Proctitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Empirical medical therapy for patients with infectious acute proctitis generally includes ceftriaxone and doxycycline. Treatment for presumptive lymphogranuloma venereum or genital herpes may be indicated in some patients. Medical therapy for non-infectious proctitis, such as that caused by inflammatory bowel disease, includes anti-inflammatory and immunosuppressive therapy.
Medical Therapy
Infectious Acute Proctitis
- All patients with infectious acute proctitis should be treated empirically with antimicrobial therapy.
- Infectious acute proctitis empirical therapy
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg PO bid for 7 days
- Note: Patients should abstain from sexual activity until they and their partners have been treated adequately for 7 days and report no symptoms
- Specific considerations
- MSM patients with either bloody discharge, perianal ulcers, or mucosal ulcers and either positive rectal Chlamydia NAAT or HIV infection should be additionally treated for lymphogranuloma venereum. The antimicrobial regimen (regimen to cover both proctitis + lymphogranuloma venereum) among these patients is shown below:
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg PO bid for a total of 3 weeks and until all lesions completely heal
- Note: To view alternative therapies for lymphogranuloma venereum, click here.
- Note: Patients should abstain from sexual activity until they and their partners have been treated adequately for 7 days and report no symptoms
- Patients with either painful perianal ulcers or mucosal ulcers on anoscopy should be additionally treated for genital herpes. The antimicrobial regimen (regimen to cover both proctitis + genital herpes) among these patients is shown below:
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg PO bid for 7 days AND Acyclovir 5-10 mg/kg IV q8h for 2-7 days or until clinical improvement THEN Acyclovir 400 mg PO tid for at least 10 days OR Acyclovir 200 mg PO five times a day for at least 10 days OR Famciclovir 250 mg PO tid for at least 10 days OR Valacyclovir 1 g PO bid for at least 10 days)
- Note: To view alternative therapies for genital herpes, click here.
- Note: Patients should abstain from sexual activity until they and their partners have been treated adequately for 7 days and report no symptoms
- HIV-positive patients should be additionally treated for both lymphogranuloma venereum and genital herpes. The antimicrobial regimen (regimen to cover both proctitis + lymphogranuloma venereum + genital herpes) among these patients is shown below:
- Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg PO bid for 7 days AND Acyclovir 5-10 mg/kg IV q8h for 2-7 days or until clinical improvement THEN Acyclovir 400 mg PO tid for at least 10 days OR Acyclovir 200 mg PO five times a day for at least 10 days OR Famciclovir 250 mg PO tid for at least 10 days OR Valacyclovir 1 g PO bid for at least 10 days)
- Note: To view alternative therapies for genital herpes, click here.
- Note: Patients should abstain from sexual activity until they and their partners have been treated adequately for 7 days and report no symptoms
Treatment of Sexual Partner
- Infectious acute proctitis is considered a sexually transmitted disease.
- Sexual partners who have had sexual activity within 60 days with patients diagnosed with infectious acute proctitis should also be evaluated and treated.
- Both the patient and the sexual partner should abstain from sexual activity until treated adequately (7-day antimicrobial therapy and resolution of symptoms)
Follow-up
- Follow-up is based on the severity of symptoms and causative agent.
- Patients diagnosed with either chlamydial or gonorrheal proctitis should be re-evaluated 3 months following the completion of antimicrobial therapy.
Non-Infectious Acute Proctitis
- If the proctitis is caused by Crohn's disease or ulcerative colitis, 5-aminosalicyclic acid (5ASA) or corticosteroids administered directly to the area in either enema, suppository form, or orally.
- Enema and suppository applications are usually more effective than the oral route of administration, but some patients may require a combination of both oral and rectal doses.