Proctitis

Proctitis is inflammation of the anus and rectal lining.

Proctitis is defined as inflammation of your anus (the opening) and lining of your rectum (lower part of the intestine leading to the anus). Symptoms can vary greatly. You may at first have only minor problems. Proctitis affects the last 6 inches of the rectum and can cause the following:

• Pain during a bowel movement
• Soreness in your anal and rectal area
• Feeling that you didn't completely empty your bowels after a bowel movement
• Involuntary spasms and cramping during bowel movements
• Bleeding, and possibly a discharge

Proctitis can last a short time or become a chronic condition (last for weeks or months or longer).

Proctitis has many causes, but sexually transmitted diseases (STDs) are the most common. Gonorrhea, syphilis, herpes, anal warts, and chlamydia are the most common cause of sexually transmitted proctitis. Proctitis is increasingly more common in homosexual men and in people engaging in oral-anal or anal intercourse with many partners.

Other causes include the following:

• Nonsexually transmitted infections
• Autoimmune diseases of the colon such as Crohn disease and ulcerative colitis
• Harmful physical agents
  • Chemicals
  • Foreign objects placed in the rectum
  • Trauma to your anorectal area
  • Radiation (a side effect from treatment for another illness)
  • Antibiotics (a side effect from treatment for another illness)

Symptoms of proctitis are different depending on the cause.

The most common symptom is that you feel a continuing urge to have a bowel movement. Your rectum could feel "full." Or you could have constipation (unable to have a bowel movement).

You may have minor symptoms such as tenderness in the anal region and mild irritation of the rectum.

More serious symptoms may occur, such as pus and blood in discharge accompanied by severe cramps and pain during bowel movements.

If you have severe bleeding associated with proctitis, you may developanemia (from loss of blood). Anemia can cause you to have pale skin, irritability, weakness, dizziness, brittle nails, and shortness of breath.

With sexually transmitted proctitis, you may have these symptoms:

• Gonorrhea (gonococcal proctitis): The primary cause appears to be anal intercourse. You may not have symptoms. If you have symptoms, you may have soreness, itching, bloody or puslike discharge, or diarrhea. Other rectal problems may be present such as anal warts, which are genital warts, anal tears, fistulas (abnormal passages that connect an organ or natural tube, like the rectum, to another surface), and hemorrhoids (dilated veins in the anus).
• Syphilis (syphilitic proctitis): Symptoms are similar to those of other causes of infectious proctitis - rectal pain, discharge, and spasms during bowel movements. But you may have no symptoms. Syphilis occurs in 3 stages:
  • Primary stage: A single painless sore with raised borders can be found at the site of sexual contact. These sores, or chancres, are less than an inch across. During acute stages of infection, the lymph nodes in your groin become diseased, firm, and rubbery.
  • Secondary stage: Syphilis produces sores around your anus and rectum. These are wartlike growths resembling cauliflower.
  • Third stage: This usually appears late in the course of syphilis and affects mostly your heart and nervous system.
• Chlamydia (chlamydial proctitis): This bacterial form of sexually transmitted proctitis may account for a significant portion of cases. You may show no symptoms, mild symptoms, or severe symptoms. Mild symptoms might be mild rectal pain with bowel movement, anal discharge, and cramping. With a severe case, you may have discharge containing blood and pus, severe rectal pain, and diarrhea. Some people may have rectal strictures, a narrowing of the rectal passageway. This narrowing might cause constipation, straining, and thin stools.

With proctitis caused by viruses, you may have these symptoms:

• Herpes simplex: The herpes simplex type 2 virus usually causes proctitis, but type 1 also can trigger the disease. As with the other causes, you may show no symptoms. Herpes proctitis is accompanied by anal pain and tenderness, discharge, and constipation. Tiny painful blisters or sores may be seen in clusters around your anus. In contrast to other causes of proctitis, if you have herpes, you also may have urinary retention and a weak stream, impotence, and pain in the buttocks and thigh.
• Anal warts: A virus known as human papillomavirus (HPV) causes anal warts, which begin as soft, fleshy growths around the anus. These warts can extend to affect the lower part of the rectum. You may have anal itching, varying degrees of pain, and, with time, bleeding and discharge.
• Anorectal trauma: Trauma to your anus or rectum, in which the anal and rectal linings stretch and tear, can be a potential cause of proctitis. Health care providers usually see such trauma in people who introduce any foreign object into their rectum. Foreign objects include a penis during anal intercourse or sex toys. Tiny cracks may be seen in the anal or rectal linings. It’s important to tell your health care provider if you may be at risk for this type of proctitis. Sometimes, the foreign object may still be present in the rectum. People with anorectal trauma also may have an accompanying infection as a result of high-risk sexual behavior.
• Radiation proctitis: Radiation therapy is used to treat prostate cancer in men and cancers of the female organs such as the cervix and uterus. The rectum is close to these organs and is at risk for damage from the radiation. Radiation-induced injury to the rectum can appear in 2 ways.
  • You may have diarrhea and tenesmus, which is a painful spasm of the urogenital diaphragm coupled with an urgent desire to urinate or have a bowel movement. Symptoms can occur while you receive radiation therapy or within 6 weeks after completion.
  • You may have more lasting problems from radiation treatment. In addition to rectal pain and diarrhea, you may have bleeding, which signifies chronic changes of the rectal lining. This condition includes the presence of multiple tiny blood vessels on the surface of the mucous membranes in the rectum. These vessels are fragile and bleed easily as a result of minor trauma. If the bleeding is severe, you may have weakness, dizziness, palpitations (feel your heart beating), and tiredness - all signs of iron deficiency anemia from blood loss.

• If you have any of the symptoms—especially if you have a history of high-risk sexual behavior that may lead to proctitis—you should contact your health care provider to be checked. Other minor conditions such as hemorrhoids also can cause similar symptoms. Your doctor can tell the difference and provide the right treatment.
• If you have bleeding and mucus in a bowel movement, severe pain, and diarrhea, seek treatment at a hospital’s emergency department. Complications such as severe bleeding and anemia need immediate medical attention. As a result of diarrhea, you also may be dehydrated. Symptoms indicating severe disease include weakness, dizziness, irritability, shortness of breath, and headaches.

The diagnosis of proctitis is based on the suspected cause.

• Your health care provider will take a thorough medical history to determine your sexual practices and if you have any high-risk behaviors.
• Most cases of suspected proctitis require a procedure called a proctosigmoidoscopy. A lighted tube with a camera is passed through the anus and used to look at the surface of your rectum. The image is projected on a TV screen and is magnified to identify changes.
• In addition, your doctor also may take a biopsy (small piece of tissue) of your rectum for testing for disease or infection.
• Any discharge present will undergo lab testing to identify sexually transmitted organisms.
• Doctors also frequently test your blood for the presence of antibodies to support the diagnosis.

Treatment of proctitis depends on the cause of the disease.

• Because the most common cause of proctitis remains sexually transmitted disease, you may be given antibiotics to kill the organism. The presence of one type of infection also suggests the presence of other types of sexually transmitted diseases, so antibiotic treatment may be directed at 2 or more infectious organisms at the same time. Some of the medications can be given in a single injection.
• You must use safe sex practices, such as condoms, if you engage in high-risk sexual behavior.
• If you have inflammatory disease causing proctitis, such as ulcerative colitis or Crohn disease, you will require continuing treatment. Treatments include medications that suppress the immune system, such as steroids. Your doctor may prescribe steroid suppositories to provide relief in your rectum. In addition you may receive treatment for control of symptoms such as diarrhea.

If the disease stems from a chronic illness, surgery may be required. A gastroenterologist, a specialist who deals with all the organs from the mouth to the anus, should advise you.

• Follow-up is an integral part of treating proctitis.
• You must finish all the antibiotics given you.
• You should abstain from any sexual practice that may irritate the disease.
• Follow up with a visit to your health care provider after 1-2 weeks to determine whether the inflammation has cleared or if you should continue therapy.
• At any point, if the symptoms get worse, either contact your doctor or go to the emergency department, depending on the severity of your symptoms.

Prevention 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

In most cases, anal/rectal problems go away with treatment.

• Because most cases of proctitis are caused by sexually transmitted infection, antibiotics are useful.
• Proctitis caused by other conditions, such as radiation therapy, ulcerative colitis, and Crohn disease, may last a long time. You may need long-term therapy. Your symptoms may return from time to time (in a relapse or flare-up).
• In certain instances, where medications are not effective, you may need surgery to remove the diseased part of your GI tract. There can be complications as a result of proctitis, especially if it goes untreated. Some complications include severe bleeding, anemia, and fistulas.
• Fistulas may occur in many parts of your body. Women typically may get recto-vaginal fistulas in which a tube grows to connect the rectum to the vagina. Hence women may have fecal matter coming out of their vagina. Both men and women may get anal fistulas, which connect the rectum to the skin. Feces may come out of an opening other than the anus. These fistulas can also become infected and cause complications themselves.