Proctitis is a chronic inflammatory disease arising in the rectum and characterized by bloody diarrhea. There are two types of proctitis, ulcerative and gonorrheal, which are differentiated by the means in which they are contracted. Gonorrheal proctitis is transmitted through sexual contact.
Symptoms of proctitis are most frequently pain in the rectal area and a frequent desire to pass feces. Bloody diarrhea, painful defecation and bleeding in the rectal area are also common. Diarrhea may be followed by constipation with spasm and severe straining of the rectal muscles (tenesmus). In some cases, stools may be well formed but surrounded by blood and mucus.
Proctitis usually runs a mild, intermittent course over many years. Occasionally there is neurological involvement with urinary bladder dysfunction, weakness and burning of the lower limbs (paresthesias) and pain in the thighs. Men may have difficulty maintaining penile erections. When a diagnosis of gonorrheal proctitis is confirmed, individuals also should be tested for other sexually transmitted organisms such as syphilis, amebiasis, chlamydia, campylobacter, shigella, and herpes simplex virus infections.
Upon examination, individuals with ulcerative proctitis show ulcers in the rectum. Ulcerations are usually accompanied by rectal bleeding, straining of rectal muscles (tenesmus) and an anal discharge of bloody mucus. However, anal bleeding is seldom severe. Individuals with diarrhea often describe no increase in stool volume but rather frequent passage of small amounts of mucous or blood. Fever and weight loss are rare. Symptoms of ulcerative proctitis are very similar to ulcerative colitis. However, ulcerative proctitis is not as serious as colitis and is limited to the rectum. (See related disorder section for more information on Ulcerative Colitis.)
Proctitis can be caused by the pus-producing bacteria gonococci and by the herpes simplex virus, primary and secondary syphilis, chlamydia trachomatis and the human papilloma viruses. Gonococcal Proctitis usually results from passive anal intercourse with men who have infection in the canal that empties urine from the bladder (urethra).
Ulcerative Proctitis may be caused by radiation injury, trauma from a foreign body, constriction or obstruction of a blood vessel (ischemia), infection or the cause may be unknown (idiopathic).
The effects of irritating enemas or laxatives may be confused with Ulcerative Proctitis. This disorder may also mimic the symptoms of long-term trauma.
Proctitis is increasing in incidence. Gonococcal Proctitis is most frequently found in women and homosexual men who practice anal-receptive intercourse.
Diagnosis of proctitis is made when sigmoidoscopy reveals inflammation of the mucus lining of the rectum with a clearly demarcated upper border above which the lining is normal. The remainder of the colon and small intestine is found to be normal by barium x-rays, while colonoscopy and rectal biopsy may show changes which are indistinguishable from those of chronic ulcerative colitis. (For more information on chronic ulcerative colitis, see the related disorder section of this report.)
The treatment of proctitis is determined by cause. Gonococcal proctitis responds to standard intramuscular injection with procaine penicillin or spectinomycin, but less consistently to oral treatment with penicillin or tetracycline. Primary herpetic proctitis responds well to acyclovir. Chlamydial proctitis responds to tetracycline. Treatment of idiopathic (unknown cause) ulcerative proctitis is very similar to that of ulcerative colitis and Crohn's disease, and includes a nonlaxative diet, the administration of antidiarrheal drugs such as diphenoxylate hydrochloride with atropine sulfate (Lomotil) or loperamide. Topical corticosteroids may be applied in the form of suppositories, steroid enemas or steroid foam. Enemas or suppositories should be administered at bedtime to maximize their retention. Other symptoms may be treated by pain-killing and antispasmodic drugs. Hospitalization may be necessary for a thorough physical examination.
Although proctitis may persist for many years, it is not associated with an increased incidence of cancer of the rectum or colon. With treatment, proctitis usually runs a course with periodic mild to severe episodes of symptoms. The inflammation spreads beyond the rectum in only 10 to 30% of individuals affected with proctitis. Less than 15% of individuals with ulcerative proctitis will develop chronic ulcerative colitis.
Approximately 40% of homosexual males with proctitis also have anorectal gonorrhea. It is not unusual to discover multiple disease producing organisms in patients with proctitis. Men who have had passive rectal intercourse with sex partners who have gonococcal infection of the ureter should have cultures performed for gonorrhea, regardless of an apparent lack of symptoms.
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