Proctitis is defined as inflammation of the mucosal lining of the rectum, whereas anusitis is simply inflammation of the anal canal. Inflammation in these areas can cause symptoms, such as itching, burning, rectal bleeding, pelvic pressure, and foul-smelling discharge. The distinction between proctitis and anusitis is not overly pertinent, in that the etiology and treatment of the two conditions are similar. For the purposes of this article, the term proctitis will be understood to include anusitis, though there has been a stronger correlation between diet and anusitis (which is more commonly seen in those with higher intake of citrus, alcohol, garlic, and spices).
Several different etiologies exist, including inflammatory bowel disease (IBD; eg, ulcerative colitis [UC]), infectious organisms (eg, Neisseria gonorrhoeae, Salmonella, Shigella, Clostridioides [Clostridium] difficile,Chlamydia trachomatis, cytomegalovirus [CMV], human papillomavirus [HPV]), noninfectious causes (eg, radiation, ischemia, and diversion), and other causes (eg, vasculitis, toxins, and certain medications). For convenience, the majority of proctitis cases may be grouped into three broad categories—IBD, infectious proctitis, and noninfectious proctitis—with other causes accounting for the relatively small remainder.
Proctitis can occur in both the acute setting and the chronic setting and can cause significant anorectal complaints. Treatment is generally nonsurgical; however, in certain cases, surgery is indicated.
It is important to recognize that most inflammatory processes of the rectum also involve the adjacent colon and the anus. The exact anatomy of the rectum and anus and the delineation of where each one begins and ends are ongoing topics of discussion, with some authorities appreciating the start of the rectum at the level of the third sacral vertebra and others considering the start of the rectum to be at the sacral promontory. Most agree that the rectum transitions to the anus where the epithelial cells change from columnar cells to squamous cells.
The World Health Organization (WHO) and the American Joint Cancer Committee (AJCC) have defined the anal canal as the distal portion of the gastrointestinal (GI) tract that corresponds to the internal anal sphincter.
In proctitis and anusitis, the anatomy does not change therapy, because a significant overlap between anorectal inflammation and rectosigmoid inflammation exists.
The pathophysiology of proctitis is dependent on the various etiologies and is not completely understood. In addition, some patients seem more susceptible to this inflammatory condition, with factors such as young age, previous abdominal surgery, hypertension, vasculopathy, and diabetes cited as possible contributing factors. The pathophysiology of proctitis in IBD is believed to be caused by an autoimmune process.
Infectious etiologies may be related to the organism itself or to a toxin produced by the organism.
Radiation proctitis is due to the radiation itself causing damage to intestinal cell DNA, which results in the cells being rendered unable to repair themselves and eventually becoming atrophic. Over time, these ischemic changes turn into fibrotic changes. Diversion proctitis is thought to be caused by a deficiency of short-chain fatty acids (SCFAs), which are the main fuel source for the cells of the colon and rectum. Ischemic proctitis may be due to mesenteric venous occlusion, aortoiliac surgery, radiotherapy, vascular intervention, atherosclerotic disease, or use of drugs (eg, cocaine).
Other causes (medications, vasculitis) all eventually cause proctitis through much the same mechanisms as the causes listed above, with damage to the lining of the rectum and anus.
Regardless, all three main categories of proctitis (ie, IBD, infectious, and noninfectious) result in an unrestrained inflammatory response, with the inflammatory cells being products that mediate cellular-tissue injury.
Most of the potential causes of proctitis can be usefully classified into one of the following three categories:
Proctitis due to inflammatory bowel colitides (eg, UC and Crohn disease [CD])
Proctitis due to infection (eg, by C difficile or Salmonella); in most cases, the rectal inflammation caused by an infection is likely to cause inflammation in the colon as well
Proctitis due to noninfectious conditions (eg, diversion, ischemia, and radiation)
A minority of cases of proctitis are attributable to other causes (eg, medication side effects, vasculitis, or toxins)
The prevalence of proctitis in the general population has not been established through epidemiologic studies. However, it is possible to ascertain the incidence of proctitis through analysis of specific disease states. For example, patients with UC displayed a 31-50% frequency of proctitis upon diagnosis, depending on age at diagnosis. A study in the pediatric UC population demonstrated a significant increase in the occurrence of proctitis in female children as compared with males.[1] The frequency of chronic radiation-induced proctitis has been reported to be in the range of 2-20% and is influenced by total radiation dose, mode of delivery, and dose fractionation.[2]
Infectious proctitis is typically due to sexually transmitted disease (STD) and is more common in those with a history of anal receptive intercourse. Of these infections, gonorrhea and chlamydia were the most common STDs, followed by herpes and syphilis. Some studies have reported the incidence of gonorrheal and chlamydial proctitis among men who have sex with men (MSM) to be as high as 8.5% and 7.9%, respectively.[3]
In the acute setting, most bouts of proctitis have a good outcome and prognosis. More specifically, infectious proctitis, once appropriately treated, tends not to recur.
For the more chronic diseases, such as IBD, outcomes and prognoses vary. Clearly, in medically treated ulcerative colitis and proctitis, approximately 40-70% of cases do not require operation. If proctocolectomy is performed, the patient is cured of the disease. CD is another story: Because it can occur in all portions of the GI tract, even after a proctectomy, CD has a recurrence rate in the range of 45-90%.
Diversion proctitis generally has a good outcome and prognosis once the diversion is reversed.
The outcome and prognosis of radiation proctitis vary with the severity of proctitis. Outcomes range from requiring only a few medical treatments in the form of enemas to requiring surgical treatment. Complication rates for surgical treatment have been reported to be as high as 75%.
A patient with proctitis may present with some of the following symptoms and/or signs:
Rectal bleeding tends to be bright red in color and persistent but is rarely severe; it may last for several weeks or longer
Changes in bowel habits tend to occur, usually with a decrease in volume and an increase in mucoid contents; patients will complain of a mild diarrhea with a large amount of mucus; the mild diarrhea is the most common complaint
Patients may report tenesmus or fecal urgency
Severe diarrhea generally is uncommon
Constipation may occur if the inflammation is severe
Patients may also complain of abdominal cramping; this is caused by the inflammation in the pelvis
In taking the patient's history, pertinent questions should include a personal history of inflammatory bowel disease (IBD), pelvic irradiation, travel history, and sexual history (including questions regarding anal intercourse).[4] The patient's HIV status is important to note as well. Obtaining a list of medications used (eg, nonsteroidal anti-inflammatory drugs [NSAIDs] or antibiotics) is clearly important. A family history of IBD or other gastrointestinal (GI) diseases is extremely important.
A review of systems is needed to identify any systemic conditions that can be related to the proctitis, such as IBD and collagen vascular disorders. In addition, identifying patients who are immunocompromised is important because some infections that may cause proctitis (eg, cytomegalovirus [CMV] infection and cryptosporidiosis) affect only this subset of patients.
The findings from physical examination may be unremarkable. Abdominal tenderness may be seen in IBD, infectious colitides, and ischemic proctitis. As a consequence of tenderness, it may not be possible to perform a digital rectal examination (DRE). If this is the case, an evaluation under anesthesia (EUA) is required.
In general, for all patients diagnosed with proctitis, a routine workup should be performed to rule out infectious etiologies. The laboratory workup includes stool cultures, ova and parasite analysis, and fecal smears.
In patients at risk, an anorectal swab should be obtained and sent to test for gonococcal, chlamydial, and herpes simplex virus (HSV) proctitis. Darkfield microscopy and Venereal Disease Research Laboratory (VDRL)/rapid plasma reagin (RPR) tests should be performed for suspected syphilitic proctitis. Additional tests (eg, polymerase chain reaction [PCR], serologic studies, and nucleic acid amplification tests [NAATs]) may be performed, depending on the suspected etiology.
If the patient is immunocompromised, fungal and viral cultures should be performed. (Fungal and viral anorectal infections are rare in the immunocompetent population.)
With regard to pseudomembranous proctitis or colitis due to C difficile, whenever a patient has a history of current or recent antibiotic usage, stool should be sent for C difficile toxin titers. To ensure an accurate result, this must be done three times; many of the tests have a sensitivity of only 60%. Sending the collection and cultures in accordance with the laboratory specifications is important because specifications may vary from hospital to hospital.
Entamoeba histolytica is diagnosed by finding the organism in the stool; again, three stool samples must be sent for the analysis to be valid. In addition, serologic tests exist, including indirect hemagglutination, indirect electrophoresis, and an enzyme-linked immunosorbent assay (ELISA).
Generally, no imaging studies are needed if the inflammation is known to be limited to the rectum and the anus. However, if the possibility of inflammatory bowel disease (IBD; ie, Crohn disease [CD] or ulcerative colitis [UC]) or ischemia exists, then further imaging studies may be necessary.
If CD is a possibility, a contrast upper gastrointestinal (GI) radiograph with a small bowel follow-through may reveal terminal ileal disease and jejunal ileal strictures. A baseline computed tomography (CT) scan of the abdomen and pelvis may also show enteroenteric fistulas and bowel-wall thickening consistent with CD.
In infectious colitides, if the patient has been admitted to the hospital, a CT scan may be obtained, which may show colonic- and rectal-wall inflammation. This may help in determining the diagnosis.
In ischemic proctitis, CT of the abdomen and pelvis with oral and intravenous (IV) contrast is obtained. The most common finding is mural thickening confined to the rectum and the sigmoid colon, which is associated with perirectal fat stranding.
The diagnostic procedure of choice for patients with proctitis and anusitis is endoscopy, including anoscopy, sigmoidoscopy (rigid or flexible), and colonoscopy. (See the image below.) These tests allow the provider to view the mucosa of the anus and rectum as well as the area above the rectum into the sigmoid. In addition, tissue biopsies may be taken with these procedures. A full colonoscopy is recommended for patients with proctitis; biopsy specimens obtained from the right side of the colon may show hallmarks of IBD, such as cell metaplasia.
Histologic findings are usually consistent with inflammation. Often, however, detailed histology leading to the etiology is not possible. Severe inflammation destroys the specific histopathologic findings of other diseases, such as IBD or C difficile infection.
With respect to infectious proctitis, diversion colitis, or radiation proctitis, the inflammatory histology is not pathognomonic. The one exception is cytomegalovirus (CMV) colitis in patients who are immunocompromised, in which inclusion bodies may be seen.
The indications for therapy vary according to the etiology of the proctitis. For example, in patients with inflammatory bowel disease (IBD), a colonoscopy should be performed to assess the extent of the inflammation. Many patients with IBD who present with proctitis may progress to left-side colitis and possibly pancolitis. The first-line management of these patients is medical therapy (see below). Surgical treatment is indicated for failed medical therapy, any dysplasia seen on biopsy specimens, and cancer.
Surgery is rarely indicated for proctitis secondary to infection. The goal of therapy is to treat the infection causing the inflammation. Partners of affected patients should also be offered screening for sexually transmitted infections (STIs). Rarely, profound sepsis may necessitate surgical resection as a life-saving maneuver.
Finally, the indication for treatment of chronic radiation proctitis is also based on the symptomatology and grade of proctitis. Persistent rectal bleeding and diarrhea initiate a workup, including a rigid proctoscopy and/or colonoscopy. The presence of intractable bleeding despite multiple medical/endoscopic modalities, perforation, strictures, or fistulas is an indication for surgical intervention.
In the course of any proctitis, antispasmodic agents may prove helpful in alleviating abdominal complaints. In addition, institution of a low-residue diet and the use of antidiarrheal agents and stool softeners are beneficial in view of the friability of the rectal mucosa and its vulnerability to damage from fecal contents.
Idiopathic proctitis and inflammatory bowel disease
If proctitis is idiopathic or related to IBD, steroids, sulfasalazine, mesalamine, 5-aminosalicylic acid (5-ASA) products, and even immunosuppressive medications may be used. Many of these products are available as oral medications as well as enemas and suppositories.[5] Combination therapy using both oral agents and topical agents (eg, 5-ASA) has been shown to be more effective than therapy with either modality alone. In cases of refractory ulcerative proctitis, infliximab has been found to be effective in inducing a clinical response.[6, 7]
Calcineurin inhibitors (eg, tacrolimus) have also been shown to be effective in treating refractory ulcerative colitis (UC) proctitis.[8] Other less commonly used agents include tofacitinib, a Janus kinase (JAK) inhibitor that selectively targets JAK1 and JAK3 and has shown promising results, particularly in UC proctitis.[9] Finally, on the basis of the theory that the appendix plays an immunomodulary role in UC, some studies have suggested performing appendectomy as an adjunct in the treatment of UC proctitis; there is evidence showing significant improvement of symptoms to the point where pharmacologic therapy can be discontinued.[10]
Infectious proctitis
If the cause of proctitis is infectious, the treatment is targeted toward the pathogen responsible.
Infectious proctitis due to Salmonella species is usually self-limited, and antibiotics are not required. Maintaining adequate fluid and electrolyte balances and providing supportive care are all that is required.
Shigella proctitis is usually self-limited, but the duration may be shortened by the addition of antibiotics. An appropriate 1-week antibiotic course may include ampicillin, tetracycline, ciprofloxacin, or trimethoprim-sulfamethoxazole (preferred).
Yersinia proctitis is also self-limited and should not be treated with antibiotics unless systemic bloodstream infection (BSI) occurs, in which case antibiotics (eg, trimethoprim-sulfamethoxazole, aminoglycosides, tetracycline, or a third-generation cephalosporin) should be given.
Campylobacter proctitis is usually self-limited as well.
E histolytica proctitis generally is treated with metronidazole or tinidazole followed by an intraluminal agent such as paromomycin, diloxanide furoate, clioquinol, or iodoquinol.[11]
Sexually transmitted proctitis requires treatment similar to the corresponding treatment for a genital infection. In patients with mild symptoms, empiric treatment should ideally be avoided to reduce the risk of antibiotic resistance. Once the pathogen is determined, specific therapy should be initiated.[12] C trachomatis infection is treated with doxycycline; gonorrheal proctitis is treated with ceftriaxone or cefixime. Syphilitic proctitis responds to intramuscular (IM) penicillin G benzathine, and herpes simplex virus (HSV)-2 infection is treated with acyclovir.
C difficile infection generally is treated with intravenous (IV) or oral metronidazole or oral vancomycin.[13] A more aggressive C difficile mutation has been observed that may have a rapidly progressive course toward BSI and toxic colitis. In patients who do not appear to be responding to metronidazole and who have leukocytosis (leukocyte count >20,000/µL), therapy should be switched to oral vancomycin. Vancomycin enemas may also be used in individuals in whom oral antibiotics may not reach a part of the colon (eg, those with a Hartmann pouch, ileostomy, or colonic diversion). Any other antibiotics should be discontinued if the clinical situation allows.
Patients colonized with C difficile have a likelihood of recurrence; consequently, whenever they are placed on antibiotics, they should be aware of the possibility of diarrhea. In patients with recurrent C difficile infections, physicians may consider fecal microbiota transplantation, which has been reported to achieve cure rates of 90% and higher in multiple studies. A study by Orenstein et al reported a successful fecal transplant in an isolated patient with C difficile proctitis who had already undergone a total abdominal colectomy for treatment.[14]
Noninfectious proctitis
Acute radiation proctitis is usually a self-limited condition, but supportive medical management (eg, hydration, antidiarrheals, and steroid or 5-ASA enemas) may be of benefit.[15]
Chronic radiation proctitis involves more extensive medical treatment, including both oral and rectal therapies. Oral medications include 5-ASA, sulfasalazine, steroids, and metronidazole. In cases of hemorrhagic proctitis, the use of WF10, an IV therapy initially developed as an adjunctive AIDS treatment, has been shown to be effective. Initial studies demonstrated control of bleeding within two doses of therapy and maintenance of results with once- to twice-yearly repeat therapy.[16]
Rectal therapy for chronic radiation proctitis with sucralfate or pentosan polysulfate has been shown to result in better symptomatic relief than oral anti-inflammatory therapy. Studies have found sucralfate enemas to be the most effective medical therapy for radiation proctitis when they are administered twice daily for 3 months. Such rectal therapies are believed to work via stimulation of epithelial healing and formation of a protective barrier.
Steroid and short-chain fatty acid (SCFA) enemas have been used with moderate success.[17] When given in enemas, hydrocortisone seems to relieve symptoms and rectal bleeding more effectively than other steroids (eg, betamethasone). Whereas SCFA enemas (eg, butyrate) have some proven benefit in other types of proctitis, they have not been conclusively demonstrated to have any beneficial effect on proctitis secondary to radiation. In fact, American Society of Colon and Rectal Surgeons (ASCRS) guidelines have stated that SCFAs are not recommended in the treatment of chronic hemorrhagic proctitis.[18]
Hyperbaric oxygen (HBO) has been shown to have some efficacy in the treatment of radiation-induced proctitis.[19, 20] A large single-center study reported a 63% response rate in patients with gastrointestinal (GI) radionecrosis, supporting the findings of several previous smaller series.[21] HBO has emerged as a potential therapy for radiation proctitis because of its ability to increase the number of blood vessels in irradiated tissues by acting as a stimulant for angiogenesis.[22] HBO is not widely available, because of high costs and the need for specialized equipment, but it has been recommended by the ASCRS for treatment of chronic radiation proctitis and is considered effective.[18]
Other medical therapies aimed at the treatment of radiation proctitis (eg, antioxidant therapy with vitamins A, C, and E) have shown efficacy in small single-institution studies.[23] A study by Wu et al showed significantly improved outcomes with high-dose vitamin C when it was combined with traditional drugs such as cyclooxygenase (COX)-2 inhibitors, though this study was limited by the small sample size.[24] Additionally, ozone therapy via rectal insufflation and topical ozonized oil have shown some promise, but large randomized clinical trials are lacking.
More invasive management of radiation proctitis with rectal/topical formalin is believed to work via sclerosis of neovasculature in a form of chemical cauterization. Multiple studies have demonstrated the efficacy of formalin in the resolution of hemorrhagic proctitis, with success rates in the range of 70-80%.[25, 26, 27] Significant complications from treatment include stricture and damage to the perianal skin.
Symptomatic diversion proctitis generally improves after the ostomy is taken down and bowel continuity is restored. However, in patients who need to be out of circuit indefinitely, SCFA enemas may be beneficial.
Many factors come into play in deciding when to operate and which operation to perform. For most cases of proctitis, medical treatment should suffice. However, for certain disease processes, surgical treatment is more likely.
Choice of procedure
For patients with UC who require surgical therapy, a total proctocolectomy should be performed because of the risk of cancer in the remaining rectal stump.[28] Ileostomy or reconstruction with an ileal pouch may be offered after total proctocolectomy. In patients with severe Crohn disease (CD) colitis or proctitis, options range from fecal diversion to proctectomy to total proctocolectomy, depending on the extent of the disease process.
In the infectious causes of proctitis, surgical treatment is rarely required. In cases of severe C difficile colitis, a subtotal colectomy may be warranted.
For patients with radiation proctitis complicated by refractory bleeding, endoscopic therapy seems to be more effective than medical therapy; it also results in less morbidity. Specifically, argon plasma coagulation (APC)[25, 29, 30] may be superior to formalin and endoscopic laser treatments, though some studies have reported similar outcomes when comparing APC with formalin.[31, 32] Other endoscopic therapies include endoscopic thermal methods, such as heater probes and lasers, which destroy telangiectasias to stop bleeding.
If, despite medical and endoscopic measures, significant hemorrhage still occurs, a laparoscopic fecal diversion (ileostomy or colostomy) should be performed. Although fecal diversion alleviates patients' symptoms, it rarely eliminates them entirely; it should be reserved for truly refractory cases. Fewer than 10% of patients do not respond to some form of medical management and require surgical intervention.
Rarely, radiation proctitis can be so severe that it ulcerates, potentially leading to the formation of a rectourethral fistula. In these cases, temporary fecal and urinary diversion should be performed until the inflammation subsides. Definitive therapy may then be provided. The procedure of choice is a perineal approach with repair of the defect with muscle and mucosal flaps.
Preparation for surgery
As always, general surgical preparation includes optimizing medical status and providing deep vein thrombosis (DVT) prophylaxis, bowel preparation, and preoperative antibiotic prophylaxis. A Foley catheter is placed after induction of anesthesia.
Preoperative nutritional status may be the most significant predictor of outcomes. Every effort should be given to assess the patient's nutritional status and improve it if necessary. The author's current practice is to obtain a prealbumin level in all patients scheduled to undergo laparotomy. If it is low, the author will delay the surgery and place them on nutritional supplementation.
If the patient is going to have a stoma, preoperative counseling with a trained enterostomal nurse is essential. The nurse will educate the patient about life with a stoma and will also mark the patient preoperatively to ensure optimal stoma placement.
For patients requiring a subtotal colectomy, assessment of their sphincter complex is helpful in determining postoperative fecal continence. This is also true for patients undergoing a total proctocolectomy with an ileal pouch.
In addition, for patients undergoing a proctectomy, it is important to discuss their sexual and urinary function before performing the procedure; there is a small but real possibility of diminished sexual function and bladder continence after pelvic surgery.
Operative details
Good surgical technique is imperative. In the performance of a pelvic dissection, knowing the anatomic planes and adjacent structures is important for avoiding injury.
The presacral nerves are on the anterior aspect of the sacrum. These nerves usually can be identified at the sacral promontory, approximately 1 cm lateral to the midline.
Be aware of the parasympathetic innervation to the urinary and genital organs and the rectum at the lateral edges of the rectum, near the lateral stalks. The parasympathetic nerve supply in this area is from the nervi erigentes. Dissection that is too lateral will likely affect this nerve supply.
Maintain the correct plane of dissection along the posterior rectum. In line with the same principles that apply to total mesorectal excision, the plane outside the mesorectum but above the presacral fascia is the correct plane to dissect. Dissection that is too anterior results in entry into the mesorectum. Dissection that is too deep through the presacral fascia risks presacral bleeding.
Maintain the correct plane of dissection along the anterior rectum. Clearly, important structures exist in both females (vagina) and males (prostate, seminal vesicles).
Remain cognizant of the course of the ureters along the lateral rectum when dissection enters into the pelvis.
As with any major surgical procedure, close monitoring of fluid status, cardiac status, pulmonary status, and return of GI function is important. For patients who require a hospital stay, DVT prophylaxis is essential. Many centers have different protocols for removing a Foley catheter. The author tends to remove the Foley catheter on postoperative day 3.
One of the more important concerns has to do with patients who have a perineal wound. Often, tension on the wound may be significant, depending on whether the sphincter mechanism is resected or not. Because patients often are in the supine position, overlooking examination of the perineal wound is easy. Close observation of this area is important; problems with wound healing in this area are significant. The risk of wound complications increases in those patients who have undergone irradiation of the pelvis.
Wound infection may develop with a proctectomy. It is not uncommon for the perineal wound to separate slightly during the immediate postoperative period. If any discharge or erythema is noted around the wound, especially if there was some tension upon closure, opening the wound earlier rather than later is prudent. Addressing the open wound with wet-to-dry dressing changes routinely allows the wound to close without incident. Advancement flaps may be necessary and can be beneficial in decreasing wound complications, though they are not appropriate in all patients and certainly have thier own associated complications.
Sexual dysfunction can occur when the pelvic nerves are injured. The best way of dealing with this complication is to be cognizant of the possibility prior to surgery and take steps to avoid it; once it occurs, very little can be done to help the nerves. The role of medications such as sildenafil remains unclear, though sildenafil has been reported to help. Pelvic floor rehabilitation is recommended as first-line therapy.
As with sexual dysfunction, every effort should be made in the operating room to avoid urinary dysfunction.
Avoiding ureteral injury by remaining cognizant of the ureteral anatomy is a paramount consideration. Once the injury occurs, prompt recognition at the time of operation is clearly best. The repair is dictated by where the injury occurs in the ureter. Consultation with a urologist is prudent.
In a few cases, presacral bleeding has been reported to progress to death. Clearly, avoidance is the best way to deal with this complication. If it does occur in the midst of the procedure, cauterization or pressure generally does not stop true presacral bleeding from the pelvic veins. The usual method of stopping the bleeding is to use a thumbtack. A muscle pledget is also a clever way of stopping the bleeding. This is done by obtaining a piece of rectus muscle, applying it to the bleeding site, and cauterizing the muscle on a high coagulation setting.
Doxycycline is being evaluated by the Centers for Disease Control and Prevention (CDC) for postexposure prophylaxis (Doxy-PEP) to prevent gonorrhea, chlamydia, and syphilis after unprotected anal sex in gay and bisexual men and transgender women.[33]
Doxycycline postexposure prophylaxis was tested in an a randomized open-label trial among men who have sex with men (MSM) and transgender women living with HIV or on preexposure prophylaxis (PrEP) who had had N gonorrhoeae infection, C trachomatis infection, or early syphilis in the preceding year.[34] Patients were randomized 2:1 to either (a) doxycycline 200 mg PO within 72 hours of condomless sex or (b) no doxycycline with testing for STI at enrollment, quarterly, and when symptomatic. Among the 360 patients on PrEP, 65 STI endpoints (29.5%) occurred in the 120 control subjects and 47 (9.6%) in the 240 Doxy-PEP participants.
In an earlier study, participants in a randomized controlled trial took either (a) a single oral 200-mg dose of Doxy-PEP (n = 116) within 24 hours after sex or (b) no prophylaxis (n = 116) and were followed for a median of 8.7 months.[35] During follow-up, 73 participants presented with a new STI: 28 in the Doxy-PEP group and 45 in the no-PEP group. Occurrence of a first STI was lower in the Doxy-PEP group than in the no-PEP group. Similar results were observed for the occurrence of a first episode of chlamydia or syphilis. For a first episode of gonorrhea, results did not differ significantly.
The CDC officially endorsed the use of doxycycline for postexposure prophylaxis, and its use is becoming more widespread across sexual health clinics. Early data on the impact of decreasing bacterial STI incidence have been encouraging.[36]
Follow-up care with regard to the surgical wounds (both perineal and abdominal) and the colostomy is important. In addition, postoperative sexual and urinary function should be discussed and a further workup initiated if required.
What are proctitis and anusitis?Which anatomy is relevant to proctitis and anusitis?What is the pathophysiology of proctitis and anusitis?What causes proctitis and anusitis?What is the prevalence of proctitis and anusitis?What is the prognosis of proctitis and anusitis?What are the signs and symptoms of proctitis?What is the focus of the clinical history for suspected proctitis and anusitis?What is the role of lab studies in the diagnosis of proctitis and anusitis?What is the role of imaging studies in the diagnosis of proctitis and anusitis?What is the role of endoscopy in the diagnosis of proctitis and anusitis?Which histologic findings are characteristic of proctitis and anusitis?How are proctitis and anusitis treated?How is medical therapy for proctitis and anusitis selected?How are idiopathic proctitis and inflammatory bowel disease-related proctitis treated?How is infectious proctitis treated?How is noninfectious proctitis treated?When is surgery indicated in the treatment of proctitis and anusitis?What is included in the preoperative evaluation of proctitis and anusitis?How is surgery for proctitis and anusitis performed?What postoperative care is provided following proctitis and anusitis surgery?What are the possible complications of proctitis and anusitis surgery?What is included in the long-term monitoring following proctitis and anusitis surgery?What are the goals of drug treatment for proctitis and anusitis?Which medications in the drug class Calcineurin Inhibitors are used in the treatment of Proctitis and Anusitis?Which medications in the drug class Antivirals, HSV are used in the treatment of Proctitis and Anusitis?Which medications in the drug class Antiparasitic Agents are used in the treatment of Proctitis and Anusitis?Which medications in the drug class Antibiotics, Other are used in the treatment of Proctitis and Anusitis?Which medications in the drug class Antibiotics, Combos are used in the treatment of Proctitis and Anusitis?Which medications in the drug class 5-Aminosalicylic Acid Derivatives are used in the treatment of Proctitis and Anusitis?Which medications in the drug class Aminoglycosides are used in the treatment of Proctitis and Anusitis?
David E Stein, MD, MHCM, Regional Chief of Surgery, Baltimore
MedStar Health
Disclosure: Nothing to disclose.
Coauthor(s)
Jonah A Schindelheim, DO, Resident Physician, General Surgery Department, MedStar Union Memorial Hospital
Disclosure: Nothing to disclose.
Kaitlin A Ritter, Drexel University College of Medicine
Disclosure: Nothing to disclose.
Nicholas A Davis, MD, Resident Physician, General Surgery Department, MedStar Union Memorial Hospital
Disclosure: Nothing to disclose.
Specialty Editors
,
Disclosure: Nothing to disclose.
Chief Editor
John Geibel, MD, MSc, DSc, AGAF, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine
Disclosure: Nothing to disclose.
Additional Contributors
Amy L Friedman, MD, Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University
Disclosure: Nothing to disclose.
Marc D Basson, MD, PhD, MBA, FACS, Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences
Disclosure: Nothing to disclose.
Acknowledgements
Elisa A Stein, MD Staff Physician, Department of Surgery, Drexel University College of Medicine, Hahnemann University Hospital
Elisa A Stein, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Medical Student Association/Foundation, American Medical Women's Association, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.
Sarosh N Zafar, MD Resident Physician, Department of General Surgery, Drexel University College of Medicine
Sarosh N Zafar, MD is a member of the following medical societies: Phi Beta Kappa
Wu H, Liu M, Jiang H, Xu H, Peng J, Dai J, et al. Treatment of severe radiation proctitis with high dosage of vitamin C in combination with cyclooxygenase-2 inhibitor. Radiat Med Prot. 2024 Jun. 5 (2):113-117.
Luetkemeyer A, Dombrowski J, Cohen S, Donnell D, Grabow, C, et al. Doxycycline post-exposure prophylaxis for STI prevention among MSM and transgender women on HIV PrEP or living with HIV: high efficacy to reduce incident STI's in a randomized trial. Presented at AIDS 2022 July 29 – August 2.
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