Approach

The approach to patients with symptoms of proctitis is guided by a careful history to differentiate between infectious and non-infectious causes.

A clear history that implicates sexually transmitted proctitis may be sufficient to warrant rectal swabs and empirical therapy. Other causes of proctitis usually require endoscopic assessment to assist in the diagnosis.

Historical considerations

A careful history should elicit the common symptoms of proctitis, including diarrhoea, urgency, rectal bleeding or discharge, lower abdominal cramps, tenesmus, and painful defecation. Systemic symptoms such as fever, malaise, weight loss, and vomiting also should be sought and may point to a more diffuse pathological process. Diarrhoea is not a prerequisite, as some patients with proctitis have constipation. In contrast to other causes, the onset of ischaemic proctitis is usually abrupt. The history should include specific questions about:

  • Anal-receptive sexual intercourse

  • Immunosuppressive disease (e.g., HIV)

  • Coeliac disease

  • Prior or recent history of pelvic irradiation

  • Recent hypotensive episode

  • Recent pelvic surgery

  • History of psychiatric disease involving self-harm

  • Use of immunosuppressive drugs such as prednisone, azathioprine/6-mercaptopurine, ciclosporin

  • Use of non-steroidal anti-inflammatory drugs in suppository or oral form

  • Use of antibiotics in the last 6 months

  • Insertion of caustic agents per rectum (e.g., hydrogen peroxide)

  • Family history of inflammatory bowel disease.

Physical examination

On physical examination, the following should be noted:

  • Fever, hypotension, or tachycardia (sepsis, ischaemic risk)

  • Cachexia, nail clubbing (coeliac disease, Crohn's disease)

  • Injection marks of intravenous drug use (lifestyle risk for HIV)

  • Lymph nodes (systemic infection such as cytomegalovirus [CMV], tuberculosis, lymphogranuloma venerum caused by Chlamydia trachomatis)

  • Abdominal tenderness (bowel infarction, colitis, Crohn's ileitis)

  • Anal condylomata (anal infections), anal fissures (Crohn's disease), anal chancre (syphilis)

  • Rectal blood (ulcerative proctitis, ischaemic proctitis, radiation proctitis).

A digital rectal examination should be performed, but this may be restricted due to severe tenderness. In such instances an examination under anaesthesia is recommended. The presence of fever, abdominal tenderness, and guarding in the setting of suspected proctitis is a red flag and indicates more extensive colonic involvement by inflammation or infarction. Large-volume fresh rectal bleeding is also a red flag sign and raises the possibility of deep rectal ulcers in proctitis, which may require urgent haemostasis, and treatment of the underlying cause.

Tests

The appropriate tests needed for a patient with suspected proctitis can be tailored to the likely aetiology based on the differential. Anoscopy or sigmoidoscopy is the definitive test to diagnose proctitis. Biopsies of the rectal mucosa are helpful in distinguishing acute from chronic proctitis. In the outpatient or emergency department setting some of the testing can be done immediately, including anoscopy, but other endoscopic evaluation may take day(s) to arrange.

If there is a history of anal-receptive sex, HIV, or immunosuppression, further testing should include:

  • Rectal swab for microscopy, Gram stain, and culture (Neisseria gonorrhoeae,com.bmj.content.model.assessment.Caption@7d1f4b92[Figure caption and citation for the preceding image starts]: Gram stained photomicrograph of rectal smear revealing the presence of Gram-negative Neisseria gonorrhoeaeCDC/ Joe Miller [Citation ends].com.bmj.content.model.assessment.Caption@101ba6c[Figure caption and citation for the preceding image starts]: Gram stained micrograph of rectal smear revealing the presence of Gram-negative Neisseria gonorrhoeae diplococci CDC/ Joe Miller [Citation ends].Chlamydia trachomatis, Herpes simplex,Treponema pallidum)

  • Stool microscopy and culture (Shigella, Campylobacter, Salmonella, Clostridium difficile, Giardia lamblia, Entamoeba histolytica)

  • Serological testing (rapid plasma reagin test, Venereal Disease Research Laboratory test, fluorescent treponemal antibody- absorption test for Treponema pallidum)

  • Tissue biopsy (immunofluorescence staining for T pallidum and Chlamydia trachomatis;com.bmj.content.model.assessment.Caption@1588d77d[Figure caption and citation for the preceding image starts]: Rectal mucosa showing non-specific active chronic proctitis in a patient with lymphogranuloma venerum (due to Chlamydia trachomatis)Laverse E, Jaleel H, Evans D, et al. Sexual history: its importance in averting detrimental misdiagnosis and delayed diagnosis. BMJ Case Reports. 2009; doi: 10.1136/bcr.04.2009.1773 [Citation ends]. polymerase chain reaction for Herpes simplex and CMV)

  • HIV testing if HIV status is unknown.

If no clear cause of proctitis is evident from the history or physical examination, the following should be considered:

  • Full colonoscopy and terminal ileum intubation in patients with ulcerative proctitis or Crohn's proctitis to establish the extent of the disease[11][12][13]

  • Abdominal computed tomography (CT) with intravenous and oral contrast if ischaemic proctitis or Crohn's disease is suspected; may also be considered in the acute setting if the patient presents with significant abdominal pain, rebound tenderness, guarding, or fever

  • Check of serum anti-tissue transglutaminase IgA antibody (anti-tTG, IgA) levels if coeliac disease is suspected (e.g., anaemia, chronic diarrhoea, steatorrhoea, young age). In cases of IgA deficiency associated with coeliac disease IgG-deamidated gliadin peptide serology should be requested.

A biopsy of the affected area is often taken to confirm a diagnosis. Other confirmatory tests include CT enterography, small bowel follow-through, and magnetic resonance imaging.

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