Proctitis, or inflammation of the anal canal and distal rectum, can be infective or non infective. Sexually acquired proctitis is commonly asymptomatic but when symptoms are present they usually include pain with or without discharge and bleeding. Tenesmus – a sensation of constantly needing to pass stool – may also be present. Rectal infections increase the risk of HIV acquisition.
Sexually acquired proctitis occurs predominantly among men who have sex with men (MSM) but can occur in men or women who have had receptive anal intercourse. Sexually acquired proctitis is commonly caused by:
- Chlamydia trachomatis (including Lymphogranuloma Venereum or LGV)
- Neisseria gonorrhoeae and
- Herpes Simplex viruses types 1 and 2 (HSV-1 and -2)
HSV, LGV and proctitis associated with combinations of the above pathogens is more common among HIV positive MSM compared with HIV negative MSM. While painful perianal ulcers can be indicative of HSV, HSV proctitis is often not associated with the presence of visible ulcers.
A number of studies have not shown a significant association between Mycoplasma genitalium and proctitis, although cases of proctitis in which M.genitalium is the sole pathogen detected have occurred. Testing first line for M.genitalium in men with proctitis is therefore not recommended.
Procto-colitis can also be caused by enteric pathogens such as campylobacter, salmonella and shigella some of which may be transmitted between men during sexual contact via the faecal-oral route. Inflammatory bowel disease - ulcerative colitis or Crohn’s disease - should also be considered.
Proctitis is a clinical syndrome and diagnosis is made where there are suggestive features on history and examination. Proctoscopy is a useful adjunct to the clinical examination and may show mucosal inflammation and discharge. However, proctoscopy should not be performed when examination is uncomfortable due to the presence of tender ulcers. Laboratory testing is always required to determine the infective agent.
The following laboratory testing should be performed in MSM presenting with symptoms suggestive of proctitis using anal swabs:
- N. gonorrhoeae by culture if rectal discharge is present or nucleic acid amplification testing (NAAT)
- C. trachomatis NAAT: genotype for LGV should be requested and
- HSV PCR even in the absence of any visible external ulceration.
Testing for syphilis by PCR should also be considered, especially where proctitis is associated with ulceration.
Where chlamydia is confirmed in MSM with symptomatic proctitis ask your laboratory to forward the sample to the Victorian Infectious Diseases Reference Laboratory for testing for LGV. A positive chlamydia result alone will not distinguish between LGV and non-LGV chlamydia.
Serology for syphilis and HIV should also be performed.
If an enteric infection is suspected, for example where abdominal pain and diarrhoea are present, a faecal specimen should be obtained for microscopy and culture including ova.
If symptoms of proctitis persist following treatment and tests for other STIs are negative then testing for M.genitalium and macrolide-resistance (PCR) may be indicated.
Treatment of suspected proctitis should be empirical and commenced prior to test results being available. Treatment should take into account the clinical picture and epidemiology of STIs in the particular patient group.
As it can be difficult to distinguish clinically between symptomatic proctitis caused by chlamydia, gonorrhoea and HSV, it is recommended that treatment of MSM with proctitis should cover all of these using a combination of:
- Doxycycline 100mg twice daily for 3 weeks plus
- Ceftriaxone 500mg single dose by intramuscular injection plus
- Valaciclovir 500mg twice daily for 7-10 days
If a specific pathogen is identified management should be directed accordingly with appropriate follow up testing where indicated. Please refer to the relevant MSHC treatment guidelines on: chlamydia, gonorrhoea, M. genitalium and herpes.
Note if testing for M.genitalium is performed and M.genitalium is detected, please refer to the Mg treatment guidelines.
All MSM with symptomatic proctitis who have a positive test for chlamydia should be treated presumptively for LGV and the specimen sent for genotyping. Please refer to MSHC treatment guidelines on LGV.
Where chlamydia, gonorrhoea, M. genitalium or LGV are identified, sexual partners should be notified with the relevant empirical treatment offered to those contacts.
Chlamydia, LGV, gonorrhoea and syphilis are notifiable infections in Victoria and a notification form to the Department of Health should be completed.
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.
Last Updated September 2019