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
    • 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

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
      • 500 mg, if weight <150 kg
      • 1 g, if weight ≥150 kg
  • Chlamydia


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

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