Proctitis

To diagnose proctitis, a health care provider will take a complete medical history and do a physical exam. The health care provider will ask the patient about symptoms, current and past medical conditions, family history, and sexual behavior that increases the risk of STD-induced proctitis. The physical exam will include an assessment of the patient’s vital signs, an abdominal exam, and a rectal exam.

Based on the patient’s physical exam, symptoms, and other medical information, the doctor will decide which lab tests and diagnostic tests are needed. Lab tests may include blood tests such as a complete blood count to evaluate for blood loss or infection, stool tests to isolate and identify bacteria that may cause disease, and an STD screening. The doctor also may use one of the following diagnostic tests:

Rectal culture. A cotton swab is inserted into the rectum to obtain a sample that can be used in tests that isolate and identify organisms that may cause disease.

Anoscopy. This test allows examination of the anal canal and lower rectum by opening the anus using a special instrument called an anoscope.

Flexible sigmoidoscopy and colonoscopy. These tests are used to help diagnose Crohn’s disease. The tests are similar, but colonoscopy is used to view the entire colon and rectum, while flexible sigmoidoscopy is used to view just the lower colon and rectum. For both tests, a health care provider will provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for 1 to 3 days before the test. A laxative may be required the night before the test. One or more enemas may be required the night before and about 2 hours before the test.

For either test, the person will lie on a table while the doctor inserts a flexible tube into the anus. A small camera on the tube sends a video image of the intestinal lining to a computer screen. The doctor can see inflammation, bleeding, or ulcers on the colon wall. The doctor may also perform a biopsy by snipping a bit of tissue from the intestinal lining. The person will not feel the biopsy. The doctor will look at the tissue with a microscope to confirm the diagnosis. In most cases, a light sedative, and possibly pain medication, helps people relax during a colonoscopy.

Cramping or bloating may occur during the first hour after the test. Driving is not permitted for 24 hours after a colonoscopy to allow the sedative time to wear off. Before the appointment, a person should make plans for a ride home. Full recovery is expected by the next day.

Treatment of proctitis depends on its cause. The goal of treatment is to reduce inflammation, control symptoms, and eliminate infection, if it is present. Only a doctor can determine the cause of proctitis and the best course of treatment. With proper medical attention, proctitis can be successfully treated.

Proctitis from Infection

If lab tests confirm that an STD or non-STD infection is present, medication is prescribed based on the type of infection found. Antibiotics are prescribed to kill bacteria; antiviral medications are prescribed to treat viruses. Although some STD viruses cannot be eliminated, antivirals can control their symptoms.

Proctitis from Other Causes

If antibiotic use triggered proctitis, the doctor may prescribe a different antibiotic designed to destroy the harmful bacteria that have developed in the intestines.If proctitis is caused by anorectal trauma, the activity causing the inflammation should be stopped. Healing usually occurs in 4 to 6 weeks. The doctor may recommend over-the-counter medications such as antidiarrheals and those used for pain relief, such as aspirin and ibuprofen.

Treatment of radiation proctitis is based on symptoms. Radiation proctitis causing only mild symptoms such as occasional bleeding or tenesmus may heal without treatment. For people with persistent or severe bleeding, thermal therapy may be used to stop bleeding and inflammation. Thermal therapy is done during flexible sigmoidoscopy or colonoscopy and targets the rectal lining with a heat probe, electric current, or laser.

Argon plasma coagulation is the most common thermal therapy used to control bleeding in radiation proctitis. In many cases, several treatments are required. Obstruction that results from a stricture—a narrowing of the rectum—caused by radiation proctitis may be treated with stool softeners in mild cases. In people with narrower strictures, dilation to enlarge the narrow area may be required. Sucralfate, 5-aminosalicylic acid—known as 5-ASA—or corticosteroid enemas can also be used to ease pain and reduce inflammation from radiation proctitis, although their effectiveness is limited.

When a chronic IBD such as ulcerative colitis or Crohn’s disease causes proctitis, treatment aims to reduce inflammation, control symptoms, and induce and maintain remission—a period when the person is symptom-free. Treatment depends on the extent and severity of the disease.

Anti-inflammation medications. Mild proctitis can often be effectively treated with topical mesalamine, either suppositories or enemas.Some people with IBD and proctitis cannot tolerate—or may have an incomplete response to—rectal therapy with 5-ASA suppositories or enemas. For these people, the doctor may prescribe oral medications alone or in combination with rectal therapy. Oral medications commonly used for proctitis contain salicylate. These include sulfasalazine- or mesalamine-containing medications, such as Asacol, Dipentum, or Pentasa. Possible side effects of oral administration of sulfasalazine- or mesalamine containing medications include nausea, vomiting, heartburn, diarrhea, and headache. Improvement in symptoms, including a decrease in bleeding, can occur within a few days, although complete healing requires 4 to 6 weeks of therapy.

Cortisone or steroids. These medications, also called corticosteroids, are effective at reducing inflammation. Prednisone and budesonide are generic names of two medications in this group. Corticosteroids for proctitis may be taken in pill, suppository, or enema form. When symptoms are at their worst, corticosteroids are usually prescribed in a large dose. The dosage is then gradually lowered once symptoms are controlled. Corticosteroids can cause serious side effects, including greater susceptibility to infection and osteoporosis, or weakening of the bones.

Immune system suppressors. Medications that suppress the immune system—called immunosuppressive medications—are also used to treat proctitis. The most commonly prescribed medication is 6-mercaptopurine or a related medication, azathioprine. Immunosuppressive medications work by blocking the immune reaction that contributes to inflammation. These medications may cause side effects such as nausea, vomiting, and diarrhea and may lower a person’s resistance to infection. Some patients are treated with a combination of corticosteroids and immunosuppressive medications. Some studies suggest that immunosuppressive medications may enhance the effectiveness of corticosteroids.

Infliximab (Remicade). Researchers have found that high levels of a protein produced by the immune system, called tumor necrosis factor (TNF), are present in people with Crohn’s disease. Infliximab is the first of a group of medications that bind to TNF substances to block the body’s inflammation response. The U.S. Food and Drug Administration approved the medication for the treatment of moderate to severe Crohn’s disease that does not respond to standard therapies—mesalamine substances, corticosteroids, immunosuppressive medications— and for the treatment of open, draining fistulas. The medication is also given to people who have Crohn’s disease with proctitis. Some studies suggest that infliximab may enhance the effectiveness of immunosuppressive medications.

Bacterial infection can occur with flare-ups of ulcerative colitis or Crohn’s disease. Antibiotics may also be used to treat flare-ups in people with IBD and proctitis.

Eating, Diet, and Nutrition

Drinking plenty of fluids is important when diarrhea or frequent passage of loose or liquid stools occurs.

Avoiding caffeine and foods that are greasy, high in fiber, or sweet may lessen diarrhea symptoms. Some people also have problems digesting lactose—the sugar found in milk and milk products—during or after a bout of diarrhea. Yogurt, which has less lactose than milk, is often better tolerated. Yogurt with active, live bacterial cultures may even help people recover from diarrhea more quickly.

If diarrhea symptoms improve, soft, bland foods can be added to the diet, including bananas, plain rice, boiled potatoes, toast, crackers, cooked carrots, and baked chicken without the skin or fat. If the diarrhea stops, a normal diet may be resumed if tolerated.