Ulcerative colitis limited to the rectum is a common presentation of inflammatory bowel disease. It can generate significant symptom burden and may progress to more proximal disease over time. Proctitis requires appropriate assessment and exclusion of alternative diagnoses, including infection. The mainstay of therapy for ulcerative proctitis is topical therapy, especially 5-ASAs, for inducing and maintaining remission. Proctitis is often considered a mild and easy-to-treat form of ulcerative colitis; however, we know that proctitis can greatly impact a patient’s quality of life and can be difficult to manage. Refractory disease, which fails to respond to 5-ASA or steroid treatment, is experienced in up to one-third of patients and may require treatment with advanced therapy. The practical implementation of rectal therapy, patient education, and identification of barriers to adherence are critical to ensuring adequate treatment and disease control.