Proctitis: Symptoms, Types, Causes and Treatment

Proctitis is an inflammatory condition affecting the lining of the rectum, the final segment of the large intestine just above the anus. Understanding proctitis is essential, as it not only causes significant discomfort but can also indicate underlying health problems, including infections, autoimmune disorders, or complications from medical treatments. This comprehensive guide explores the symptoms, various types, underlying causes, and evidence-based treatments for proctitis.

Symptoms of Proctitis

When the rectum becomes inflamed, it often sends clear signals. For many, the symptoms are disruptive and sometimes alarming. Recognizing these signs early can lead to timely diagnosis and effective management, minimizing complications and improving quality of life.

Symptom	Description	Frequency/Specifics	Source(s)
Rectal bleeding	Blood in or on stool, or on toilet paper	Common symptom	1, 2, 4, 6
Rectal pain	Pain or burning sensation in the rectum	May be severe or mild	1, 2, 4, 6
Tenesmus	Urgent, frequent need to pass stool	Often with little stool passage	2, 3, 4, 5
Mucous discharge	Mucus or pus from the rectum	Sometimes mixed with blood	1, 2, 4
Itching	Pruritus in and around the anal area	May accompany other symptoms	2, 3, 4
Diarrhea	Loose or frequent stools	Can be mild to severe	10, 11, 5
Asymptomatic	No noticeable symptoms	Especially in some infections	2, 4, 8

Table 1: Key Symptoms of Proctitis

Common Presentations

Rectal Bleeding and Pain
Rectal bleeding is one of the hallmark symptoms of proctitis, often accompanied by varying degrees of rectal pain. The bleeding may be visible on toilet paper, in the stool, or as separate blood. Pain may range from mild discomfort to severe, throbbing aches, especially when passing stool 1, 2, 4, 6.

Tenesmus and Discharge
Tenesmus—an urgent, persistent feeling of needing to pass stool even when the rectum is empty—is particularly distressing. Mucous or pus discharge is also common, sometimes mixed with blood, and can be mistaken for hemorrhoidal disease 2, 3, 4.

Itching and Diarrhea
Itching (pruritus) is often reported, especially in infectious proctitis. Diarrhea, though less specific, can also occur, particularly with radiation-induced or infectious forms 10, 11, 5.

Asymptomatic Cases
Notably, some cases—especially those caused by sexually transmitted pathogens—may be entirely asymptomatic. This is particularly true for rectal chlamydia and gonorrhea, making routine screening crucial in high-risk groups 2, 4, 8.

Types of Proctitis

Proctitis is not a singular disease but rather a manifestation of diverse underlying conditions. Understanding its types helps guide diagnosis and targeted therapy.

Type	Defining Feature	Typical Cause/Trigger	Source(s)
Infectious Proctitis	Inflammation due to infection	Bacteria, viruses, protozoa	1, 2, 3, 4, 9
Ulcerative Proctitis	Chronic, relapsing inflammation	Autoimmune (IBD)	6, 12, 13
Radiation Proctitis	Damage following pelvic radiation	Cancer treatment	6, 10, 11
Diversion Proctitis	Inflammation after bowel diversion surgery	Lack of fecal stream	6
Traumatic Proctitis	Injury to rectal mucosa	Physical/sexual trauma	4
Mpox-induced Proctitis	Inflammation related to monkeypox virus	Viral infection	5

Table 2: Main Types of Proctitis

Infectious Proctitis

Often linked to sexually transmitted infections (STIs), infectious proctitis is most commonly caused by Neisseria gonorrhoeae, Chlamydia trachomatis (including lymphogranuloma venereum, LGV), Herpes Simplex Virus, and Treponema pallidum (syphilis). Less commonly, protozoa like Shigella and Trichomonas vaginalis are implicated 1, 2, 3, 4, 9.

Ulcerative Proctitis

This is a localized form of ulcerative colitis, an inflammatory bowel disease (IBD). It can be persistent or relapsing, characterized by chronic inflammation limited to the rectum. Symptoms and disease activity tend to fluctuate 6, 12, 13.

Radiation Proctitis

Radiation proctitis arises after pelvic radiotherapy, most often for prostate, cervical, or rectal cancers. It may present acutely (weeks after treatment) or chronically (months to years later), causing pain, bleeding, and diarrhea 6, 10, 11.

Diversion Proctitis

This form develops in the rectal segment excluded from the fecal stream after surgical diversion (e.g., colostomy or ileostomy). The absence of normal fecal passage leads to mucosal inflammation 6.

Traumatic Proctitis

Physical injury—such as from anal intercourse, foreign bodies, or medical procedures—can cause traumatic proctitis. Such cases are particularly important to recognize in sexually active individuals 4.

Mpox-induced Proctitis

Mpox (formerly monkeypox) can occasionally cause proctitis, especially in those exposed through anal-receptive sex. Symptoms may overlap with other types and include pain, discharge, and tenesmus 5.

Causes of Proctitis

Identifying the cause of proctitis is critical for effective treatment and prevention of complications. Causes can be broadly categorized into infectious, inflammatory, iatrogenic, trauma-related, and idiopathic origins.

Cause Category	Example Agents/Triggers	Notes on Transmission/Mechanism	Source(s)
Bacterial Infection	N. gonorrhoeae, C. trachomatis, Shigella	Often sexually transmitted, sometimes asymptomatic	1, 2, 3, 4, 9
Viral Infection	Herpes Simplex Virus, Mpox, CMV	HSV common in immunocompromised, mpox emerging	1, 2, 4, 5
Protozoal Infection	Trichomonas vaginalis, Entamoeba histolytica	Less common, oral-anal transmission possible	8
Autoimmune	Ulcerative colitis	Immune-mediated, not infectious	6, 12, 13
Iatrogenic	Pelvic radiation	Damage from cancer treatment	6, 10, 11
Surgical	Diversion of fecal stream	Post-colostomy/ileostomy	6
Traumatic	Sexual activity, foreign bodies	Direct mucosal injury	4

Table 3: Main Causes of Proctitis

Infectious Causes

• Bacteria: Gonorrhea and chlamydia are particularly common in sexually active individuals, including men who have sex with men (MSM) and women engaging in receptive anal intercourse. Syphilis and shigellosis are less common but important to consider. Mycoplasma genitalium has been increasingly recognized as a cause, particularly in MSM 1, 2, 3, 4, 8, 9.
• Viruses: Herpes simplex virus (HSV) can cause painful ulcerations. Recently, monkeypox virus (mpox) has been identified as a cause of proctitis, often linked to sexual transmission 1, 2, 4, 5.
• Protozoa: Trichomonas vaginalis, while more widely known as a cause of urethritis or vaginitis, can infect the rectum 8.

Non-infectious Causes

• Autoimmune/Inflammatory: Ulcerative colitis and, less commonly, Crohn's disease can cause proctitis, driven by immune system dysfunction 6, 12, 13.
• Radiation: Pelvic radiotherapy can damage rectal mucosa, leading to acute or chronic proctitis 6, 10, 11.
• Diversion: Lack of fecal stream in a diverted rectum changes the microbial environment and leads to inflammation 6.
• Trauma: Physical injury from foreign bodies, sexual activity, or procedures can result in traumatic proctitis 4.

Treatment of Proctitis

Managing proctitis requires a tailored approach based on the underlying cause. Treatment aims to reduce symptoms, eradicate infection or inflammation, and prevent complications.

Treatment Type	Indication/Use	Mode of Action/Key Points	Source(s)
Antibiotics	Infectious (bacterial) proctitis	Empiric, then targeted therapy; treat partners	1, 2, 3, 4, 7, 9
Antivirals	HSV, mpox-related proctitis	Reduce viral load/symptoms	1, 4, 5
Topical 5-ASA (Mesalamine)	Ulcerative proctitis	Anti-inflammatory; first-line	6, 12
Topical steroids	Ulcerative proctitis (refractory)	Reduce mucosal inflammation	12
Oral immunomodulators	Moderate/severe ulcerative proctitis	E.g., etrasimod for select cases	13
Hyperbaric oxygen	Chronic radiation proctitis	Promotes healing, reduces bleeding	10, 11
Supportive care	All types	Pain control, stool softeners	6, 10, 11
Surgical intervention	Severe, refractory, or complicated cases	Diversion or removal of rectum	6

Table 4: Main Treatments for Proctitis

Infectious Proctitis

• Antibiotics: Empiric antibiotics are started pending test results, then tailored based on pathogen identification. For example, doxycycline is recommended for LGV; ceftriaxone plus azithromycin or doxycycline for gonorrhea/chlamydia. Treating sexual partners and HIV testing are essential 1, 2, 3, 4, 7, 9.
• Antivirals: Acyclovir or valacyclovir for HSV; supportive care and occasionally antivirals for mpox 1, 4, 5.

Ulcerative Proctitis

• Topical Mesalamine (5-ASA): First-line therapy for mild-to-moderate ulcerative proctitis. Suppositories or enemas are highly effective in inducing remission 6, 12.
• Topical Steroids: Budesonide suppositories are an effective alternative when mesalamine is ineffective or not tolerated 12.
• Oral Immunomodulators: For those with moderate to severe disease or who fail topical therapy, agents like etrasimod have shown promising results 13.

Radiation Proctitis

• Supportive Therapy: Stool softeners, anti-diarrheal agents, and pain management are foundational.
• Hyperbaric Oxygen Therapy (HBOT): Shown to improve bleeding, pain, and diarrhea in chronic cases resistant to medical therapy 10, 11.

Diversion Proctitis

• Restoration of Fecal Stream: If feasible, reestablishing normal bowel passage may resolve inflammation.
• Topical Therapy: Short-chain fatty acid enemas and topical anti-inflammatories can be used for symptom relief 6.

Traumatic and Mpox-induced Proctitis

• Removal of Causative Factor: For traumatic cases, eliminate the inciting factor.
• Symptomatic Management: Supportive care and wound healing are the focus. For mpox, address symptoms and monitor for complications 4, 5.

Conclusion

Proctitis is a multifaceted condition with numerous causes and presentations. Prompt recognition and accurate diagnosis are crucial for effective treatment and prevention of complications. Here’s a summary of what we’ve covered:

• Symptoms: Rectal bleeding, pain, tenesmus, discharge, itching, diarrhea, and sometimes asymptomatic cases.
• Types: Infectious, ulcerative, radiation-induced, diversion, traumatic, and mpox-induced proctitis.
• Causes: Sexually transmitted infections, autoimmune disease, radiation, surgical diversion, trauma, and emerging viral pathogens.
• Treatment: Etiology-driven—antibiotics/antivirals for infections, topical/oral agents for autoimmune causes, hyperbaric oxygen for radiation proctitis, and supportive/surgical care when needed.

Key Takeaways:

• Proctitis can have serious health impacts but is often treatable.
• Early diagnosis—especially in at-risk groups—is vital.
• Tailored therapies based on the underlying cause improve outcomes.
• Regular follow-up and partner testing/treatment are important in infectious cases.
• Emerging causes like mpox remind clinicians to maintain a broad differential diagnosis.

By understanding the full spectrum of proctitis, patients and healthcare professionals can work together for timely management and improved quality of life.