Proctitis is an inflammatory condition affecting the lining of the rectum, the final segment of the large intestine before the anus. This inflammation causes uncomfortable symptoms, including rectal bleeding, the passage of mucus, and tenesmus (a persistent, painful sensation of needing to have a bowel movement). Effective treatment depends on identifying the specific underlying cause, ranging from simple medication for acute cases to complex interventions for chronic or severe inflammation.
Determining the Origin of Proctitis
Effective treatment begins with accurately identifying the source of inflammation, as protocols are tailored to the specific cause. Proctitis is broadly categorized into four primary types that dictate therapeutic strategy.
The first is Inflammatory Bowel Disease (IBD)-related proctitis, most commonly seen as a localized form of Ulcerative Colitis (UC) or, less often, Crohn’s disease.
Infectious proctitis is often acute and temporary. This type is typically caused by sexually transmitted infections (STIs) like chlamydia, gonorrhea, or herpes simplex virus, or by non-STI bacteria such as Salmonella or Clostridioides difficile. Treating this form requires targeting the specific pathogen responsible.
The third type is radiation-induced proctitis, which occurs as a complication following radiation therapy to the pelvic area for cancers (e.g., prostate, cervical). This can manifest acutely or become a chronic issue years later, known as chronic radiation proctopathy. The resulting damage involves tissue scarring and poor blood supply.
Finally, diversion proctitis develops after a colostomy or ileostomy diverts the flow of stool away from the rectum. This inflammation is believed to result from the lack of exposure to short-chain fatty acids (SCFAs), which are nutrients normally produced when bacteria ferment stool. Recognizing these distinct origins is paramount, as a treatment for one type, such as antibiotics for an infection, would be ineffective for proctitis caused by IBD or radiation.
Pharmacological Treatment Strategies
Pharmacological treatment is directly linked to the cause of the inflammation. For IBD-related proctitis, the goal is to reduce inflammation in the rectal lining. The primary treatment involves 5-aminosalicylates (5-ASAs), such as mesalamine, which are anti-inflammatory drugs.
These 5-ASAs are often delivered topically via suppositories or enemas to maximize the concentration of the medication directly at the inflamed site. This delivery method is more effective for localized disease than oral administration alone. Topical corticosteroids, like budesonide foam, may also be prescribed as potent anti-inflammatory agents that can quickly reduce swelling and bleeding. For severe IBD inflammation that does not respond to topical therapy, systemic treatments, including oral corticosteroids or advanced biologic medications, may be necessary to suppress the immune system.
In cases of infectious proctitis, the treatment is highly specific to the identified pathogen. Bacterial infections, including STIs like chlamydia and gonorrhea, are treated with targeted antibiotics, such as doxycycline or ceftriaxone. Viral infections, like herpes simplex proctitis, require antiviral medications such as acyclovir to clear the infection and reduce symptoms.
Treatment for chronic radiation proctopathy and diversion proctitis focuses on symptom relief and tissue repair. Anti-inflammatory agents like mesalamine, often delivered as a rectal enema, are commonly used. Sucralfate enemas, which form a protective barrier over damaged tissue and stimulate healing, are also effective, particularly for radiation-induced ulcers. Diversion proctitis may respond to enemas containing short-chain fatty acids (SCFAs) to restore the missing nutrient source needed for rectal health.
Supportive Care and Lifestyle Modifications
Non-pharmacological approaches and changes to daily habits play a considerable role in managing the symptoms of proctitis and supporting the healing process. Dietary adjustments are often recommended during periods of inflammation to reduce strain on the digestive system.
Dietary Adjustments
Consuming a low-residue diet, which limits high-fiber foods, helps reduce the frequency and volume of bowel movements, thereby decreasing irritation to the inflamed rectal lining. Maintaining adequate hydration is important, especially if diarrhea is present, to prevent fluid and electrolyte imbalances. Individuals may find relief by identifying and avoiding specific trigger foods, which often include spicy foods, dairy products, or high-fat items. Keeping a food and symptom journal can be a valuable tool for pinpointing these personal triggers.
Comfort Measures
For local pain and discomfort, practical measures can provide significant relief. Warm sitz baths, where the lower body is submerged in shallow, warm water, can soothe the anal and rectal area. It is advisable to avoid harsh soaps or excessive rubbing, which can further irritate the sensitive tissue. Avoiding anal intercourse is another necessary modification to allow the inflamed tissue time to heal without additional trauma.
Options for Refractory or Severe Disease
When proctitis does not respond sufficiently to standard drug therapies or involves severe complications, treatment must be escalated to specialized procedures or surgery. For chronic radiation proctopathy that causes persistent bleeding, endoscopic therapy is frequently employed.
Specialized Procedures
Argon Plasma Coagulation (APC) uses a jet of ionized gas to deliver heat energy to the abnormal, fragile blood vessels (telangiectasias) in the rectal wall, effectively sealing them to stop the bleeding. Hyperbaric oxygen therapy (HBOT) is another option for refractory radiation proctopathy, particularly for non-healing ulcers. This treatment involves breathing 100% oxygen in a pressurized chamber, which significantly promotes new blood vessel growth and tissue healing in the radiation-damaged area.
Surgical Options
Surgical intervention is generally reserved as a measure of last resort for the most challenging cases, such as severe, uncontrolled IBD-related proctitis or complications like strictures or fistulas. A diverting ostomy creates a temporary or permanent opening in the abdomen to divert stool away from the rectum, allowing the inflamed rectum time to heal. The most definitive surgery is a proctectomy, which involves the complete removal of the diseased rectum. This is typically reserved for patients with severe, life-altering ulcerative colitis that has failed all other medical management.