Causes
Sexually acquired proctitis can occur in any person who has had receptive anal intercourse.
Sexually acquired proctitis is commonly caused by:
- Chlamydia trachomatis (including LGV)
- Neisseria gonorrhoeae
- Herpes simplex virus types 1 and 2 (HSV-1 and -2)
- Syphilis
- Mpox
Other considerations:Mycoplasma genitalium: Evidence for the association with proctitis is mixed. Therefore testing first line for Mycoplasma genitalium in men with proctitis is not recommended
- Proctocolitis can also be caused by enteric pathogens such as campylobacter, salmonella and shigella which are transmitted between men during oral to anal sexual contact
Non-infective causes of proctitis may include:
- inflammatory bowel disease (Ulcerative colitis or Crohn's disease)
Clinical presentation
Proctitis is a clinical syndrome and diagnosis is made where there are suggestive features on history and examination.
Common symptoms are:
- Anorectal discomfort
- Discharge
- PR bleeding
- Tenesmus – a sensation of frequently needing to pass stool
Proctoscopy may be a useful adjunct to the clinical examination for signs of show mucosal inflammation and discharge.
Proctoscopy should not be performed when there is significant pain or the present of anal ulcers. .
Laboratory testing is always required to determine the infective agent.
| Test | Site/ Specimen | Comments |
|---|---|---|
| NAAT | Anorectal swab |
For N. gonorrhoea, C. trachomatis (reflex LGV testing is done automatically) Viral swab for: HSV, syphilis and Mpox pcr (this should be done even in the absence of visible ulcers) If proctitis persists and tests for other STIs are negative, thentesting for M. genitalium could be considered. |
| Culture | Anorectal swab | For N. gonorrhoea if rectal discharge is present |
| Serology | Blood | For HIV and syphilis |
| Microscopy | Anorectal swab |
Microscopy has low sensitivity for the detection of both syphilis and gonorrhoea and false positives on dark ground microscopy can also occur due to the presence of non-treponemal spirochaetes present in the normal bowel flora. Consider DGI where there is an anal ulcer Gram stain is generally unhelpful unless there is frank discharge suggestive of NG. |
|
Microscopy and culture, including ova PCR for enteric pathogens |
Faecal specimen | If enteric infection is suspected, for example when abdominal pain and diarrhoea are present |
Management
Index patient
| Condition | Recommended | Comments |
|---|---|---|
| Proctitis – likely to be sexually acquired |
Doxycycline 100mg PO, twice daily for 1 week AND Ceftriaxone 1g IM, stat AND consider Valaciclovir 500mg PO, twice daily for 7-10 days |
Treatment of suspected proctitis should be empirical and commenced prior to test results being available. If LGV is detected, extend doxycycline to 3 weeks. 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 proctitis caused by chlamydia, gonorrhoea, and HSV, it is recommended that treatment of MSM with proctitis should cover all of these. Antiherpes treatment should be given with painful or ulcerative proctitis. For Mpox proctitis, refer to the Mpox treatment guidelines. |
| Proctitis – likely from an enteric pathogen | Refer to Enteric infections in MSM treatment guideline | Treatment of enteric infection such as shigella should be guided by antibiotic sensitivities |
| Proctitis – likely to be non-infectious | Refer to gastroenterologist for colonoscopy |
Contact tracing & partner management
Contact tracing is required where an STI is detected. Management should be in line with the causative agent and may involve notification, testing and treatment according to guidelines of those conditions.
Where Mpox is the causative agent, partner management may also include initiation or completion of Mpox vaccine schedule.
Disclaimer
We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.
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.