Inflammation of Rectum mucosa, distal to the rectosigmoid junction, within 18 cm of the anal verge. It can be acute or chronic. Anusitis is inflammation of the lining of the anal canal. Anusitis is a common disorder that is rarely diagnosed and is often misdiagnosed as hemorrhoids.
Proctitis refers to inflammation of the rectum, a diagnosis made by endoscopic evaluation. Symptoms of proctitis include rectal bleeding, urgency, tenesmus, diarrhea or constipation, and occasionally rectal pain. The causes of proctitis include infection, medication, ischemia, radiation, and ulcerative proctitis. Ulcerative proctitis is an important and increasingly common subcategory of ulcerative colitis (UC) in which inflammation is limited to the rectum.
Types of Proctitis
Proctitis and anusitis may happen secondary to ulcerative colitis (UC),
- Chronic Radiation Proctitis
- Proctopathy (CRP)
- Diversion Proctitis (DP)
- Gonorrhea (Gonococcal proctitis) – This is the most common cause. Strongly associated with anal intercourse. Symptoms include soreness, itching, bloody or pus-like discharge, or diarrhea. Other rectal problems that may be present are anal warts, anal tears, fistulas, and hemorrhoids.
- Chlamydia (chlamydia proctitis) – Accounts for twenty percent of cases. People may show no symptoms, mild symptoms, or severe symptoms. Mild symptoms include rectal pain with bowel movements, rectal discharge, and cramping. With severe cases, people may have discharge containing blood or pus, severe rectal pain, and diarrhea. Some people have rectal strictures, a narrowing of the rectal passageway.
- Herpes Simplex Virus 1 and 2 (herpes proctitis) – Symptoms may include multiple vesicles that rupture to form ulcers, 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.
Syphilis (syphilitic proctitis)
The symptoms are similar to other causes of infectious proctitis; rectal pain, discharge, and spasms during bowel movements, but some people may have no symptoms. Syphilis occurs in three stages.
- The primary stage – One painless sore, less than an inch across, with raised borders found at the site of sexual contact, and during acute stages of infection, the lymph nodes in the groin become diseased, firm, and rubbery.
- The secondary stage – A contagious diffuse rash that may appear over the entire body, particularly on the hands and feet.
- The third stage – occurs late in the course of syphilis and affects mostly the heart and nervous system.
Causes of Inflammation of Rectum
- Infectious causes – include Clostridium difficile, enteric infections (Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis), and STI’s (Gonorrhea, Chlamydia, Syphilis, HSV, Lymphogranuloma venereum, chancroid, CMV, HPV).[rx]
- Causes include ischemia vasculitis – toxins as hydrogen peroxide enemas or medication side effects. The most common cause of anusitis is diet, as with excess citrus, coffee, cola, beer, garlic, spices, and sauces. Diarrhea noted after intake of laxatives as in preparation for colonoscopy is noted to cause anusitis and stress may be another etiologic factor.
- Inflammatory bowel disease – About 30% of people with inflammatory bowel disease (Crohn’s disease or ulcerative colitis) have inflammation of the rectum.
- Infections – Sexually transmitted infections, spread particularly by people who engage in anal intercourse, can result in proctitis. Sexually transmitted infections that can cause proctitis include gonorrhea, genital herpes and chlamydia. Infections associated with foodborne illness, such as salmonella, shigella and campylobacter infections, also can cause proctitis.
- Radiation therapy for cancer – Radiation therapy directed at your rectum or nearby areas, such as the prostate, can cause rectal inflammation. Radiation proctitis can begin during radiation treatment and last for a few months after treatment. Or it can occur years after treatment.
- Antibiotics – Sometimes antibiotics used to treat an infection can kill helpful bacteria in the bowels, allowing the harmful Clostridium difficile bacteria to grow in the rectum.
- Diversion proctitis – Proctitis can occur in people following some types of colon surgery in which the passage of stool is diverted from the rectum to a surgically created opening (stoma).
- Food protein-induced proctitis – This can occur in infants who drink either cow’s milk- or soy-based formula. Infants breastfed by mothers who eat dairy products also may develop proctitis.
- Eosinophilic proctitis – This condition occurs when a type of white blood cell (eosinophil) builds up in the lining of the rectum. Eosinophilic proctitis affects only children younger than 2.
- Unsafe sex – Practices that increase your risk of a sexually transmitted infection (STI) can increase your risk of proctitis. Your risk of contracting an STI increases if you have multiple sex partners, don’t use condoms and have sex with a partner who has an STI.
- Inflammatory bowel diseases – Having an inflammatory bowel disease (Crohn’s disease or ulcerative colitis ) increases your risk of proctitis.
- Radiation therapy for cancer – Radiation therapy directed at or near your rectum (such as for rectal, ovarian or prostate cancer) increases your risk of proctitis.
Symptoms of Inflammation of Rectum
Proctitis signs and symptoms may include
- A frequent or continuous feeling that you need to have a bowel movement
- Rectal bleeding
- Passing mucus through your rectum
- Rectal pain
- Pain on the left side of your abdomen
- A feeling of fullness in your rectum
- Pain with bowel movements
- Pain in your rectum, anus, and abdominal region
- Bleeding from your rectum
- Passing of mucus or discharge from your rectum
- Very loose stools
- Watery diarrhea
Diagnosis of Inflammation of Rectum
Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
- Blood tests – These can detect blood loss or infections.
- Stool test – You may be asked to collect a stool sample for testing. A stool test may help determine if your proctitis is caused by a bacterial infection.
- Scope exam of the last portion of your colon – During this test (flexible sigmoidoscopy), your doctor uses a slender, flexible, lighted tube to examine the last part of your colon (sigmoid), as well as the rectum. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis.
- Scope exam of your entire colon – This test (colonoscopy) allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. Your doctor can also take a biopsy during this test.
- Tests for sexually transmitted infections – These tests involve obtaining a sample of discharge from your rectum or from the tube that drains urine from your bladder (urethra).
Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
- Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
- Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
- Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of cancer cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose cancer.
- Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
- Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of rectal cancer or other conditions.
- Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
- Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
- Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
- Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
- Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
- Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
- Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
- Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
- Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]
Treatment of Inflammation of Rectum
When the presentation is consistent with acute proctitis in patients with receptive anal intercourse, therapy should be initiated while awaiting results of laboratory tests. Partners of patients with STI’s should be evaluated and patients should refrain from sexual intercourse until they are treated.
- Antibiotic – Gonococcal proctitis is treated with ceftriaxone 250 mg intramuscular one time plus azithromycin 1 gram oral one time.
- An alternative regimen is cefixime 400 mg -moral one time plus doxycycline 100 mg oral twice daily for seven days.mChlamydia is treated with azithromycin.
- Doxycycline – erythromycin, ofloxacin, or Levofloxacin may be used as an alternative regimen.
- LGV – has treated with doxycycline 100 mg twice daily for 21 days.
- Erythromycin or azithromycin – may be used as alternative regimens for the same period of 21 days.
- Herpes proctitis – is treated with acyclovir 400 mg oral three times daily or valacyclovir 1 gram twice daily or famciclovir 250 mg three times daily for 7 to 10 days. The course of treatment may be extended if no complete healing is achieved by the end of the 10-day course of treatment.[rx][rx]
For patients with mild to moderate UP, guidelines from American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) recommend
- Rectal 5-Aminosalicylic Acid (5-ASA) – mesalamine rather than oral mesalamine. Suppositories are more effective than enemas. For induction of remission, the dose is 1 g/day and this is to be continued at the same dose to maintain remission.
- Rectal therapy – In cases of intolerance, refractoriness, hypersensitivity to mesalamine suppositories, inability to retain rectal therapy, rectal corticosteroid therapy is suggested for induction of remission rather than no therapy, despite the superiority of rectal 5-ASA over rectal steroids.
- Corticosteroids – are not recommended and are not effective in the maintenance of remission secondary to side effects and long-term complications. Up to 46% of patients with UP may develop extensive colitis. This should be especially suspected in patients refractory to topical treatment and follow-up is recommended.[rx][rx]
- UP is treated with topical mesalazine – in the form of suppositories, enemas, foams, and gels in severe cases combined with oral mesalazine with topical steroids or systemic corticosteroids in more severe cases.
- In steroid-resistant cases – the addition of cyclosporine or immunomodulators; thiopurines as azathioprine (AZA) and 6-mercaptopurine (6-MP) is considered. Other options include anti-TNF-α (infliximab, adalimumab, and golimumab), anti-integrin antibodies as vedolizumab, and certolizumab, or oral tacrolimus.[rx][rx]
For CRP, topical
- Sucralfate enema – is the best available treatment. For DP, topical short-chain fatty acids (SCFAs) enemas, topical 5-ASA, or topical steroids are used.
- In patients with intractable symptoms – despite intensive therapy or complications including strictures, fistulas, and persistent bleeding, colostomy, ileostomy, proctectomy or proctocolectomy with ileal pouch-anal anastomosis (IPAA) may be considered.
- The application of a cold – retaining probe to the anal canal may give relief to anusitis patients as well as diet change and better handling of stress.[rx]
- Proctitis due to injury, such as anal sex or anal play, requires the person to stop the activity that is responsible for the inflammation. The doctor may also prescribe or recommend medications to treat pain and relieve diarrhea, if necessary.
- The National Institute of Diabetes and Digestive and Kidney Diseases note that healing from injury in the rectum usually takes 4–6 weeks.
- Proctitis from radiation therapy is common. As a 2015 study notes, close to 75% of people who have radiation therapy in the pelvis will develop acute proctitis symptoms, while 20% may experience chronic, long lasting symptoms.
- Doctors will treat radiation proctitis on a case-by-case basis. If the person has mild symptoms of proctitis due to radiation therapy, they may need no treatment, and the symptoms may clear up on their own.
- In some cases, doctors may use corticosteroid enemas to help with severe symptoms or pain. These medications reduce inflammation in the rectum.
- A doctor may also recommend other medications, such as sucralfate, which is a drug that is primarily for the treatment of ulcers but which may help with symptoms.
Inflammatory bowel disease
- Inflammatory bowel disease is a more long-term cause of proctitis, and people with this condition will require consistent treatment to control the symptoms.
- There is no cure for inflammatory bowel disease, so the treatment goal is to keep inflammation in check, prevent flare-ups, and put the body in remission.
- To achieve these goals, doctors may recommend several different types of drugs, including:
Corticosteroids in different forms may help reduce immune system activity in the area to decrease inflammation. These include steroids such as:
Immunomodulators reduce the overall activity in the immune system. As autoimmune factors often seem to play a role in chronic disorders such as Crohn’s disease, this treatment often helps reduce and manage symptoms.
Common immunomodulators include:
Aminosalicylates, also called 5-ASA drugs, help control inflammation. These include:
Prevention of Proctitis
Prevention of proctitis begins with addressing the high-risk sexual behaviors that you may engage in. Sexually safe behaviors include using protection such as the condom, knowing your sexual partner and history, and avoiding anal intercourse. You must use safe sex practices, such as condoms, if you engage in high-risk sexual behaviors such as these:
- Having multiple sexual partners (or changing sexual partners)
- A previous history of any sexually transmitted disease
- Having a partner with a past history of any STD
- Having a partner with an unknown sexual history
- Using drugs or alcohol (these may increase the likelihood of unsafe sexual practices)
- Having a partner who is an IV drug user
- Bisexual or homosexual partners
- Anal intercourse (Anal sex with a condom decreases the risk of proctitis by STDs, but you can still get proctitis from anal trauma)
- Having unprotected intercourse (sex without the use of a condom) with an unknown partner
Outlook for Proctitis
In most cases, anal/rectal problems like proctitis go away with treatment.
- Because most cases of proctitis are caused by sexually transmitted infections, antibiotics may be needed.
- Proctitis caused by other conditions, such as radiation therapy, ulcerative colitis, and Crohn’s disease, may last a long time. You may need long-term therapy. Symptoms may return from time to time (in relapse or flare-up).
- In certain instances, where medications are not effective, you may need surgery to remove the diseased part of your gastrointestinal tract. There can be complications as a result of proctitis, especially if it goes untreated. Some complications include severe bleeding, anemia, ulcers, and fistulas.
- Fistulas may occur in many parts of the body. Women typically may get recto-vaginal fistulas in which a tube grows to connect the rectum to the vagina. Both men and women may get anal fistulas, which connect the rectum to the skin. These fistulas can also become infected and cause complications themselves.
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