Proctitis

Overview of Proctitis

Rectal diseases are generally very serious and can give rise to bowel incontinence in the more advanced stages. These may be triggered by infections or unhygienic sexual activities. A common disorder of the rectum is proctitis, which is characterized by inflammation of the rectal lining. NCBI reports suggest that in the year 2012, cases of proctitis have increased up to about 107.5 cases per 1,00,000 population. A large section of this population has been found to be engaged in receptive anorectal sexual intercourse.

What is Proctitis?

Proctitis is a condition in which inflammation of the anus and a part of the rectum occurs, that affects about 6 inches of the rectum and about 10-12 cm of the anal canal. It mainly spreads via sexual or mucosal contact. The main causative pathogens of the disease are- T pallidum, Herpes Simplex virus, C. trachomatis and Neisseria gonorrhoeae. Prolonged proctitis can increase the risks of colorectal cancer.

What are the main causes of Proctitis?

In many cases, proctitis is idiopathic in nature, that is, it does not have any identifiable cause. Commonly, the following predisposing conditions lead to proctitis-

• Infections caused by T pallidum, Herpes Simplex virus, C. trachomatis and Neisseria gonorrhoeae
• Unprotected and unhygienic sexual activities
• Receptive anorectal sex
• Mucosal contact with an infected person
• Having sex with a person of the same gender
• Anal sex with a partner diagnosed with sexually transmitted disease(s)
• Shared enema usage
• Celiac diseases arising from intolerance to gluten
• Prolonged exposure to harmful radiations in the course of radiation therapy for treating prostate and cervical cancer
• A history of Sexually Transmitted Diseases like Chlamydia, AIDS, Gonorrhoea or Syphilis
• Genital infection that spreads to the rectum due to proximity to the vagina (in women)
• Oral-anal sex contact
• Abdomino-pelvic surgery
• Pelvic inflammatory diseases
• Immobility of the loops in the small intestine due to adhesions in the abdomen
• Diseases like Diabetes Mellitus, Collagen vascular disease, Hypertension and Body Habitus
• Immune system disorders

What are the main signs and symptoms of proctitis?

The manifestations of proctitis are not so prominent in the initial stages. This often leads to misdiagnosis and improper treatment. The commonly observed signs and symptoms of proctitis are as follows-

• Pain and inflammation in the anal and the rectal portions
• Appearance of rectal ulcers
• Painful bowel movements
• Frequent urge for bowel movements even if the rectum does not have any content
• Tenderness, warmth and irritation of the rectal and anal regions
• Abnormal secretion of mucus
• Presence of blood and at times pus in the stool and mucus
• Mucopurulent anal discharge
• Tenesmus
• Cramps during bowel movement
• Small-volume diarrhoea
• Feeling of rectum-fullness and constipation
• Pain, cramps and discomfort in the lower abdomen
• Nausea (with or without vomiting)
• Anaemia arising from persistent rectal bleeding
• Pallor (due to loss of blood)
• Brittle nails
• Shortness of breath
• Dizziness, fatigue and general body weakness
• Loss of appetite and weight loss
• Mood swings and irritability

What are the main types of proctitis?

Proctitis is classified into different types, mainly based on the etiology, that is the causative factors. These are described below-

Sexually Transmitted Proctitis: This type of Proctitis normally arises from sexual interactions with an infected partner. The primary diseases belonging to this category are as follows-

Gonococcal Proctitis: It is a very commonly observed type and is mainly associated with anal intercourse. The main symptoms of this disease are- purulent pus-like discharge, soreness, itching, blood in stool or mucus and diarrhea (large or small volume). In the later stages, more serious problems like hemorrhoids, fistulas, anal tear, and warts may take place. Once these problems are developed, they rarely get cured on their own or with only over the counter medications. Surgery is the preferred option in such cases. Laser surgery, specially, is considered the best treatment for piles.

Chlamydia Proctitis: It occurs in 20% of the Proctitis cases and is characterized by mild, moderate or severe symptoms. The patients generally experience blood or pus containing discharge, rectal pain, diarrhea and cramps. Rectal constrictions may occur in some cases, which can lead to acute constipation.

Herpes Proctitis: The symptoms are very severe and may include ulcers, ruptured vesicles, rectal tenesmus and hematochezia (blood in stool).

Syphilis Proctitis: It is mainly characterized by rectal pain, bloody discharge, and spasms during bowel movements. The three stages of this disease are-

• Primary stage: Painless sores with elevated borders
• Secondary stage: Infectious diffuse rashes
• Advanced stage: Neurological and cardiovascular disorders

Ulcerative Proctitis: Ulcerative Proctitis is characterized by ulcerations in the inner mucosal lining of the large intestine. The inflammation normally begins at the rectum and gradually spreads to the colon. The patients usually have blood in stool and an urge for frequent bowel movements. Anal hemorrhoids may occur in the very extreme stages.

Radiation Proctitis: This mainly results from applying radiation to the lower abdomen and the pelvic region. The main features are-

• Formation of crypt abscess
• Presence of acute inflammatory cells and sloughed epithelial cells
• Ulceration of the mucosa
• Thickening and fibrotic appearance of the submucosa
• Generation of fibroblasts
• Fibrosis of the connective tissues
• Rectal tissue ischaemia
• Fistula formation
• Renal constriction
• Mucosal friability

Diagnosis, treatment, & prevention

The following diagnostic tests are carried out for Proctitis-

• Colonoscopy
• Sigmoidoscopy
• Defecography
• Anal manometry
• Abdominal X-ray
• Endoanal ultrasound
• Stool culture
• Blood test
• Colonic and rectal biopsy

The first course of treatment of proctitis is antibiotic drugs. This helps get rid of the bacterial infection responsible for the inflammation.  In some cases, anti-viral drugs may also be prescribed if an STD has been diagnosed as the cause of proctitis. Steroid enemas are also proven to be effective in few cases.  Prevention against proctitis includes:

• Refrain from anal penetration/ anal sex.
• Avoid introducing foreign objects in the anal region.
• Practice safe sex. Refrain from having multiple sexual partners.
• Consume a diet rich in non-inflammatory foods such as whole grains, lean meats, and fish.

References