327-335/Art. 1.1462 6-12-2006 9:18 Pagina 327 European Review for Medical and Pharmacological Sciences 2006; 10: 327-335 A review of proctological disorders P.J. GUPTA Gupta Nursing Home, Laxminagar, NAGPUR – (India) Abstract. – Ano-perianal lesions are es- anatomy are occupied by disorders like hemor- sential part of the family practice setup. Patients rhoids, fissures, and pruritus ani3. usually present with symptoms like pain, bleed- This brief treatise discusses various ano-peri- ing, pruritus, and constipation. In the modern era, the patients prefer a con- anal lesions and an approach to their diagnosis servative therapy or else they opt for a quick of- and treatment. fice procedure to get rid of the symptoms. New- er pharmacological therapies and a handful of The Anal Canal simple and safe office procedures have emerged The anus is the outlet to the gastrointestinal in the last decade for treatment of ano-perianal tract, and the rectum is the lower 10 to 15 cm of lesions. A judicious application of these tech- niques has been found successful in tackling the large intestine. The anal canal starts at the most of the proctological ailments. ano-rectal junction and ends at the anal verge. Complicated or advanced pathologies, how- The average length of the anal canal is 4 cm. The ever, require an expert opinion and it is desir- midpoint of the anal canal is called the dentate able that such patients are referred to the care line. This dentate or pectinate line divides the of colorectal clinics. squamous epithelium from the mucosal or This paper describes presentation symptoms, columnar epithelium. Four to eight anal glands approach towards diagnosis, and various thera- peutic modalities of common anal disorders drain into the crypts of Morgagni at the level of commonly seen in a developing country. the dentate line. Most rectal abscesses and fistu- lae originate in these glands. The dentate line al- Key Words: so delineates the area where sensory fibers end. Proctology, Family practice, Office treatment, Ano-pe- Above the dentate line, the rectum is supplied by rianal disorders. stretch nerve fibers and not the pain nerve fibers. This allows many surgical procedures to be per- formed without anesthesia above the dentate line4. Conversely, below the dentate line, there is extreme sensitivity, and the perianal area is one of the most sensitive areas of the body. The evac- Introduction uation of bowel contents depends on action by the muscles of both the involuntary internal The prevalence of anal pathologies in general sphincter and the voluntary external sphincter. population is probably much higher than what is seen in clinical practice, since most patients with Symptomatology of the symptoms confined to the anorectum tend to shy Ano-Perianal Lesions away and do not seek medical attention1. While in most of the time, patients with ano- A primary care physician frequently faces perianal pathologies presents with typical symp- difficult questions concerning the optimum toms, at times these may be misleading due to management of ano-perianal symptoms. While the patient’s inability to explain or his under- the examination and diagnosis of certain ano- statement or underplaying of symptoms5. perianal disorders is challenging, most of the The common symptoms denoting ano-perianal common disorders of the ano-rectum can be pathology are listed (in order of frequency) in easily recognized with a careful local examina- Table I. tion and proctoscopy2. A systematic approach to the patient with On a rough estimate, more than 81% of the anorectal complaints allows for an accurate and complaints centering on this part of human efficient diagnosis of the underlying problem. Corresponding Author: Pravin J. Gupta, MD; e-mail: [email protected] 327 327-335/Art. 1.1462 6-12-2006 9:18 Pagina 328 P.J. Gupta Table I. Symptomatology of ano-perianal pathologies. Table III. Causes of anal pain. • Anal Pain • Anal fissure (acute or chronic) • Bleeding per rectum • Perianal hematoma • Pus discharge from and around anus • Anal sepsis •Prolapse •Prolapsed and thrombosed hemorrhoids • Anal pruritus • Anal fistula •Presence of swelling or lump in or around anus • Anal malignancy • Constipation or fecal obstruction • Thrombosis in internal hemorrhoids (acute • Difficulty in passing stool attack of piles) • Incontinence to flatus or feces • Functional disorders (proctalgia fugax and Levator ani syndrome) •Presence of foreign bodies in the anus The process can be divided into the interview, the examination, and conveyance of information6. Throughout this process, the patient must be reas- Pain during bowel movements that is de- sured and made as comfortable as possible. scribed as “similar to one caused by a cut with The key to diagnosis lies in the patient history, sharp glass” usually indicates a fissure. The acute with confirmation by visual inspection and onset of pain with a palpable mass is usually due anoscopy. Expensive workups are usually not re- to a thrombosed external hemorrhoid (perianal quired. Based on the symptoms and possible dif- hematoma). Anorectal pain that begins gradually ferential diagnosis, further investigation may be and becomes excruciating over a few days may necessary7. The common ano-perianal lesions en- indicate infection. Anal pain accompanied by countered in the family practice are listed (in or- fever and inability to pass urine signals perineal der of frequency) in Table II. sepsis9. Anal Pain (Table III) Bleeding per Rectum This is the commonest complaint among the There is no overemphasis when it is said that patients attending a proctology clinic8. all cases of rectal bleeding ought to be evaluated and the cause identified. Causes of bright red rectal bleeding are listed in Table IV. Table II. Common ano-perianal lesions. Pus Discharge Commonest Discharge of pus from or around the anus is •Hemorrhoids (internal or external) another disturbing symptom. The commonest • Anal fissures (acute or chronic) • Anal fistula (low or high) cause of pus formation (Table V) is anal and pe- • Abscesses (perianal, ischio-rectal, submucus) rianal suppuration, presenting as a fistula or burst • Polyps (adenomatous, fibrous anal) abscess10. • Anal skin tags or sentinel pile A thorough evaluation of the patient is neces- • Ano-perianal sepsis (hydradenitis suppuritiva, sary to establish the actual cause of pus dis- AIDS, syphilis) charge. While abscesses and fistulae are obvious Less Common • Sacro-coccygeal pilonidal sinus disease • Neoplasms (benign or malignant) Table IV. Causes of bleeding per rectum. • Condylomas • Connective tissues masses like papilloma, fibroma, •Hemorrhoids and lipoma • Anal fissures • Antibioma (organized abscess) • Polyps • Inflammatory conditions (anal cryptitis and • Malignancy papillitis) • Inflammatory bowel disease (IBD) • Hypertrophied anal papillae. • Rectal prolapse Uncommon • Anal fistula • Strictures of anal canal • Solitary rectal ulcer • Incontinence (flatus or feces) •Arterio-venous malformations 328 327-335/Art. 1.1462 6-12-2006 9:18 Pagina 329 A review of proctological disorders Table V. Causes of pus discharge. Table VII. Causes of prolapse from the anus. • Anal fistula •Hemorrhoids • Anal fissure with suppuration or fistula formation • Rectal prolapse (mucosal or complete) • Submucus or perianal antibioma [aseptic abscess] • Polyps (rectal, fibrous anal polyp) •Proctitis • Neoplasms (melanoma, angioma, papilloma) • Inflammatory bowel disease (IBD) • Intussusception • Anal malignancy • Solitary rectal ulcer • Suppuration in thrombosed hemorrhoids Prolapse from the Anus Protrusion of “something” from the anus is a symptom, which denotes various pathological on inspection and palpation, other lesions may conditions of the ano-rectum. The prolapse may need a careful search to reach to the source of occur during defecation getting reduced sponta- suppuration. Sigmoidoscopy, examination of the neously or manually. In other situations, there discharge, biopsy, and endoanal ultrasonography could be found a permanently prolapsed mass may be required in such attempt11. outside the anus13. Few common lesions presenting with prolapse Pruritus Ani (Anal Itch) are listed (in order of frequency) in Table VII. Pruritus ani is an extremely common and an- noying symptom, associated with a wide range of Swelling or Lump Around Anus (Table VIII) mechanical, dermatological, infectious, systemic, Anal or perineal “lumps” are indicative of le- or certain unidentifiable conditions12. Regardless sions that may or may not be related to the of the etiology, the itch/scratch cycle becomes pathology of the ano-rectum. Lumps or masses self-propagating and results in chronic patholog- of a recent origin or those that are painful have ic changes that persist even if the initiating factor an infective or hemorrhagic etiology like an ab- is removed. scess, a perianal hematoma, or thrombosis and In a belief that pruritus ani is caused by poor should call for a thorough examination14. hygiene, patients become overzealous in keeping the perianal area clean (Table VI). Excessive Constipation cleaning, particularly using brushes and caustic The term constipation can have a variety of soaps, irritates the sensitive anal and perianal re- meanings. Patients may use the term to indicate gion to exacerbate the symptoms further. The pe- the lack of an urge to defecate, a decreased fre- rianal area may be highly sensitive to perfumes, quency of bowel movements, difficulty in pass- soaps, clothes, fabrics, dietary intake, and super-