Proctitis

Background

Causes

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

Clinical Features

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

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
  • Internal hemorrhoid
  • External hemorrhoid
• 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

• Prostatitis

Management by Disease Process

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 + azithromycin 2gm PO single dose

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

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

Standard

• Gonorrhea
  • Ceftriaxone IM x 1
    • 500 mg, if weight <150 kg
    • 1 g, if weight ≥150 kg
• 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

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
• Treatment
  • Non-LGV: Azithromycin 2gm PO x1 or doxycycline 100mg PO BID x7d
  • LGV: Doxycyline 100mg PO BID x21d

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)
• Treatment
  • Penicillin G 2.4mil IM x1

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

• Anorectal Disorders