What is Proctitis and Anusitis?
Proctitis refers to swelling or irritation of the inner lining of the rectum, which is the last section of your bowel just before the sigmoid colon. This condition is typically found in the area located within 18 cm up from the anus. It can either occur suddenly (acute) or last for a long duration (chronic). Anusitis is similar, but it specifically refers to inflammation of the lining of the anal canal. Despite being a common condition, anusitis often goes undiagnosed or is incorrectly identified as hemorrhoids, another condition that affects the anus and lower rectum.
What Causes Proctitis and Anusitis?
Proctitis and anusitis are conditions where the rectum or anus becomes inflamed. These can happen because of several diseases such as ulcerative colitis (which is a chronic disease that causes inflammation and sores in the digestive tract), Chronic Radiation Proctitis (inflammation or damage to the rectum from radiation therapy), or Diversion Proctitis (inflammation that happens after a surgery that reroutes the colon).
These conditions can also be caused by infections like Clostridium difficile (a bacterium that causes inflammation of the colon), enteric infections (infections in the intestines from bacteria like Campylobacter, Shigella, Escherichia coli, and Salmonella, as well as amebiasis), and sexually transmitted infections (STIs such as Gonorrhea, Chlamydia, Syphilis, herpes simplex virus, and others).
Other causes can include restricted blood supply to the rectum (ischemia), inflammation of the blood vessels (vasculitis), use of hydrogen peroxide enemas or bad reactions to medications. The most common cause of anusitis is diet, especially eating too much citrus fruits, coffee, cola, beer, garlic, spices, and sauces. Anusitis can also develop after having diarrhea caused by taking laxatives to prepare for a colonoscopy, and stress could also be a contributing factor.
Risk Factors and Frequency for Proctitis and Anusitis
Gonococcal and chlamydial proctitis and anusitis, which are conditions affecting the rectum and anus, are more common in young adults and are found more often in males. Those under the age of 25 are most likely to have gonococcal proctitis. Men who have sex with men (MSM) have a prevalence rate of 9% for rectal chlamydia and 5% for rectal gonorrhea. People of Jewish descent have a higher chance of developing ulcerative colitis (UC), and when they do, their rectum is likely to be involved. A quarter of all children diagnosed with UC only have ulcerative proctitis, and this condition is twice as likely to occur in girls than in boys. Acute radiation proctitis and anusitis typically occur after someone starts radiotherapy but don’t last longer than three months. Chronic radiation proctitis (CRP) can begin anywhere from 8 to 13 months after exposure to radiation, and diverting proctitis (DP) can start between three and 36 months after a fecal diversion surgery has been performed. It’s important to note that not everyone who has these conditions will show symptoms.
- Gonococcal and chlamydial proctitis and anusitis mainly occur in young adults and are more frequent in males.
- Gonococcal proctitis is most common in individuals younger than 25 years.
- Among MSM, the rates of rectal chlamydia and rectal gonorrhea are 9% and 5% respectively.
- People of Jewish descent are 3-5 times more likely to develop UC, and more than 30% of UC patients have isolated rectal involvement.
- In children diagnosed with UC, 25% will only have ulcerative proctitis.
- Girls are two times more likely to have ulcerative proctitis than boys.
- Acute radiation proctitis and anusitis start and end within three months of starting radiotherapy.
- Chronic radiation proctitis can start 8 to 13 months after radiation exposure.
- Diverting proctitis begins between three and 36 months after fecal diversion surgery.
- Less than half of the patients with these conditions show symptoms.
Signs and Symptoms of Proctitis and Anusitis
Anorectal issues, like proctitis and anusitis, can cause several symptoms. Proctitis affects the rectum’s lining, while anusitis affects the anus. These conditions can cause discomfort, discharge, and bleeding. It’s also common to experience itchiness in the case of anusitis. LGV proctitis is a particular type of infection that might not show any symptoms, or it can lead to mucus or bloody rectal discharge, anal pain, constipation and having the feeling like needing to go to the loo when you don’t really need to (known as tenesmus).
Chronic proctitis, which is long-term inflammation of the rectum’s lining, can cause rectal bleeding, diarrhea, urgency, tenesmus, inability to control bowel movements, or discomfort in the pelvis. UP, another anorectal condition, often has periods of worsening and improving symptoms.
Proctitis and anusitis caused by radiation or inflammatory bowel diseases may also lead to abscesses (pockets of infection) around the anus, anal tears or abnormal tunnels in the skin near the anus. Similar symptoms can occur if the diseases are due to sexually transmitted infections. You may also notice ulcers near the anus or rectum, sores, warts, or swelling and tenderness in the groin area’s lymph nodes. Inflammatory bowel disease or radiation proctitis can also result in these symptoms, together with rectal bleeding or fecal tests that indicate blood in the stool.
- Bloody or purulent discharge
- Pain during defecation, digital exam, or anal intercourse
- Itchiness in anusitis
- Mucus or bloody rectal discharge in LGV proctitis
- Anal pain
- Constipation
- Fever
- Tenesmus
- Rectal bleeding
- Diarrhea
- Urgency to defecate
- Inability to control bowel movements
- Pelvic discomfort
- Anal abscesses, tears, or abnormal tunnels in proctitis and anusitis caused by radiation or inflammatory bowel diseases
- Anal or rectal ulcers, sores, warts, or tender groin lymph nodes in proctitis and anusitis due to sexually transmitted infections
- Rectal bleeding or a fecal test indicating blood in the stool in inflammatory bowel disease or radiation proctitis
Testing for Proctitis and Anusitis
When you visit the doctor with symptoms that might suggest an infection or condition involving your rectum or anus, you may need to undergo a few tests. One basic test your doctor might perform is an anal examination or anoscopy, which involves inserting a small instrument into your anus to check for any abnormalities. A small sample of any fluid found there would be collected and examined under a microscope for the presence of a type of white blood cell known as polymorphonuclear leukocytes. This can help determine if there is an infection present.
A stool culture is another test your doctor might order. This test is used to check for the presence of certain bacteria or parasites in your stool such as E. coli, Salmonella, Shigella, or particular amebas that cause amebiasis, a type of amoebic infection.
Sometimes your doctor might test for antibodies in your blood that indicate certain diseases such as Ulcerative Proctitis (UP), a type of inflammation of the rectum. However, these blood tests, p-ANCA and ASCA, often do not provide definitive results for this condition.
If your doctor suspects you have a sexually transmitted disease (STD), they might conduct additional tests. These could include a Nucleic Acid Amplification Test (NAAT), a type of genetic test, to check for the bacteria that cause chlamydia and gonorrhea. A polymerase chain reaction (PCR) test, another type of genetic test, would be used to check for the viruses that cause genital herpes (HSV) or lymphogranuloma venereum (LGV). The doctor may also specifically check for harmful substances, or toxins, that Clostridium difficile bacteria might have introduced into your stool. An ELISA test, a type of antibody test, can be used to check for HIV, while darkfield and other serologic tests can check your body’s response to infection with T. pallidum, the bacterium that causes syphilis.
If an infant or child is found to have STD-related proctitis, an inflammation of the rectum typically caused by STDs, it could indicate sexual abuse.
Finally, if your doctor suspects that you have Inflammatory Bowel Disease (IBD), they may perform additional procedures such as anoscopy, proctosigmoidoscopy (a type of endoscopic examination of the lower bowel), or taking a biopsy (a small tissue sample) from your rectum. In people with a condition called Chronic Radiation Proctitis (CRP) – an inflammation in the rectum due to previous radiation therapy – biopsies should be taken specifically from the back and sides of the rectum. This specific area is the focus for biopsies in this case because of the risk of forming abnormal passages between different parts of the body, or fistulas.
Treatment Options for Proctitis and Anusitis
If a patient has acute proctitis, which is inflammation of the rectum lining, treatment should start right away, even before lab test results come back. This is especially important for individuals who engage in anal intercourse. For those who have proctitis as a result of sexually transmitted infections (STI’s), their partners should also be checked. Patients should also refrain from sexual intercourse until treatment is over.
Gonococcal proctitis, which is caused by the gonorrhea bacteria, is treated with a one-time dosage of antibiotics called ceftriaxone and azithromycin. There’s an alternative treatment involving cefixime and doxycycline. Chlamydia proctitis is treated with azithromycin, but doxycycline, erythromycin, ofloxacin, or Levofloxacin are also viable options. LGV, a strain of chlamydia, requires a 21-day treatment of doxycycline. Should doxycycline not be appropriate, erythromycin or azithromycin can be used. Herpes proctitis is usually treated with antiviral drugs like acyclovir, valacyclovir, or famciclovir for 7 to 10 days. If the condition hasn’t healed at the end of this period, the treatment may be extended.
For patients with mild to moderate cases of Ulcerative proctitis (UP), which is a distinctive form of ulcerative colitis that affects only the rectum, it is suggested by the American College of Gastroenterology (ACG) and the American Gastroenterological Association (AGA) to use rectal 5-ASA mesalamine rather than oral medication. It’s also noted that suppositories are more effective than enemas. In some cases, rectal corticosteroid therapy may be suggested. However, corticosteroids are generally not recommended for long-term usage due to side effects and possible complications.
For the treatment of Ulcerative proctitis, alternatives include mesalazine in different forms like suppositories or enemas, and in severe cases, corticosteroids. In some cases, drugs like cyclosporine, immunomodulators like azathioprine (AZA) or 6-mercaptopurine (6-MP), anti-TNF-α, anti-integrin antibodies such as vedolizumab and etrolizumab, or oral tacrolimus may be considered.
For Chronic Radiation Proctitis (CRP), a condition where the rectum becomes inflamed as a result of radiation treatment for certain cancers, sucralfate enemas are the best treatment. For radiation proctitis that occurs right after radiation treatment, topical short-chain fatty acids (SCFAs) enemas, topical 5-ASA, or topical steroids may be applied. For severe or hard-to-treat symptoms or complications such as strictures, fistulas, and consistent bleeding, surgeries like colostomy, ileostomy, proctectomy, or proctocolectomy with ileal pouch–anal anastomosis (IPAA) may be considered. Additionally, patients suffering from anusitis, or inflammation of the anal canal, might find relief by applying a cold retaining probe to the anal canal, as well as making dietary changes and managing stress better.
What else can Proctitis and Anusitis be?
Here are some conditions that can cause similar symptoms and may be considered by a doctor when making a diagnosis:
- Anal fistulas
- Anal fissures
- Chancroid
- Clostridium difficile colitis
- Diverticulitis
- Herpes simplex
- Infectious bacterial or viral diarrhea
- Inflammatory bowel disease
- Lymphogranuloma venereum
- Rectal foreign body
- Syphilis
- Traumatic proctitis
- Vulvovaginitis
