eMedicine Specialties > Emergency Medicine > Gastrointestinal

Proctitis

Author: Lisandro Irizarry, MD, MPH, FAAEM, Chair, Department of Emergency Medicine, Brooklyn Hospital Center; Assistant Professor, Department of Emergency Medicine, Weill Cornell School of Medicine
Coauthor(s): Ibis Yarde, MD, Staff Physician, Department of Emergency Medicine, Brooklyn Hospital Center
Contributor Information and Disclosures

Updated: Apr 27, 2009

Introduction

Background

Proctitis is inflammation of the lining of the rectum, called the rectal mucosa. Proctitis can be short term (acute) or long term (chronic). Proctitis has many causes. It may be a side effect of medical treatments like radiation therapy or antibiotics. Proctitis involves an inflammatory change of the rectum (within 15 cm of the dentate line). Proctitis is similar to proctosigmoiditis but is not necessarily associated with proximal extension of disease into the colon and usually does not evolve into ulcerative colitis. If proximal extension does occur, it usually does so within the first 2 years of initial diagnosis.

Proctitis caused by sexually transmitted diseases (STDs) is transmitted through receptive anal intercourse and is most commonly due to gonorrhea and chlamydia, or less commonly lymphogranuloma venereum or herpes virus. Nonsexually transmitted causes include autoimmune disease of the colon, such as Crohn disease and ulcerative colitis, chemicals, rectal instrumentation, and trauma to the anorectal area. It may also occur as idiopathic proctitis. Other causes include radiation therapy or celiac disease.

For more information on Crohn disease and ulcerative colitis, see Medscape’s Inflammatory Bowel Disease Resource Center.

Pathophysiology

Proctitis involves mucosal cell loss, acute inflammation of the lamina propria, eosinophilic crypt abscess, and endothelial edema of the arterioles. These may improve or progress with subsequent fibrosis of connective tissue and endarteritis of the arterioles, resulting in rectal tissue ischemia and leading to mucosal friability, bleeding, ulcers, strictures, and fistula formation.

Frequency

United States

Frequencies of proctitis are associated with their individual etiologies. With radiation therapy, 5-20% of patients display proctitis, usually within 3-24 months after completion of therapy with a total dose greater than 50 Gy.

Race

Incidence is higher in Jewish persons.

Sex

Males are affected more often than females.

Age

Proctitis occurs predominantly in adults.

Clinical

History

• General symptoms
  • A feeling of rectal fullness
  • Anal and rectal pain
  • Diarrhea, usually frequent, small amounts
  • Frequent or continuous urge to have a bowel movement
  • Pain in the lower left abdomen
  • Passing mucus through the rectum
  • Rectal bleeding
• Idiopathic proctitis
  • Passage of blood and mucus per rectum
  • Tenesmus
  • Occasionally, passage of loose stool, with or without lower abdominal pain or rectal cramping
• Infectious proctitis
  • Pruritus
  • Rectal and anal pain (may become severe)
  • Avoidance of defecation
  • Most common causes - Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus (HSV) types 1 and 2
• Indolent and extensive HSV types 1 and 2 infections
  • Tenesmus
  • Rectal pain
  • Discharge
  • Hematochezia
  • The disease may run its natural course of exacerbations and remissions but is usually more prolonged and severe in patients with immunodeficiency disorders.
  • Presentations may resemble dermatitis or decubitus ulcers in debilitated, bedridden patients.
  • A secondary bacterial infection may be present.
• Radiation-induced proctitis
  • Early symptoms include tenesmus and diarrhea that resolve shortly after the treatment period.
  • Later symptoms of proctitis (occurring months to years after the completion of radiation therapy) include tenesmus, bleeding, low-volume diarrhea, and rectal pain.
  • Symptoms of radiation-induced proctitis are associated with low-grade obstruction or fistulous tracts into adjacent organs.

Physical

• Mucosal erythema
• Mucosal friability
• Groups of vesicles eroding into circular superficial ulcers enlarged
• Tender inguinal lymph nodes (HSV)
• Painless chancres
• Hemoccult positive stools

Causes

• N gonorrhoeae
• C trachomatis
• HSV 1 (10%) and HSV 2 (90%)
• Radiation therapy
• Immunodeficiency disorders
• Crohn disease
• Syphilis (usually secondary)
• Papillomavirus
• Amebiasis
• Lymphogranuloma venereum
• Ischemia
• Toxins (eg, hydrogen peroxide enemas)
• Vasculitis
• Cytomegalovirus (CMV)
• Clostridium difficile
• Campylobacter species

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