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=== | ===General=== | ||
*Inflammation of the rectal mucosa | *Inflammation of the rectal mucosa | ||
*Pain on defecation | *Pain on defecation | ||
| Line 14: | Line 24: | ||
*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=== | ===By Causative Agent=== | ||
*[[Condyloma Acuminata]] | |||
*[[Gonorrhea]] | *[[Condyloma Acuminata|Condyloma Acuminata]] | ||
*[[Gonorrhea|Gonorrhea]] | |||
**Symptoms vary from none to severe rectal pain with yellow, bloody discharge | **Symptoms vary from none to severe rectal pain with yellow, bloody discharge | ||
**Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt | **Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt | ||
*[[Chlamydia]] | *[[Chlamydia|Chlamydia]] | ||
**Infection due to direct anorectal infection or via vaginal seeding to perirectal lymphatics | **Infection due to direct anorectal infection or via vaginal seeding to perirectal lymphatics | ||
**Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge | **Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge | ||
**Lymphogranulomatous variety | **Lymphogranulomatous variety | ||
***Acutely painful anal ulcerations associated with unilateral lymph node enlargement | ***Acutely painful anal ulcerations associated with unilateral lymph node enlargement | ||
***[[Fever]] and flulike symptoms | ***[[Fever|Fever]] and flulike symptoms | ||
***May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas | ***May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas | ||
*[[Syphilis]] | *[[Syphilis|Syphilis]] | ||
**Primary | **Primary | ||
***Anal chancres appear ~2-6 weeks after intercourse, are often painful | ***Anal chancres appear ~2-6 weeks after intercourse, are often painful | ||
| Line 35: | Line 47: | ||
**Secondary | **Secondary | ||
***Condylomata lata (flatter and firmer than condylomata acuminata) | ***Condylomata lata (flatter and firmer than condylomata acuminata) | ||
*[[Herpes Simplex Virus-2]] | *[[Herpes Simplex Virus-2|Herpes Simplex Virus-2]] | ||
**Itching and soreness in perianal area progressing to severe anorectal pain | **Itching and soreness in perianal area progressing to severe anorectal pain | ||
***Accompanied by flulike illness, inguinal adenopathy | ***Accompanied by flulike illness, inguinal adenopathy | ||
**Early lesions are small, discrete vesicles on erythematous base | **Early lesions are small, discrete vesicles on erythematous base | ||
***Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers | ***Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Anorectal DDX}} | {{Anorectal DDX}} | ||
==Evaluation== | ==Evaluation== | ||
*Consider Gram stain and culture | *Consider Gram stain and culture | ||
==Management== | ==Management== | ||
{{Presumed GC chlamydia of cervix, urethra, or rectum}} | {{Presumed GC chlamydia of cervix, urethra, or rectum}} | ||
===[[Lymphogranuloma Venereum]]=== | ===[[Syphilis|Syphilis]]=== | ||
*[[Penicillin|Penicillin]] G 2.4mil IM x1 | |||
===[[Herpes Simplex Virus-2|Herpes Simplex Virus-2]]=== | |||
*[[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 | *Consider in patients with bloody discharge, perianal or mucosal ulcers, chlamydia NAAT+, and MSM | ||
*Extend [[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> | *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== | ==Disposition== | ||
==See Also== | ==See Also== | ||
*[[Anorectal Disorders]] | |||
*[[Anorectal Disorders|Anorectal Disorders]] | |||
==External Links== | ==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
- May be misdiagnosed as simple fissure
- Anal chancres appear ~2-6 weeks after intercourse, are often painful
- Secondary
- Condylomata lata (flatter and firmer than condylomata acuminata)
- Primary
- 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
- Itching and soreness in perianal area progressing to severe anorectal pain
Differential Diagnosis
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Coccydynia
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Fecal impaction
- Hemorrhoids
- Levator ani syndrome
- Pedunculated polyp
- Pilonidal cyst
- Proctalgia fugax
- Proctitis
- Pruritus ani
- Enterobius (pinworms)
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
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
- Gonorrhea
- Ceftriaxone IM x 1 (500mg if <150kg, 1g if ≥150kg)
- Chlamydia
- Nonpregnant: Doxycycline 100 mg PO BID x 7 days
- Pregnant: Azithromycin 1 g PO x 1
Ceftriaxone contraindicated
- Gonorrhea
- Gentamicin 240 mg IM x 1 PLUS azithromycin 2 g PO x 1, OR
- Cefixime 800 mg PO x 1
- Chlamydia^
- Nonpregnant: doxycycline 100 mg PO BID x 7 days
- Pregnant: azithromycin 1 g PO x 1
^Additional chlamydia coverage only needed if treated with cefixime only
Partner Treatment
- Gonorrhea
- Cefixime 800mg PO x 1
- Chlamydia
- Nonpregnant: doxycycline 100mg PO BID x 7 days, OR
- Pregnant: azithromycin 1g PO x 1
Syphilis
- Penicillin G 2.4mil IM x1
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
- Doxycycline 100mg PO q12h x 7 days
Pediatric
- Doxycycline Adolescents; 100mg PO q12h x 7 days
Disposition
See Also
External Links
References
- ↑ 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
- ↑ 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