What is proctitis?

Proctitis is an inflammatory condition of the inner lining (mucosa) of the rectum (lowest part of the large instestine). Males and females tend to be equally affected and no age group is excluded.

What is the cause of proctitis?

The actual cause is unknown. Most cases of proctitis are part of the spectrum of chronic inflammatory bowel diseases of which ulcerative colitis and Crohn’s disease are examples. Others may be due to infectious agents, some of which may be sexually transmitted. Inflammation following radiotherapy to pelvic organs is also a cause of proctitis (radiation proctitis). 

What are the effects of proctitis?

Non-specific proctitis involves the rectum above the anus and spreads for a variable distance upwards and is like a “burn” of the bowel lining. Crohn’s proctitis varies from small scattered ulcers through to deep, large, irregularly placed ulcers. Radiation proctitis tends to occur next to the organ that was irradiated. For example, the inflammation is close to the anus after prostate cancer irradiation and higher up after radiation for cervix cancer. The effects of radiotherapy vary from burn-like damage to discrete bleeding areas due to the development of multiple small fragile abnormal blood vessels.

What are the symptoms of proctitis?

The main symptoms are the need to pass a lot of stools (frequency) or the need to pass stools in a hurry (urgency), passage of blood and mucus, and looseness of stool, although some of these symptoms may be absent. Pain in either the lower abdomen or anus can sometimes occur. Because bleeding is a major symptom of proctitis, anaemia (low blood count) may result. Depending on the cause, the symptoms may last several days, weeks or years, continuously or intermittently.

Can other problems occur with proctitis?

It is very rare for other symptoms to occur with non-specific proctitis. Radiation proctitis may be associated with symptoms related to the original cancer if it recurs.

How is proctitis diagnosed?

The diagnosis is based on the clinical features and the appearance of the bowel lining at sigmoidoscopy. Colonoscopy is sometimes undertaken to exclude more extensive inflammation. There are no diagnostic blood tests. Biopsies may be helpful and bacteriology cultures may reveal the cause in infectious proctitis. Sigmoidoscopy is necessary to exclude other conditions which may mimic proctitis, such as rectal cancer or haemorrhoids. 

How is proctitis treated?

The treatment is usually medical. It is only in rare circumstances that surgery is necessary. Non-specific proctitis is frequently treated with suppositories or rectal foam containing cortisone compounds. Occasionally cortisone enemas are used. Failure to respond to “local” treatment may require the use of tablets of salazopyrin or related compounds, and occasionally oral prednisone. Infective proctitis may resolve spontaneously (without treatment) but if a particular germ is isolated then a course of the appropriate antibiotic is indicated. Radiation proctitis is difficult to treat and troublesome bleeding can be improved with instillation of formalin-soaked packs in the rectum, or laser ablation of the bleeding points. Rarely surgical removal of part or all of the rectum is undertaken for intractable, severe bleeding due to radiation proctitis.

Who should look after my proctitis?

A specialist with an interest in inflammatory bowel disease and conditions involving the rectum is an appropriate person to look after you. The members of the Colorectal Surgical Society of Australia and New Zealand have this expertise.

What about the future?

Proctitis is usually a “nuisance” rather than a serious problem and frequently has no effect on your health. About 10% of patients with non-specific proctitis go on to develop more extensive ulcerative colitis, but mostly the condition runs a course over years with variable symptom-free periods punctuated with exacerbations of inflammation and usually the condition eventually “burns out”. Crohn’s proctitis may remain confined to the rectum. However, sometimes it is the first manifestation of a condition that can affect other parts of the large or small bowel, or anus. Radiation proctitis is frequent during or within the first few weeks of receiving pelvic radiotherapy and very often completely resolves. However damage following irradiation may appear years after receiving radiotherapy, and may be persistent.