===
 
*Consider in patients with bloody discharge, perianal or mucosal ulcers, chlamydia NAAT+, and MSM
*Extend [[doxycycline|doxycycline]] 100mg PO BID for 21 days total<ref>Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1</ref>
 
 
 
===Antibiotic Dosing===
====Adult====
*{{AntibioticDose|drug=Doxycycline|dose=100mg PO q12h x 7 days|context=Proctitis|disease=Proctitis|population=Adult}}
====Pediatric====
*{{AntibioticDose|drug=Doxycycline|dose=Adolescents; 100mg PO q12h x 7 days|context=Proctitis|disease=Proctitis|population=Pediatric}}
 
==Disposition==


===[[Herpes Simplex Virus-2]]===
*Itching and soreness in perianal area progressing to severe anorectal pain
**Accompanied by flulike illness, inguinal adenopathy
*Early lesions are small, discrete vesicles on erythematous base
**Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers
*Treatment
**[[Acyclovir]] 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes


==See Also==
==See Also==
*[[Anorectal Disorders]]
 
*[[Anorectal Disorders|Anorectal Disorders]]
 
 
==External Links==
 


==References==
==References==
<references/>
<references/>
[[Category:GI]]
[[Category:GI]]

Latest revision as of 11:00, 20 March 2026


Background

Causes

  • Radiation treatment
  • Autoimmune
  • Vasculitis
  • Ischemia
  • Infectious (STI and enteric organisms)


Clinical Features

General

  • Inflammation of the rectal mucosa
  • Pain on defecation
  • Tenesmus
  • Mucoid discharge
  • Inguinal lymphadenopathy (may be seen with T. pallidum)


By Causative Agent

  • Condyloma Acuminata
  • Gonorrhea
    • Symptoms vary from none to severe rectal pain with yellow, bloody discharge
    • Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt
  • Chlamydia
    • Infection due to direct anorectal infection or via vaginal seeding to perirectal lymphatics
    • Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge
    • Lymphogranulomatous variety
      • Acutely painful anal ulcerations associated with unilateral lymph node enlargement
      • Fever and flulike symptoms
      • May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas
  • Syphilis
    • Primary
      • Anal chancres appear ~2-6 weeks after intercourse, are often painful
        • May be misdiagnosed as simple fissure
          • Symmetric lesion on opposite side of anal margin is distinguishing feature
          • Inguinal adenopathy is often present
    • Secondary
      • Condylomata lata (flatter and firmer than condylomata acuminata)
  • Herpes Simplex Virus-2
    • Itching and soreness in perianal area progressing to severe anorectal pain
      • Accompanied by flulike illness, inguinal adenopathy
    • Early lesions are small, discrete vesicles on erythematous base
      • Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers


Differential Diagnosis

Anorectal Disorders


Non-GI Look-a-Likes


Evaluation

  • Consider Gram stain and culture


Management

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[1]

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard


Ceftriaxone contraindicated

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment


Syphilis


Herpes Simplex Virus-2

  • Acyclovir 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes


Lymphogranuloma Venereum

  • Consider in patients with bloody discharge, perianal or mucosal ulcers, chlamydia NAAT+, and MSM
  • Extend doxycycline 100mg PO BID for 21 days total[2]


Antibiotic Dosing

Adult

Pediatric

Disposition

See Also


External Links

References

  1. ↑ Cyr SS et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
  2. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1
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