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Sexually transmitted proctitis is inflammation of the rectum caused by an infection transmitted through sexual contact. It can cause rectal pain, discharge, or a persistent feeling that you need to pass stool, but symptoms cannot identify the specific infection. A clinician can examine the rectum and test the exposed site to determine what is causing the symptoms and which treatment is appropriate.
What sexually transmitted proctitis means
Proctitis is inflammation of the rectum, specifically its lowest 10–12 cm. It occurs most often after receptive anal exposure, which can include genital-anal, oral-anal, or digital-anal contact. It can affect people of any gender or sexual identity.
Related terms describe inflammation in different parts of the digestive tract:
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- Proctocolitis: rectal inflammation extending farther into the colon; it may cause proctitis symptoms along with diarrhea or abdominal cramps.
- Enteritis: inflammation of the intestines that usually causes diarrhea and abdominal cramping without signs of proctitis or proctocolitis.
These distinctions matter because a rectal STI is not the only possible explanation for digestive symptoms, and the likely tests and treatment depend on the affected area and cause.
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Symptoms and common causes
Symptoms that may occur
Possible symptoms of proctitis include anorectal pain, rectal discharge, and tenesmus—the feeling of needing to pass stool even when the rectum is empty. Blood or ulcers may also be present in some cases. Some people have few or no obvious symptoms.
These symptoms do not reveal which organism is responsible. In particular, sexually transmitted proctitis can resemble inflammatory bowel disease or, less commonly, malignancy. The CDC warns that this resemblance can delay diagnosis, so symptoms alone are not a reliable basis for diagnosing or treating the condition.
Infections associated with proctitis
The most common sexually transmitted pathogens associated with proctitis are gonorrhea, chlamydia (including lymphogranuloma venereum, or LGV), herpes simplex virus (HSV), and syphilis. HSV and LGV proctitis are more prevalent among people with HIV.
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Mycoplasma genitalium has been detected in some cases, but its role in causing proctitis is unclear. A clinician may consider testing for it when symptoms persist after standard treatment.
Other infections and syndromes
Diarrhea or abdominal cramps alongside rectal symptoms may indicate proctocolitis. Possible causes include LGV chlamydia, syphilis, and enteric infections such as Campylobacter, Shigella, or Entamoeba histolytica. In people with HIV-related immunosuppression, clinicians may also consider cytomegalovirus (CMV) or other opportunistic infections.
Enteritis can involve infections transmitted through oral-anal contact, including Giardia, Shigella, Salmonella, E. coli, Campylobacter, and Cryptosporidium. These are possible causes of enteritis, not all causes of proctitis.
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How clinicians test for rectal STIs
For acute proctitis symptoms, the CDC recommends an examination that may include anoscopy, in which a clinician uses a short instrument to look inside the anus and rectum. Anorectal discharge may also be examined for white blood cells that indicate inflammation. The exact tests depend on symptoms, examination findings, sexual exposures, and the body sites involved.
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Testing may include:
- Chlamydia: a nucleic acid amplification test (NAAT) from a rectal sample.
- Gonorrhea: a rectal NAAT or culture.
- HSV: preferably a NAAT from a rectal lesion when one is present.
- Syphilis: blood tests and, where available, testing of a lesion.
If proctocolitis or enteritis related to sexual exposure is suspected, clinicians may also test for HIV, syphilis, gonorrhea, and chlamydia, including at other exposed sites. A urine-only STI screen does not rule out infection in the rectum; testing needs to include the symptomatic or exposed site.
When clinicians consider LGV
If a rectal chlamydia test is positive and there are severe findings such as bloody discharge, rectal or perianal ulcers, or tenesmus, CDC guidance recommends presumptive treatment for LGV. LGV-specific molecular tests are not widely available and often do not return soon enough to guide initial treatment.
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How treatment is chosen
Treatment depends on the examination, test results, suspected organism, and severity. Antibiotics or antivirals should be prescribed by a clinician; the regimens below summarize CDC recommendations for clinicians, not instructions to self-treat.
Acute proctitis
CDC recommends presumptive treatment for acute proctitis when anorectal discharge or white blood cells are found, or when anoscopy or Gram stain is unavailable and symptoms are consistent with acute proctitis in someone reporting receptive anal exposure. The recommended empiric regimen is ceftriaxone 500 mg by intramuscular injection once plus doxycycline 100 mg by mouth twice daily for 7 days. For people weighing at least 150 kg, the guideline specifies ceftriaxone 1 g.
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Possible LGV or herpes
When rectal chlamydia is positive alongside bloody discharge, perianal or mucosal ulcers, or tenesmus, CDC recommends extending doxycycline to 100 mg twice daily for 21 days for presumptive LGV. Painful perianal ulcers or mucosal ulcers seen during anoscopy also prompt presumptive herpes treatment. A clinician determines whether these recommendations apply and selects any additional treatment.
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Proctocolitis and enteritis
Treatment for proctocolitis or enteritis should target the identified enteric pathogen. A single antibiotic regimen is not appropriate for every case. CDC notes antimicrobial resistance concerns during Shigella and Campylobacter outbreaks, which is another reason treatment needs to be guided by clinical evaluation and, when appropriate, testing.
Follow-up, partners, and reducing risk
Sexual partners and retesting
For gonorrhea or chlamydia, partners exposed during the 60 days before symptoms began should be referred for evaluation, testing, and presumptive treatment as appropriate. Partners should also be assessed for the conditions diagnosed in the patient.
CDC advises avoiding sex until the patient and partners have been treated and symptoms have resolved. For acute proctitis, that means at least completing the 7-day regimen. Retesting for gonorrhea or chlamydia associated with proctitis is recommended three months after treatment.
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If an exposure may qualify for HIV post-exposure prophylaxis (PEP), seek a timely clinician discussion; PEP is time-sensitive. For ongoing HIV risk, ask a clinician whether pre-exposure prophylaxis (PrEP) is appropriate. Eligibility depends on individual circumstances.
Reducing exposure to enteric pathogens
CDC says evidence-based interventions specifically for preventing sexually transmitted enteric pathogens are unavailable. As general infection-control and STI-prevention practices, it suggests avoiding fecal contact during sex, using barriers, and washing hands after touching the anus or rectum or handling items that contacted the anal area, such as barriers and sex toys. These are sensible precautions, not proven guarantees against enteric infections.
When to seek an evaluation
Arrange professional evaluation if you have rectal pain, discharge, tenesmus, ulcers, or other symptoms after a possible sexual exposure. Because several infections—and noninfectious conditions—can look similar, an examination and site-specific testing are more useful than trying to identify the cause from symptoms. A clinician can also determine whether testing at other exposed sites or follow-up testing is needed.
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