Causes of proctitis
There are many causes of proctitis but they can be broken down into three main categories:
- autoimmune disease (idiopathic)
- radiation injury
- sexually-transmitted disease
The majority of cases seen in our practice have no known cause and are called idiopathic proctitis. This is really a variant of a more serious condition called ulcerative colitis, but more limited in scope. While colitis can affect the lining of the entire five feet of colon, proctitis only affects the last six inches or less. The cause of colitis and idiopathic proctitis are not known, but felt to be a disorder of the immune system. Normally, your immune system has the job of protecting you from outside forces, such as infection and cancer. Sometimes, it gets confused and begins attacking you instead. Such diseases are called autoimmune disorders. In this instance, your immune system attacks the lining of your rectum.
Proctitis may also be caused by physical agents including chemicals inserted into the rectum, medications and radiation. Radiation proctitis is mostly seen now in association with radiation therapy for prostate and cervical cancer. The rectum is just behind the prostate in the male and the vagina and uterus in the female, so when radiation hits these organs to treat cancer, it also can affect the rectal wall and cause a burn on the lining of the rectum. Up to 20 percent of patients will display proctitis usually within the first year after completion of therapy with a total dose greater than 5000 rads.
Sexual disease related proctitis occurs with high frequency among homosexual men and women who engage in anal intercourse with multiple partners. Sexually-transmitted diseases which can cause proctitis include gonorrhea, herpes, chlamydia, and lymphogranuloma venereum.
Symptoms of Proctitis
The most common presenting symptom is rectal bleeding often associated with an constant urge to have a bowel movement - called tenesmus. Usually, patients report the frequent passage of small amounts of blood, mucous, and pus. This rectal discharge may come and go, oc for several days or weeks and then disappearing for weeks or months. Patients may be bothered by rectal or abdominal pain. Some have constipation and some diarrhea, but usually the stools are formed.
Your doctor can diagnose proctitis by looking inside the rectum with a proctoscope or a sigmoidoscope. A tiny piece of tissue from the rectum may be removed and sent for special lab testing. Stool specimens or rectal swabs may be sent to test for infection.
Idiopathic proctitis is most often treated with Rowasa enemas, Rowasa suppositories, or steroid enemas (Cortenemas). Most patients don't like having to insert suppositories into their rectum or give themselves an enema. But, the best results can be obtained by applying these medications directly to the affected area, the rectal lining. This is somewhat like applying a salve directly to a skin rash and allows high concentrations of the medication on the inflammed area without exposing the whole body to potential side effects. These medications don't cure proctitis, but reduce the inflammation and usually relieve symptoms in a short time. Radiation proctitis does not respond as well as ulcerative proctitis to the use of enemas and suppositories.
Infectious proctitis is caused by sexual transmission, especially in gay men. Prompt medical attention should be sought if an infection is suspected. Further sexual contact should be avoided until symptoms have been evaluated and treatment completed. It is important that sexual partners be advised so that they may be evaluated for treatment.
Most patients have no return of symptoms when the medications are discontinued. But about 20% of patients with idiopathic proctitis eventually have a return symptoms. These patients usually respond to re-treatment. If the flareups are infrequent and relatively easy to control, treatment is prescribed for each attach. If a patient has severe or frequent symptoms, chronic therapy is usually prescribed. Each case is different. Some do well with rectal suppositories only several nights per week. Others are only controlled if they take the medication once or twice every day. In severe cases, oral mesalamine and/or prednisone may be prescribed in addition to medicated suppositories and enemas.
Can proctitis spread further inside?
Usually not. Over 90 percent of the those who have idiopathic proctitis never develop colitis higher up in the colon. If this does occur it usually does so within the first two years of initial diagnosis. Once the inflammation has gone past the first six inches, the condition is called colitis. If only the left colon is involved, the term ulcerative proctosigmoiditis may be used. If most of the colon is damaged, the condition is termed total ulcerative colitis.
When to call the doctor
See your doctor is the symptoms do not respond to treatment within the first ten days or if severe symptoms develop such as heavy bleeding, weakness, frequent diarrhea, weight loss, or severe abdominal pain.