Proctitis is defined as the inflammation of the mucosal lining of the rectum. 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 aetiology and the treatment of anusitis and proctitis are similar. Anusitis is simply inflammation of the anal canal.
Signs and symptoms
- Rectal bleeding (bright red in colour and persistent) but is rarely severe
- Changes in bowel habits, like decrease in quantity and an increase in mucoid contents
- Mild diarrhoea with a lot of mucus
- Patients may report tenesmus or faecal urgency
- Constipation in case of severe inflammation
- Abdominal cramping
Can be divided into the following three categories:
- Proctitis due to inflammatory bowel diseases (ulcerative colitis, Crohn disease)
- Proctitis from infectious causes (Clostridium difficile and Salmonella species)
- Proctitis due to non-infectious conditions (diverticulum, ischemia, and radiation)
The pathophysiology of proctitis is dependent on the various aetiologies 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, though the specific antigen has not been elicited.
Infectious aetiologies may be related to the organism itself or to a toxin produced by the organism.
Radiation proctitis may be due to cellular injury secondary to ischemia from radiation. Diversion proctitis is thought to be caused by a deficiency of short-chain fatty acids. Ischemic proctitis may be due to mesenteric venous occlusion, aortoiliac surgery, radiotherapy, vascular intervention, atherosclerotic disease, or drug use (e.g., cocaine).
Regardless, all three categories of proctitis (IBD, infectious, and non-infectious) result in an unrestrained inflammatory response, with the inflammatory cells being products that mediate cellular-tissue injury.
Lab tests like stool cultures, ova and parasite analysis, and faecal smears.
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.
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. Antibiotics for 1 week may include ampicillin, tetracycline, ciprofloxacin, and trimethoprim-sulfamethoxazole (preferred).
Yersinia proctitis is also self-limited and should not be treated with antibiotics unless systemic septicaemia occurs; in which case, antibiotics (eg, trimethoprim-sulfamethoxazole, aminoglycosides, tetracycline, third-generation cephalosporin) should be used.
Campylobacter proctitis is usually self-limited as well.
E histolytica generally is treated with metronidazole and iodoquinol.
Sexually transmitted proctitis requires treatment similar to the corresponding treatment for a genital infection. Chlamydia 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 type 2 infection is treated with acyclovir.
C difficile infection generally is treated with intravenous (IV) or oral metronidazole or oral vancomycin.  A more aggressive C difficile mutation has been seen and may have a rapidly progressive course toward septicaemia 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 (e.g., Hartman pouch, ileostomy, colonic diversion). Discontinuation of any other antibiotics should be ordered if the clinical situation allows.
Acute radiation proctitis is usually a self-limited condition, but supportive medical management (e.g., hydration, antidiarrheals, and steroid or 5-ASA enemas) may be of benefit. 
Chronic radiation proctitis involves more extensive medical treatment, including both oral and rectal therapies. Oral medications include 5-ASA, sulfasalazine, steroids, and metronidazole. Another therapeutic approach is the use of WF10, an IV therapy initially developed as an adjunctive AIDS treatment. Initial studies demonstrate control of bleeding within two doses of therapy and maintenance of results with once- to twice-yearly repeat therapy. 
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.
For patients with ulcerative colitis requiring surgical therapy, a total proctocolectomy should be performed because of the risk of cancer in the remaining rectal stump.  Ileostomy or reconstruction with an ileal pouch may be offered after total proctocolectomy. In patients with severe Crohn 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 than surgical therapy. Specifically, argon plasma coagulation (APC) [16, 20, 21] has proved to be superior to formalin and endoscopic laser treatments.
Acute cases of proctitis have a good outcome and prognosis. More specifically, once appropriately treated, infectious proctitis tends not to recur.
For the more chronic diseases, such as IBD, outcomes and prognoses vary. Most cases are treated with medicine and very few cases are treated surgically. If proctocolectomy is performed, the patient is cured of the disease. But even after a proctectomy, recurrence of Crohn disease ranges from 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. Outcomes range from requiring a few medical treatments in the form of enemas to surgery. Complication rates for surgical treatment have been reported to be as high as 75%.
Abscesses—painful, swollen, pus-filled areas caused by infection
Chronic or severe bleeding that can lead to anaemia
Fistulas—an abnormal passage, or tunnel, between two organs or between an organ and the outside of the body
Rectal stricture—an abnormal narrowing of the rectum
Ulcers—sores in the lining of intestine.
Disease & Ayurveda
Causative factors for the vitiation of Kapaha and Raktha
Absence of proper personal hygiene
Pain, redness and swelling in the anus
Ulceration of the skin and mucous membrane may be present
Saadhya in new cases
Kricchrasadhya in chronic cases
Lepanam with vranahara dravyas
Prakshalana with triphala/nalpamara kwatha
Dhoopanam with guggulu
Raktamoksha with jalooka
Treatment of wound
Commonly used medicines
Applying neem paste
Apple cider vinegar
Fomentation of the area
- To be avoided
Heavy meals and difficult to digest foods – cause indigestion.
Junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine
Carbonated drinks – makes the stomach more acidic and disturbed digestion
Refrigerated and frozen foods – causes weak and sluggish digestion by weakening Agni (digestive fire)
Milk and milk products – increase kapha, cause obstruction in channels and obesity
Curd – causes vidaaha and thereby many other diseases
- To be added
Light meals and easily digestible foods
Green gram, soups, fresh fruits and vegetables
Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc
Protect yourself from hot climate.
Maintain personal hygiene
Better to avoid exposure to excessive sunlight wind rain or dust.
Maintain a regular food and sleep schedule.
Avoid holding or forcing the urges like urine, faeces, cough, sneeze etc.
Avoid sedentary lifestyle. Be active
Regular stretching and mild cardio exercises are advised. Also, specific yogacharya including naadisuddhi pranayama, bhujangaasana, pavanamuktasana is recommended.
Regular exercise helps improve bioavailability of the medicine and food ingested and leads to positive health.
Yoga can maintain harmony within the body and with the surrounding system.
Simple exercises for lungs and heart health
All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.
The purpose of the study is to look at the benefit of administration of an oral prebiotic amylase resistant starch in reducing the incidence of acute radiation proctitis, a distressing symptom in patients receiving radiation therapy for cancer of the cervix.
Material and methods: The study was conducted between 2011 and 2014 in 104 patients receiving radical chemo-radiotherapy for carcinoma cervix. Patients were randomized in to two arms, one receiving 30 gm of resistant starch and the other digestible starch on a daily basis throughout the course of the external radiotherapy. All patients received standard 4-field box radiation portals, 50 Gy in 25 fractions with 4 cycles of weekly concurrent Cisplatin. At completion of external beam radiotherapy, all patients underwent LDR/HDR brachytherapy. The study was double blinded and allocation was concealed from the investigators. The investigator recorded the radiotherapy related toxicity of the patients according to CTC V 3.0. The incidence and severity of grade 2-4 diarrhoea and proctitis were documented on a weekly basis and compared across the two groups and analyzed. Stool short chain fatty acid concentrations were measured at baseline at 2nd and 4th week and after 6 weeks of completion of radiotherapy in both study placebo arms and reported. The pattern of microbiota in the stool were also estimated in all patients at 4 time points. Two patients who progressed during therapy were not included in the analyses and two patients discontinued the intervention. A per protocol analyses was done.
Results: At analysis there were 50 patients in each arm. The severity of clinical proctitis was found to be similar in both groups of patients with 12.2 % of patients experiencing toxicity of grade 2 and above in digestible starch group versus 14.6% in the resistant starch group. Functional proctitis was similarly graded and it was found that 16.3 % patients in digestible starch group experienced toxicity against 10.2 % patients in the resistant starch group. This difference was seen at 4th week and continued in the subsequent weeks till the end of radiation. Both groups had similar reported toxicity at 6 weeks post intervention and similar incidence of grade 2 and above diarrhea. The resistant starch group was found to have 8% incidence as compared to 2% in the other group at the 5th and 6th week. The short chain fatty acid concentrations were not significantly different in the groups at any point.
Conclusion: The study did not demonstrate a significant benefit in administering resistant starch over and above normal diet to patients receiving pelvic radiotherapy. The reasons may be attributed to concurrent use of chemotherapy and decrease in intestinal probiotics. The use of digestible starch in the control arm may have contributed to lower incidence of the toxicity endpoints as well.
- PMID: 29702300
conducted a randomized phase 2 trial to determine the efficacy and safety of 2 doses of a budesonide suppository vs mesalamine suppositories vs combined budesonide and mesalamine suppositories for proctitis.
Methods: We performed a prospective, double-blind, double-dummy, multicenter trial in 337 patients with active proctitis to compare the efficacies of 4 different suppository treatments. Patients were randomly assigned to groups given 2 mg budesonide suppositories (2 mg BUS; n = 89 patients), 4 mg BUS (n = 79), 1 g mesalamine suppositories (1 g MES; n = 81), or the combination of 2 mg BUS and 1 g MES (n = 88). The study was performed from November 2013 through July 2015 at 36 study sites in Europe and Russia. The primary end point was the time to resolution of clinical symptoms, defined as the first of 3 consecutive days with a score of 0 for rectal bleeding and stool frequency.
Results: The mean time to resolution of symptoms in the 4 mg BUS (29.8 days) and combination of 2 mg BUS and 1 g MES (29.3 days) groups resembled that of the standard 1 g MES treatment (29.2 days), but was significantly longer in the 2 mg BUS group (35.5 days). Furthermore, proportions of patients with deep, clinical, and endoscopic remission, as well as mucosal healing, were similar among the 1 g MES, 4 mg BUS, and combination therapy groups, but significantly lower in the group that received 2 mg BUS. No safety signals were observed, and the patients’ treatment acceptance was high (67%-85% of patients).
Conclusions: In a multicenter randomized trial, we found that the efficacy and safety of 4 mg BUS in treatment of active proctitis did not differ significantly from those of 1 g MES. Budesonide suppositories offer an alternative therapy to mesalamine for topical treatment of proctitis.
These statements have not been evaluated by the Food and Drug Administration, United States. This product is not intended to diagnose, treat, cure or prevent any disease. Please consult your GP before the intake.
Dr. Rajesh Nair, the co-founder and chief consultant of Ayurvedaforall.Com, is a graduate of prestigious Vaidyaratnam Ayurveda College (affiliated with the University of Calicut), Kerala, India. Additionally, he holds a Postgraduate Diploma in Yoga Therapy from Annamalai University.
Dr. Nair offers consultation at two busy clinics in and around Haripad, Alleppey, Kerala, the southern state famous worldwide for authentic ayurvedic treatment and physicians. While offering consultation on all aspects of ayurvedic treatments Dr. Nair has a special interest in Panchkarma, Yoga, and Massage.
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