Proctitis
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