What Is Proctitis?

Do you find yourself constantly feeling the urge to go to the bathroom, even after you’ve just gone? And when you do pass a bowel movement, is it difficult and painful? Or perhaps you’ve even noticed blood and pus in your stool? These are all symptoms of proctitis, an inflammatory condition affecting your rectum - the last part of your large intestine before the anus where stool is stored before it leaves the body. 

Whilst it may sometimes be an uncomfortable topic to discuss, it is important to seek medical attention if you suspect you have proctitis. With proper care and treatment, proctitis is a treatable and manageable condition. 

Overview

Proctitis is an inflammatory condition affecting the rectum, which is part of your gastrointestinal (GI) tract. Your GI tract, also known as the digestive system, is composed of several organs working together to break down food and absorb nutrients from it. The rectum is the final section of the large intestine and is where poo (stool) is stored before it passes through the anus during a bowel movement. 

Proctitis is when the cells lining the rectum (rectal mucosa) become inflamed. This usually leads to uncomfortable symptoms such as pain in the rectal or lower abdominal area, rectal bleeding, and the feeling of needing to constantly pass a bowel movement. 

Inflammation is our body’s biological response to dangerous stimuli such as microbes, burns, and chemical or physical trauma. It is fundamentally a protective process, but may potentially be harmful, leading to tissue injury. Acute inflammation protects the body from further injury by recruiting white blood cells to the site of injury and fighting off the offending agent. This usually has a rapid onset and may last hours to days. Chronic inflammation persists for much longer - usually months, years, or even a lifetime - and is characterised by simultaneous injury and healing. This may be caused by a persistent infection, autoimmune diseases, allergic diseases, or prolonged exposure to toxic agents.

This article explores the common causes and treatments for each type of proctitis, some of which are acute or chronic: 

• Proctitis of inflammatory bowel disease (including ulcerative proctitis)
• Infective proctitis
• Radiation proctitis
• Diversion proctitis 

Causes of proctitis

Different types of proctitis have differing causes and are usually a symptom of another underlying condition such as:

Proctitis of inflammatory bowel disease (IBD)

Chronic proctitis is common in those who suffer from inflammatory bowel disease (IBD) and is the most common cause of proctitis. Crohn’s disease and ulcerative colitis (UC) are both autoimmune diseases causing chronic inflammation in different parts of the gastrointestinal tract. The former is characterised by inflammation only in certain areas of the intestine, whereas ulcerative colitis involves the continuous inflammation of the colon.¹ When this inflammation occurs in the rectum, it is referred to as Crohn's proctitis and ulcerative proctitis respectively.

• Crohn’s disease: may cause inflammation anywhere throughout the GI tract (mouth to anus) and can occur in all layers of the bowel walls, including the rectum
• Ulcerative colitis: causes inflammation and ulcers (sores) in the innermost layer of the colon (large intestine), including the rectum

Up to 30% of those who have been diagnosed with IBD will experience proctitis at some point.¹

Infective proctitis

Different types of infections may cause infective proctitis (also referred to as infectious proctitis), namely sexually transmitted infections (both viral and bacterial) as well as gastrointestinal infections that cause inflammation in the rectum. These are most often cases of acute proctitis.

• Sexually transmitted infections that may spread during anal intercourse:²
  • Gonorrhoea
  • Chlamydia
  • Herpes simplex 2
  • Syphilis
  • Human papillomavirus (HPV)
• Enteric pathogens are bacteria that exist in the intestines and can cause disease, such as:
  • Bacterial infections which can cause food poisoning (such as Salmonella, Shigella, and Campylobacter)
  • Clostridioides difficile, an infection frequently associated with the use of antibiotics or shortly after their use²

Radiation proctitis

Also known as radiation proctopathy, this type of proctitis may be acute or chronic and occurs after radiation therapy to the pelvic or lower abdomen area, most likely to treat cancers such as cervical, prostate, rectal or colon cancer.

• Acute radiation proctitis: occurs within 3 months of starting radiotherapy, usually lasts a short time but may develop to become chronic
• Chronic radiation proctitis: occurs 9-14 months after starting radiotherapy, but may develop years after as well³

Unlike other types of proctitis, radiation therapy damages the lining of the rectum and is less associated with inflammation, hence why medical professionals often refer to it as radiation proctopathy (disease of the rectum) instead.

Diversion proctitis

Ostomy surgery of the bowel, also called bowel diversion or faecal diversion, is a surgery performed when part or all of your bowel is diseased. The bowel is part of your GI tract and is made of your small and large intestines. A bowel diversion involves changing the way waste products of digestion exit the body, allowing intestinal products to leave through the abdominal wall instead of the anus. Medical professionals don’t know the exact reason why certain patients develop diversion proctitis following ostomy surgery. However, this condition often resolves itself after a secondary surgical procedure is conducted to close the ostomy and reestablish the connection between the rectum and the other parts of the intestine.³ 

Some other, less common factors causing proctitis include anorectal trauma (injury to the rectum or anal canal), side effects of certain non-steroidal anti-inflammatory drugs (NSAIDs), or a lack of blood flow to the rectum.

Signs and symptoms of proctitis

Common proctitis symptoms include:

• Tenesmus: the constant feeling or urge of needing to have a bowel movement
• Dyschezia: difficult or painful bowel movements 
• Diarrhoea
• Constipation
• Rectal pain, or pain in the lower left abdomen
• Rectal bleeding, or passing mucus and pus in your stool

Management and treatment for proctitis

Current therapeutic goals in the treatment of proctitis include reducing inflammation, controlling symptoms, and treating infections. Treatment for proctitis depends on the cause and underlying symptoms, and ranges from oral medication, IV drips, topical medication (cream/gel), and even surgery:³

• Antibiotics such as doxycycline, antiviral medicine such as acyclovir to treat infections
• Anti-inflammatory medication such as corticosteroids and mesalazine to reduce inflammation and provide pain relief³
• Immunosuppressants and biologics to treat proctitis of IBD such as infliximab and azathioprine¹
• Switching medication if your proctitis is a side effect of NSAIDs

In some severe cases, surgical intervention is required, such as with cases of proctitis of IBD or frequent recurring cases of proctitis.

It is also recommended that you make lifestyle adjustments which may help relieve pain associated with proctitis:

• Change your diet: avoid known ‘trigger’ foods which may cause inflammation in your GI tract (such as spicy, acidic, or fatty foods) especially during bouts of diarrhoea
• Drink plenty of fluids, but avoid caffeinated, alcoholic, or carbonated drinks
• Track your symptoms, as this will help you identify triggers, and make adjustments accordingly
• Practise safe sex: use a condom and dental dams, thoroughly clean sex toys before and after each use, get tested for STDs regularly

FAQs

How is proctitis diagnosed?

On top of taking your medical history and asking about your symptoms, common diagnostic tests include:

• Blood tests: drawing and testing blood to identify infections and blood content (including white blood cell count)
• Stool tests: collecting a stool sample which can show signs of infection and/or bleeding and white blood cell count
• Rectal culture: swabbing the inside of the rectum to identify bacteria or viruses
• Endoscopy:
  • Proctoscopy: enables visualisation of the rectum using a long hollow tube with a camera attached to one end 
  • Flexible sigmoidoscopy: enables visualisation of the sigmoid colon (where the end of your colon meets the rectum) using a long hollow tube with a camera attached to one end 

How can I prevent proctitis?

Certain types such as infectious proctitis are preventable. You should practise safe sex by always using a condom and screening your sexual partners before intercourse. Some STIs can be spread orally, and hence dental dams would be another good preventative measure. Safe food handling practices and being mindful of what you consume can help reduce the possibility of food poisoning. However, certain types such as radiation proctitis/proctopathy and proctitis of the IBD are not preventable.

What are the different types of proctitis?

Proctitis is commonly categorised into the following types:

• Proctitis of inflammatory bowel disease 
• Infective proctitis
• Radiation proctitis/proctopathy
• Diversion proctitis 

Who is at risk of proctitis?

You are more likely to develop proctitis if you:

• Suffer from inflammatory bowel disease (IBD; ulcerative colitis or Crohn’s disease)
• Engage in anal intercourse/sex (especially if you have multiple sex partners, practise unsafe sex, or have sex with a partner with an STI)
• Have a sexually transmitted disease
• Had radiation therapy for cancer 
• Had ostomy surgery of the bowel 

How common is proctitis?

Approximately 30% of those with IBD will experience proctitis.² 75% of those who undergo radiation therapy for cancer in their pelvic area or lower abdomen develop acute radiation proctopathy, and up to 20% develop chronic radiation proctopathy.⁴ Diversion proctitis is common in those who have undergone bowel diversion surgery, but only less than 50% will experience symptoms.¹  

When should I see a doctor?

You should see a healthcare professional as soon as you display any symptom of proctitis, especially if you pass blood, mucus, or pus with a bowel movement.

Summary

Proctitis is a condition causing rectal inflammation. It is mostly observed in those suffering from inflammatory bowel disease (proctitis of IBD), those with sexually transmitted disease(s) or gastrointestinal infection(s) (infectious proctitis), those who have undergone radiotherapy (radiation proctopathy), or those who have undergone bowel diversion surgery (diversion proctitis). 

It is important to seek out medical advice as soon as possible for a diagnosis commonly through blood or stool tests, or endoscopies. Treatment depends on the type of proctitis, but includes medication, lifestyle changes, and sometimes surgery. You can take measures to prevent infectious proctitis by practising safe sex and being wary of what you consume, however some other types of proctitis are not preventable.