Background
Proctitis is inflammation of the lining of the rectum, called the rectal mucosa. Proctitis can be short term (acute) or long term (chronic). Proctitis involves an inflammatory change of the rectum (within 15 cm of the dentate line). Proctitis is similar to proctosigmoiditis but is not necessarily associated with proximal extension of disease into the colon and usually does not evolve into ulcerative colitis. If proximal extension does occur, it usually does so within the first 2 years of initial diagnosis.
Proctitis has many causes. It may be a side effect of medical treatments like radiation therapy or antibiotics. Proctitis caused by sexually transmitted diseases (STDs) is transmitted through receptive anal intercourse and is most commonly due to gonorrhea and chlamydia, or less commonly lymphogranuloma venereum or herpes virus. Nonsexually transmitted causes include autoimmune disease of the colon, such as Crohn disease and ulcerative colitis, celiac disease, chemicals, rectal instrumentation, and trauma to the anorectal area. It may also occur as idiopathic proctitis.
For more information on Crohn disease and ulcerative colitis, see Medscape's Inflammatory Bowel Disease Resource Center.
Pathophysiology
Proctitis involves mucosal cell loss, acute inflammation of the lamina propria, eosinophilic crypt abscess, and endothelial edema of the arterioles. These may improve or in turn progress with subsequent fibrosis of connective tissue and endarteritis of the arterioles, resulting in rectal tissue ischemia and leading to mucosal friability, bleeding, ulcers, strictures, and fistula formation.
Etiology
Causes of proctitis may include the following:
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N gonorrhoeae
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C trachomatis
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HSV 1 (10%) and HSV 2 (90%)
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Radiation therapy
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Immunodeficiency disorders
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Crohn disease
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Syphilis (usually secondary)
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Papillomavirus
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Amebiasis
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Lymphogranuloma venereum
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Ischemia
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Toxins (eg, hydrogen peroxide enemas)
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Vasculitis
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Cytomegalovirus (CMV)
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Clostridium difficile
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Campylobacter species
Epidemiology
United States data
Frequencies of proctitis are associated with their individual etiologies.
Radiation therapy accounts for 5-20% of patients with acute proctitis, usually within 6 months of treatment with a total dose of greater than 50 Gy. Chronic radiation proctitis has a more delayed onset from 9-14 months after initial radiation exposure but can occur any time up to 30 years post irradiation. [1]
Proctitis occurs predominantly in adults.
Prognosis
Failure rates as high as 35% have been reported following treatment of rectal gonorrhea; symptoms frequently recur.
Most surgeons favor a diverting colostomy for medically intractable proctitis or proctectomy. [2, 3]
Complications
Complications of proctitis may include the following:
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Chronic ulcerative colitis
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Fistula formation
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Abscess
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Treatment failure
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Perforation
