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Anal Health Care Basics ORIGINAL RESEARCH & CONTRIBUTIONS Special Report Anal Health Care Basics Jason Chang, MD; Elisabeth McLemore, MD, FACS, FASCRS; Talar Tejirian, MD, FACS Perm J 2016 Fall;20(4):15-222 E-pub: 10/10/2016 http://dx.doi.org/10.7812/TPP/15-222 ABSTRACT diseases causing these anal symptoms. For Despite the fact that countless patients suffer from anal problems, there tends to example, although there are many prob- be a lack of understanding of anal health care. Unfortunately, this leads to incorrect lems that can lead to anal pain, one of the diagnoses and treatments. When treating a patient with an anal complaint, the primary most common is an anal fissure, which is goals are to first diagnose the etiology of the symptoms correctly, then to provide an frequently misdiagnosed as hemorrhoidal effective and appropriate treatment strategy. disease.1 The first step in this process is to take an accurate history and physical examination. Important history questions: Specific questions include details about bowel habits, anal hygiene, and fiber supple- • How often do you have a bowel move- mentation. Specific components of the physical examination include an external anal ment? examination, a digital rectal examination, and anoscopy if appropriate. • What is the quality and consistency Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess of the bowel movement (ie, hard, soft, or fistula, fecal incontinence, and anal skin tags. However, each problem presents watery)? differently and requires a different approach for management. It is of paramount im- • How long do you sit on the toilet? portance that the correct diagnosis is reached. Common errors include an inaccurate • Do you read or play games on your diagnosis of hemorrhoids when other pathology is present and subsequent treatment phone while having a bowel movement? with a steroid product, which is harmful to the anal area. • Do you have anal pain/bleeding/incon- Most of these problems can be avoided by improving bowel habits. Adequate fiber tinence to stool or gas? intake with 30 g to 40 g daily is important for many reasons, including improving the • How do you clean the area? Do you use quality of stool and preventing colorectal and anal diseases. any wipes or ointments? In this Special Report, we provide an overview of commonly encountered anal • Do you currently take a fiber supple- problems, their presentation, initial treatment options, and recommendations for ment? If yes, which type and how much? referral to specialists. ANAL HEALTH PHYSICAL EXAMINATION INTRODUCTION improved, additional evaluation may The physical examination comprises Despite the fact that countless patients be needed. three components: suffer from anal problems, there tends to The chief complaint and history of the 1. External Visual Examination be a lack of understanding of anal health present illness are the first pieces of the • Thorough visual inspection is impor- care. Unfortunately, this leads to incorrect puzzle to put together to reach the correct tant. This requires manual retraction of diagnoses and treatments. This problem diagnosis. Obtaining specific informa- the surrounding buttocks with both of is compounded by the stigma associated tion from the patient is imperative. For your gloved hands to expose the peri- with suffering from anal problems, which example, a chief complaint and history anal skin. discourages patients from seeking help of present illness of “hemorrhoids” is • Look for signs of acute or chronic skin and getting the appropriate care. not sufficient and frequently is counter- irritation, contact dermatitis, a punc- productive. tate external fistula opening, erythema The Basics and painful raised area (abscess), or When treating a patient with an anal History thrombosed external hemorrhoid with complaint, the primary goals are to Discovering the patient’s main or without overlying skin ulceration. 1. diagnose the etiology of the symptoms symptom(s) is key: pain, bleeding, itch- • Be knowledgeable about the difference correctly ing, tissue prolapse, excessive tissue, and between an anal skin tag, an external 2. provide an effective and appropriate drainage are some of the most common hemorrhoid, and a sentinel skin tag treatment strategy symptoms of underlying anal disease. adjacent to a fissure that might not be 3. confirm with a follow-up appointment Investigating the details of the patient’s evident. that the problem has resolved or is symptoms is important because “hem- • Evaluation for anal fissure can be dif- under control. If symptoms have not orrhoids” comprise less than half of the ficult as the patient typically has anal Jason Chang, MD, is a General Surgery Resident completing his training at the Los Angeles Medical Center. E-mail: [email protected]. Elisabeth McLemore, MD, FACS, FASCRS, is a Board-Certified Colorectal Surgeon, Chief of Colorectal Surgery, and Director of Minimally Invasive Surgery at the Los Angeles Medical Center in CA. E-mail: [email protected]. Talar Tejirian, MD, FACS, is a Board-Certified General Surgeon with a special interest in anal health care at the Los Angeles Medical Center in CA. E-mail: [email protected]. 74 The Permanente Journal/Perm J 2016 Fall;20(4):15-222 ORIGINAL RESEARCH & CONTRIBUTIONS Anal Health Care Basics Table 1. Anal itching (pruritus ani) What is it? Itching around the anal area, often iatrogenic or because of excessive moisture, cleaning, or harsh chemicals in wipes or ointments. This problem is unrelated to hemorrhoids. Symptoms Itching, discomfort, irritation, burning sensation in the perianal area. The itching sensation can be so severe that patients scratch in the middle of the night. Treatment 1. Properly bulk the stool with adequate fiber to bind any bile irritants or other food or digestive-related irritants to the Figure 1. Repeated tearing and healing of an anal fissure can lead to a sentinel tag (1a, left). An anal fissure (1b, right) anal area (Table 8). can be seen in the posterior midline with upward retraction. Photos courtesy of Daniel Popowich, MD, FACS, FASCRS. 2. Clean with water only; excessive cleaning is discouraged. Table 2. Anal fissure 3. Anal or intimate wipes will What is it? A cut or tear in the anal canal typically caused by passing a hard stool. Patients often induce or exacerbate anal complain of severe anal pain and bleeding with bowel movements. On physical examination, itching. The chemicals found in you may see the fissure or just the sentinel tag. If the examination appears normal, you can these products are irritants to elicit point tenderness. We recommend against continuing the digital rectal examination 2-5 the sensitive perianal skin. or anoscopy if the patient is having pain during the examination. You will need to use both 4. Dry the area without wiping or gloved hands or have an assistant help to retract the buttocks and perianal skin to examine rubbing. Pat dry, air dry, or use the anal canal. Patients frequently have anal hypertonia (spasm) as well, further making the a blow-dryer on low/medium anal canal more difficult to visualize. heat if needed. Symptoms Pain and bleeding, often after a hard stool or trauma. Pain can persist for days to years and 5. Apply skin-protecting barrier radiate down to the legs, even when bleeding is no longer present. The patient may also ointments to dry and clean have a burning or tearing sensation. perianal skin (zinc oxide 40%). Treatment The primary goals are to properly bulk the stool with adequate fiber and relax the anal muscle. 6. Avoid petroleum-based topical Specific steps include the following: ointments because patients can 1. Properly bulk the stool with adequate fiber to minimize constipation and diarrhea (Table 8); both develop contact dermatitis with frequent bowel movements and hard bowel movements can lead to an anal fissure.8 daily use.6 2. Temporary use of laxatives such as daily Miralax or senna. The dose of Miralax can be 7. Anesthetic ointment with titrated up or down to achieve desired results. As the patient’s fiber supplementation dibucaine can decrease the increases, the need for Miralax will diminish. Note: AVOID docusate (Colace) and other stool urge to scratch the skin. softeners because these agents are typically ineffective. 8. Stop any scratching. 3. Chronic use of laxatives should be avoided because it can lead to worsening colonic function 9. Avoid irritating clothing (avoid and constipation. G-strings and panty liners; wear 4. Diltiazem 2% ointment is to be placed on the anal muscle 3 times daily—continue for a underwear made of undyed minimum of 8 weeks, even if symptoms improve earlier.9 cotton). 5. If a patient cannot tolerate diltiazem, or is breastfeeding or pregnant, 0.2% nitroglycerin- 10. Do NOT prescribe compounded ointment can be prescribed. However, the proper dose of nitroglycerin is steroid-based hemorrhoid important as too high of a dose can cause severe headaches.10 treatments. They can harm 6. Do NOT prescribe hemorrhoid ointments or suppositories, especially steroid-based ones. Steroid the patients, especially with ointments do not help. They do cause perianal skin thinning and dermatitis. At best, they act as extended use.7 a placebo, but they often are used chronically and cause unpleasant perianal skin changes.11 11. There can be visible skin 7. Use mental anal muscle relaxation: Actively thinking about relaxing sphincter tone. changes, but if those are not resolving over time, the patient 8. Consider sitz baths: Soaking the anal area in warm water induces relaxation. Warmer water 12 may need a biopsy to rule out induces more relaxation. No additives are needed. another pathology (ie, Paget 9. Surgical intervention (such as Botox injections or sphincterotomy) is considered for patients disease). whose symptoms do not improve with the above management strategies. It is imperative Key point: Anal itching is most often a that the patient increases fiber and water intake so bowel movements are very soft before 13 dermatologic problem unrelated to hemorrhoids surgical intervention to maximize chances of postoperative healing.
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