ConditionDigestive system
Proctitis (Inflammation of the Rectum)
Proctitis is inflammation of the lining of the rectum, the last section of the large intestine before the anus. It causes rectal bleeding, mucus or pus discharge, rectal pain, and tenesmus, a constant feeling of needing to pass stool even when the bowel is empty. The main causes are inflammatory bowel disease (especially ulcerative colitis), sexually transmitted infections such as gonorrhea and chlamydia, and radiation therapy to the pelvis. Treatment depends on the cause and usually works well.
Also called: Rectal inflammation, inflammation of the rectum, ulcerative proctitis, infectious proctitis, radiation proctitis
At a glance
- What it is
- Inflammation of the rectal lining.
- Main causes
- Ulcerative colitis or Crohn's disease, STIs, pelvic radiation, some antibiotics and infections.
- Key symptoms
- Rectal bleeding, mucus, pain, tenesmus, urgency, sometimes diarrhea or constipation.
- Diagnosis
- Sigmoidoscopy or colonoscopy with biopsy, STI tests and stool tests.
- Treatment
- Mesalamine suppositories for IBD, antibiotics for STIs, and specific treatments for radiation proctitis.
When to get help
Call 911 or go to the ER
- Heavy rectal bleeding, or bleeding with dizziness, fainting or a racing heart
- Severe belly pain with fever and a swollen, tender abdomen
See a doctor within a day or two
- Rectal bleeding with fever, or more than 6 bloody stools a day
- Rectal pain with discharge after receptive anal sex (possible STI)
- Bloody diarrhea after a course of antibiotics
Book a routine appointment
- Rectal bleeding, mucus or a constant urge to pass stool lasting more than a few days
- New rectal bleeding after pelvic radiation, even years later
- Any rectal bleeding over age 45, or with weight loss or a change in bowel habits
What proctitis feels like
- rectal bleeding: bright red blood on the stool, toilet paper or in the bowl
- mucus or pus passed from the rectum, sometimes without stool
- tenesmus: a constant urge to have a bowel movement, often passing little or nothing
- urgency and sometimes leakage
- rectal pain, or pain on passing stool
- constipation, which is common in ulcerative proctitis because the inflamed rectum resists stool, even though the rest of the bowel works normally
- diarrhea when inflammation extends higher
- cramping in the lower left belly
Causes
| Cause | Typical clues |
|---|---|
| Ulcerative colitis | Gradual onset, bleeding and mucus, continuous inflammation starting at the anus. "Ulcerative proctitis" when limited to the rectum |
| Crohn's disease | Can affect any part of the gut, often with anal fissures, fistulas or abscesses |
| Gonorrhea, chlamydia, herpes, syphilis | Pain, discharge and bleeding after receptive anal sex. Herpes causes severe pain and ulcers |
| Lymphogranuloma venereum (LGV) | A type of chlamydia causing severe proctitis, mainly in men who have sex with men |
| Radiation proctitis | After radiotherapy for prostate, cervical, rectal or other pelvic cancers. Early (during treatment) or late (months to years later) |
| Infections | C. difficile after antibiotics, Salmonella, Shigella, Campylobacter |
| Other | Diversion proctitis after bowel surgery, NSAID suppositories, enemas, trauma |
Ulcerative proctitis
Ulcerative colitis that is limited to the rectum is called ulcerative proctitis. It is the mildest form, but in some people it later spreads further up the colon. It is treated mainly with medicines applied directly to the rectum.
Sexually transmitted proctitis
Gonorrhea, chlamydia, herpes and syphilis can infect the rectum through receptive anal sex. Some infections cause no symptoms. Partners should be tested and treated, and HIV testing is recommended.
Radiation proctitis
Radiation to the pelvis can inflame the rectum. Acute radiation proctitis causes diarrhea, urgency and tenesmus during or soon after treatment and usually settles within 3 months. Chronic radiation proctitis develops months to years later and causes bleeding from fragile new blood vessels.
Diagnosis
- Medical and sexual history, including radiation, antibiotics and bowel symptoms
- Rectal exam and anoscopy
- Flexible sigmoidoscopy or colonoscopy with biopsies to confirm inflammation and its extent
- STI tests: rectal swabs for gonorrhea and chlamydia (including LGV), herpes swabs, and blood tests for syphilis and HIV
- Stool tests: for bacteria, C. difficile toxin, and fecal calprotectin (a marker of bowel inflammation)
- Blood tests: blood count for anemia, inflammation markers
Treatment
Inflammatory bowel disease
- Mesalamine suppositories are the first choice for ulcerative proctitis and are very effective.
- Mesalamine enemas or foam if inflammation extends beyond the rectum.
- Steroid suppositories, foams or enemas for flares.
- Oral mesalamine, immune-suppressing medicines or biologics for resistant or extensive disease.
STIs
- antibiotics for gonorrhea, chlamydia (with a longer course for LGV) and syphilis
- antivirals for herpes
- treating partners and avoiding sex until treatment is complete
Radiation proctitis
- acute: stool softeners, anti-diarrheal medicines, and steroid or other suppositories
- chronic bleeding: sucralfate enemas, formalin application, argon plasma coagulation (an endoscopic heat treatment), and hyperbaric oxygen therapy in selected cases
- iron or transfusion for anemia
Infections
- treatment for C. difficile and other bacterial infections, and stopping unnecessary antibiotics
Self-care
- fiber and fluids to keep stools soft
- sitz baths for discomfort
- avoid straining
Complications
- anemia from chronic bleeding
- ulcers, fistulas and strictures (narrowing), especially with Crohn's disease or LGV
- spread of ulcerative proctitis to the rest of the colon
- an increased risk of colorectal cancer with long-standing extensive colitis, which is why surveillance colonoscopy is recommended
Frequently asked questions
What are the symptoms of proctitis?
Typical symptoms are rectal bleeding, mucus or pus discharge, rectal pain, and tenesmus, a constant feeling of needing to have a bowel movement. Some people have diarrhea, while others with ulcerative proctitis have constipation.
What causes proctitis?
The main causes are inflammatory bowel disease (ulcerative colitis or Crohn's disease), sexually transmitted infections from anal sex, radiation therapy to the pelvis, and some bowel infections, including C. difficile after antibiotics.
Is proctitis an STI?
Not always. Proctitis can be caused by STIs such as gonorrhea, chlamydia, herpes and syphilis, but it is also commonly caused by inflammatory bowel disease, radiation or other infections. Testing identifies the cause.
How is ulcerative proctitis treated?
Mesalamine suppositories, placed in the rectum daily, are the most effective first treatment. Steroid suppositories or foam help flares. Some people need oral medicines or biologics if symptoms persist or the disease spreads.
Can proctitis go away on its own?
Mild infectious or acute radiation proctitis may settle by itself, but most proctitis needs treatment. Proctitis from inflammatory bowel disease is long-term but usually controlled with medicines. See a doctor for any rectal bleeding.
Sources
This guide was written from current patient and clinical guidance, including:
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK): Proctitis
- American College of Gastroenterology: Ulcerative colitis clinical guideline
- CDC: Sexually transmitted infections treatment guidelines, proctitis, proctocolitis and enteritis
- American Society of Colon and Rectal Surgeons: Radiation proctitis
- MedlinePlus (US National Library of Medicine): Proctitis