Proctitis – an introduction

Inflammation refers to the body’s response to foreign objects, illness, or injury, which allows it to heal. Although a protective process, inflammation often comes as a double-edged sword – causing pain, swelling or redness.¹ Thus, although beneficial, inflammation may be harmful if occurring in healthy tissues for a long period.

Proctitis refers to the inflammation of the lining cells of the rectum – the final portion of the large intestine where stool is stored before passing out of the anal canal.² Apart from storing stool, the rectum plays a minor role in the absorption of water and electrolytes from the stool (the majority done in the large intestine), and when it is full, adjacent nerves are stimulated, which convey the urge to defecate.³

This article explores a specific sub-variant of proctitis – the non-infective proctitis, its causes, manifestations, prevention, and finally, treatment.

Non-infectious proctitis

Broadly, proctitis can be classified as follows:⁴

• Non-infectious proctitis
  • Proctitis in inflammatory bowel disease
  • Radiation proctitis/ proctopathy
  • Diversion proctitis
• Infectious proctitis – usually sexually transmitted, or due to food poisoning, and is acute within nature

Non-infectious proctitis types are discussed in detail in the further sections.

Causes of non-infectious

Proctitis in inflammatory bowel disease

Inflammatory bowel disease (IBD) refers to the chronic inflammation of the gastrointestinal tract which often results in clinical manifestations. IBD is an umbrella term which mostly consists of two conditions: ulcerative colitis and Crohn’s disease. About 30% of patients suffering from IBD also suffer from proctitis.⁵

Ulcerative colitis refers to the superficial inflammation (limited to intestinal mucosa) of the large intestine. Its exact aetiology is still unknown, however, it is believed to be an autoimmune condition which triggers a response to harmless gut bacteria.^6-8 

When ulcerative colitis affects only the rectum, i.e., the autoimmune response and thus mucosal inflammation occurs only in the rectum, it is known as ulcerative proctitis.⁹ An important distinction between ulcerative colitis and ulcerative proctitis, is that patients with ulcerative proctitis which has not progressed to ulcerative colitis are at a lower risk of developing colorectal cancer, compared to cases where ulcerative proctitis progresses to ulcerative colitis.⁹

Crohn’s disease refers to the chronic inflammation of the gastrointestinal tract – however, a key difference from ulcerative colitis is the location – while ulcerative colitis affects the large intestine, Crohn’s disease can involve different areas (simultaneously between mouth to anus) of the digestive tract but most commonly affects the small intestine.¹⁰ Another important difference is that the entire thickness of the intestinal wall is inflamed, unlike only the mucosa in ulcerative colitis. Crohn’s disease is also believed to be an autoimmune condition (with genetic links), with certain risk factors.¹¹

Crohn’s disease isolated in the rectal region causes proctitis.¹²

Radiation proctitis/proctopathy

Radiation proctitis mostly occurs as a side-effect of radiation therapy for cancer in the pelvic region, including reproductive organs, rectum, or prostate. Damage is caused to the rectal lining from the radiation, and this type of proctitis is broadly divided into acute and chronic phases.¹³

Acute radiation proctitis typically develops during or immediately after the therapy period, whereas chronic radiation proctitis occurs more than 3 months after completion of therapy. Out of the two types, chronic radiation proctitis is usually more persistent, often resulting in complications such as ulcerations and fistulas. This is because chronic radiation proctitis is characterised by mucosal as well as submucosal changes, including vascular abnormalities such as the destruction of small blood vessels and fibrosis. In comparison, the damage in acute radiation proctitis is much more superficial.¹⁴

Diversion proctitis

Diversion proctitis (also known as diversion proctocolitis) is a non-specific inflammatory condition which affects the rectum following an ostomy surgery of the bowel, such as a colostomy or ileostomy. In this type of surgery, the path of faecal matter exit is altered – an opening is created in the abdominal wall, instead of the rectum. This can be temporary if the diseased/injured part of the bowel (intestine) heals, or permanent if the part of the intestine is removed (e.g., due to malignancies). The reason for inflammation in this unused rectum is not clearly known, but a deficiency in nutritional factors has been indicated to play a role.¹⁵

Symptoms

Common symptoms of non-infective proctitis include:^4,5

• A constant urge to defaecate, even though the rectum is empty (tenesmus)
• Pain in the anus or rectum or on the left side of the abdomen, possibly during bowel movements
• Rectal bleeding
• Passing mucus/pus along with stool
• Diarrhoea
• Constipation

Severe pain, or passing blood, mucus or pus with stool should be an indication for consulting a medical specialist immediately.

How is it diagnosed

Non-infective proctitis is diagnosed using the following strategies:⁴

• Medical history – previous medical conditions, family history of conditions such as inflammatory bowel disease, radiation therapy, and other medications
• Physical examination – a digital rectal exam by a medical professional
• Endoscopy – a long, narrow tube with a light and camera is inserted to view the lining of the rectum.

Treatment

The treatment of proctitis depends on the condition of the individual patient and the cause of the condition. However, treatment modalities share a common aim: to reduce inflammation, promote healing, and finally, improve quality of life.

Some commonly used methods to treat non-infective proctitis include:^4,15

• Ulcerative proctitis – Medication usually involves topical or oral corticosteroids, mesalamines, immunosuppressive drugs, and monoclonal antibodies. 5-aminosalicylic acid is considered the first-line treatment for mild and moderate cases. Topical corticosteroid treatment is considered for patients where 5-aminosalicylic acid is ineffective, however, they are considered to be less effective and may cause more side effects
• Chronic radiation proctopathy – Three lines of treatment may be considered: medical, endoscopic, or surgical. Topical oral sucralfate is currently the best available medical therapy for chronic radiation proctopathy
  • For endoscopic treatment, techniques such as argon plasma coagulation (APC) are used to treat “bleeding forms” of radiation proctopathy. The surgical method is the final option for treatment, and it is reserved for patients with chronic, persistent rectal bleeding, and where medical and endoscopic methods are unsuccessful/inappropriate. An ostomy with/without reconstruction may be required. Surgical interventions are relatively rare, with less than 10% of patients requiring them¹⁵
• Diversion proctitis – Surgical restoration and intestinal continuation is the treatment of choice for these patients

Self-management

The NHS describes a self-management plan for proctitis from inflammatory bowel disease which can be found here. However, it is important to consult with a medical professional if symptoms do not subside.

Some dietary changes may also be made to avoid irritating the inflamed part of the gastrointestinal tract in inflammatory bowel disease. This includes avoiding spicy foods, caffeinated or alcoholic foods, and drinking plenty of fluids. This also helps compensate for water loss in case of diarrhoea.

Prevention

Unlike infective proctitis, non-infective proctitis is not usually preventable. The likeliness of radiation proctitis may be reduced by proper treatment planning and using protection to minimise the irradiated rectal volume (volume of the rectum exposed to radiation).¹⁶

Summary

In conclusion, non-infective proctitis refers to inflammation of the rectal lining due to non-infectious agents, such as autoimmune co-morbidities (IBD), radiation, or because of surgery. Treatment of the condition is possible however, it is essential to properly diagnose it to ensure effectiveness.

Self-management techniques and strategies do exist for this condition; however, it is essential to consult a medical professional to receive a proper diagnosis and treatment plan should symptoms not subside, or deteriorate.