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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 , bleed- This brief treatise discusses various ano-peri- ing, pruritus, and . 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 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 is the lower 10 to 15 cm of lesions. A judicious application of these tech- niques has been found successful in tackling the . 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 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 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 • (acute or chronic) • Bleeding per rectum • Perianal hematoma • Pus discharge from and around anus • Anal sepsis •Prolapse •Prolapsed and thrombosed • Anal pruritus • Anal •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 ( and 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 (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- 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) • (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 ) • Polyps • Inflammatory conditions (anal cryptitis and • Malignancy papillitis) • Inflammatory bowel disease (IBD) • Hypertrophied anal papillae. • Uncommon • Anal fistula • Strictures of anal canal • Solitary rectal ulcer • Incontinence (flatus or feces) •Arterio-venous malformations

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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 ) • • 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 (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- ing hard scybalous stools, the feeling of an in- ficial trauma. Any pruritic lesion that persists complete evacuation or prolonged straining at even after adequate treatment should necessarily toilet. In general, a condition is regarded as con- be subjected to biopsy to arrive at an appropriate stipation when a person encounters fewer than conclusion. three bowel movements per week while continu-

Table VI. Causes of anal pruritus. Table VIII. Lump or mass in or around anus.

• Discharge and soiling (from anal fistula/anal fissure) Painful masses • Allergy (drugs, clothes, local applications) • Abscess * Perianal hematoma *Anal fistula • Anal skin tags, anal papilloma • Antibioma (aseptic abscess, organized abscess) • Mucus leak from hemorrhoids or prolapse • Thrombosed hemorrhoids * Inflamed sentinel •Various skin conditions (dermatitis, psoriasis, pile of anal fissure. lichen, scabies) • Malignancy of anal canal •Worm infestation Painless masses • Condyloma (anal warts) • *External anal tags *Condyloma acuminata • Following surgical procedures in and around •Venereal warts (molluscum contagiosum) anus *Fibrous anal polyp • Anal incontinence • Papilloma *Neoplasms (leiomyoma, angiomyxoma)

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Table IX. Causes of constipation. Table XI. Causes of anal incontinence.

• Habitual or dietary • Debilitating conditions, in elderly, mentally ill • Senile and parous women •Drug induced • Obstetrical injury • • Neurological disorders • Functional disturbances • Birth injury • Systemic disease • Neuropathy like in • Neurological conditions • Post-operative • Lazy colon (colonic inertia) • Rectal prolapse •Diarrhoeal conditions • Radiation injury to rectum ing a daily consumption of at least 19 g of fiber. • Overflow incontinence with fecal impaction This condition could be due to multiple reasons. It is imperative that the clinician rule out possi- bility of obstructing lesions or other painful anal pair or restrict normal activities to make one’s lesions before undertaking the treatment of con- life miserable. stipation15. Normal continence depends on many interre- In few cases, the situation may take a more se- lated factors, including stool volume and consis- rious turn in the form of fecal impaction or fecol- tency, colonic function, rectal compliance, rectal ith obstruction. This is an acute condition and sensation and sphincter function17. needs an urgent attention. The incontinence may be partial or complete. The common causes of constipation are listed It is, however, important to rule out fecal im- in Table IX. paction with overflow before seeking a patho- physiologic cause for uncontrolled passage of Passage of Mucus (Table X) liquid stool. Passing mucus or “slime” from the anus is a disturbing symptom. Mucus discharge mostly de- Anal Stenosis or Stricture notes a pathology causing irritation of the colon, The patients complain of difficulty in passing but it could be a part of certain anal conditions stool or may feel that the “opening” has gone too. The mucus may be a part of the stool passed small. Most commonly, stricture or stenosis of or it may occasionally pass in isolation. The con- the anal outlet occur secondary to interference sistency may vary and at times, it may contain with the anal canal either by surgery or by under- blood in it. lying pathologies (Table XII)18. An extensive evaluation is necessary to rule out any specific pathology behind this symptom. Presentation of Ano-Perianal Pathologies This includes colonoscopy, microscopic and cy- at a Glance tological examination of the mucus16. As discussed earlier, the ano-perianal lesions can present in variety of forms. The demograph- Incontinence (Table XI) ics of patients attending a proctology clinic and This is the inadvertent passage of flatus, liquid or presentation of symptoms are shown in Figures solid stool. Fecal incontinence can seriously im- 1, 2, 3.

Table X. Causes of mucus discharge per rectum. Table XII. Causes of anal stenosis or stricture. • Inflammatory bowel disease (IBD) • Rectal prolapse • Surgery •Mucus • Radiation •Hemorrhoids • Neoplasm • Solitary rectal ulcer • Sepsis •Drugs containing liquid paraffin • Inflammatory bowel disease (IBD) • Hypertrophied anal papillae or fibrous anal • Anal fissure polyps •Trauma (iatrogenic or accidental)

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Various lesions presented in a proctology clinic

Figure 1. Distribution of various ano-rectal lesions in consecutive 1000 patients attending a proctology clinic in India. (Source: Fine Morning Hospital and Research Center, Nagpur, India).

Investigating a Case of needed. Determination of anorectal physiology Ano-Perianal Lesions using endoanal ultrasonography, anal manometry The patient’s history, inspection, and palpation and defecography are the essential investigative of the anorectum remain the basic, essential fea- tools for the colorectal workup. tures of diagnosis. A successful interaction with Fistulograms, Magnetic Resonance Imaging, the patient can lead to a correct diagnosis and a and tomographic scanning are few other investi- treatment plan, which would be acceptable to the gations to mention. physician and the patient himself19. Anoscopy (proctoscopy) remains a key ma- Treatment of Aano-Perianal Diseases neuver in detection of anal pathologies. When a Family physicians could manage most of the more proximal lesion is suspected, sigmoi- common anorectal disorders they see in office doscopy or a colonoscopy along with biopsy is practice. Most cases could be treated by conserv- ative medical treatment with dietary changes, sitz baths, , antibiotics, stool softeners, he- morrhoidal creams and suppositories, or will Age wise distribution of patients need an instrumental procedure, which could be carried out in the office20.

Sex-wise distribution of patients

63%

37%

Male Female

Figure 2. Patient demographics attending an ano-rectal Figure 3. Sex-wise distribution of patients attending a clinic in India. (Source: Fine Morning Hospital and Re- proctology clinic in India. (Source: Fine Morning Hospital search Center, Nagpur, India). and Research Center, Nagpur, India).

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Anal Fissures Table XIII. Medical treatment of hemorrhoids. Acute anal fissures are superficial and may be multiple. They respond well to conservative ther- • Relieving constipation using bran, mucilage, lac- apies like warm water , application of tulose or bulk forming laxatives various ‘hemorrhoidal’ creams, analgesics, and • Increasing daily intake of fibers dietary modifications. Proper anal hygiene and •Avoidance of colonic stimulants like coffee, tea regularization of bowel could prevent recurrence and spices of such fissures. • Use of flavonoid derivatives (Diosmin) and Cal- Chronic anal fissures are mostly found on the cium Dobisilate posterior or anterior midline. They may have • Use of hemorrhoidal creams, ointments and sup- associated lesions like the sentinel pile, anal positories papillae, fibrous polyps or hemorrhoids. Thera- pies useful for acute fissures could only provide • Use of anti-pruritics a short-term relief in chronic form of the dis- • Adequate local hygiene ease. An internal sphincter manipulation is needed to promote healing of chronic anal fis- sures. A variety of surgical and non-surgical ap- • Sclerotherapy proach has been proposed21. • Infra red photocoagulation Despite the initial success with these phar- • Bicap macological agents in the treatment of chronic • Doppler guided hemorrhoidal artery ligation anal fissures, a growing concern is developing (DGHAL)25 about their use. Increase in the incidences of • Radiofrequency ablation26 adverse effect and decrease in the long-term ef- • Rubber band ligation ficacy have been the major drawbacks of such • Heater probe therapies. • Ultroid (direct current probe) Surgery remains a more reliable method to be • Stapler hemorrhoidopexy27 (PPH) offered to patients with relapse or therapeutic • Surgery (conventional, diathermy, harmonic failure of the pharmacological treatment. There scalpel, laser) is a consensus that a controlled lateral internal sphincterotomy is the best surgical procedure for chronic anal fissure. Both open and closed meth- Treatment of Ano-Perianal Sepsis ods are equally effective22. The anorectal area could be involved in sever- al infectious and inflammatory processes. Ab- scesses often have their origin in an anal crypt or Treatment of Hemorrhoids in the anal glands. The suppurative process then It has been estimated that 50% of the popula- tracks through the various planes in the anorectal tion develops hemorrhoids by the age of 50 region. This manifests itself either at the anal years23. Although patients often consider the con- verge as a perianal abscess, or within the anal dition to be a single simple disease, it may not be canal. These abscesses could easily be drained in so. Hemorrhoids share their symptoms with a the office under local anesthesia. whole series of other diseases and it is this lack Bacterial, viral, and protozoal infections could of specificity that calls for a thorough examina- be transmitted to the anorectum via anoreceptive tion to reach a precise diagnosis. intercourse. Ano-perianal sepsis is a medical Medical therapy of hemorrhoids (Table XIII). emergency requiring immediate hospitalization While conservative treatment do have a role in and treatment, including surgical debridement the early stages of the disease and in attending and high dosages of broad-spectrum antibiotics. the complications of hemorrhoids, their sustain- Rarely, perineal sepsis can occur as a complica- ability in controlling the symptoms on a longer tion of rubber band ligation or sclerotherapy of duration is in question24. They however, can be internal hemorrhoids28. proposed in patients who are not willing for, or Potential rectal complications arising out of who are waiting/unfit for a definitive surgical Human Immunodeficiency Virus include infec- treatment. tious , acyclovir-resistant strains of The various instrumental and surgical treat- HSV2, Kaposi’s sarcoma, lymphoma, and squa- ment options for hemorrhoids include: mous cell carcinoma.

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Treatments of Anal Fistula Patients with anal fistula are mostly referred Table XIV. Treatment of anal warts. to a specialist for treatment. In addition to fis- • Application of 85% Trichloroacetic acid (TCA) tulotomy, treatments include insertion of cut- ting or draining setons, endo-anal mucosal ad- •Cryotherapy or oral interferon and flurouracil vancement flaps, sliding cutaneous advance- • Radiofrequency ablation or Laser removal or ment flaps, fistulectomy with muscle repair and electrodessication or surgery injection of fibrin glue in the fistulous tract.

Treatment of Pilonidal Abscess and Sinuses Pilonidal abscess could be drained under lo- Treatment of External Anal Tags cal anesthesia in the office. Sinuses could be These are usually asymptomatic. They are laid open in the similar manner. Presence of hair mere remnants of old thrombosed external hem- in the wound is one of the prime causes of in- orrhoids. But when such tags cause symptoms complete healing or recurrence. The hair should like itching, anxiety, or hygienic problems, they be meticulously shaved at regular intervals. should be removed under local anesthesia. If they Care should be taken that the wound continues are too extensive, excision may be needed under to remain free of hair all the time. a short general anesthesia. Multiple or recurrent pilonidal sinuses should preferably be dealt at specialty centers. Treatment of Anal Stenosis or Stricture A conservative approach using stool soften- Treatment of Malignancies of ers, osmotic agents, and lubricants that ensure the Anal Canal smooth passage of stool is found effective in Cancer of the ano-rectum could manifest most of the cases. Regular anal dilatation using with symptoms identical to more common le- a metal dilator is another option in anal stric- sion of the anal canal like hemorrhoids or coli- tures of recent origin. If the above treatment tis, or it may be incidentally found during a fails, then surgical correction is needed. Treat- digital rectal examination. Pain in the early ment includes laxatives and excision in appro- stages is usually absent and the pathology may priate cases. generally be presumed and treated as “piles” because of intermittent bleeding per rectum. An Treatment of Incontinence external or internal mass may be palpable. Anal Treatment is generally directed at the underly- cancer can present as an ulcer, as a polyp, or as ing cause and minimizing symptoms. Discrete a verrucous growth. Most anal cancers respond muscle injuries are usually best treated by surgi- well to treatment with combined chemotherapy cal sphincter repair. Fecal incontinence sec- and pelvic radiation. ondary to neuropathy is treated with bulking and antimotility agents. Recent approaches to the sur- Treatment of Anal Warts (Condylomas) gical therapy of incontinence include use of an They present as warty growths in or around artificial bowel sphincter, and the electrical stim- the anus. Their size and number vary from a ulation of sacral nerves to modify pelvic floor small and single wart to a crop growth of dif- function15. ferent sizes extending in the perineum and gen- itals. While it commonly spreads through un- Treatment of Constipation safe and unnatural sexual practices, it can be It is a symptom, which is not measurable sci- found in patients with no such history. The in- entifically. It has more emotional components fection in such patients is believed to occur by than physical and should therefore, be dealt with pooling of secretions in the anal area from else- in a holistic manner. where. The daily dietary fiber intake should be in- Anal warts can lead to anal pruritus, soiling, creased and bulking agents like psyllium (Fybo- bleeding, and thus become a constant source of gel), mineral oil (paraffin liquid), methylcellu- irritation. lose, bran, karaya gum or similar preparations Various office procedures are available for that are useful in facilitation of the defecatory tackling anal warts (Table XIV). process should be prescribed.

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Lactulose (Duphalac), sorbitol, and lactilol glycerine ointment is known to cause severe have minimum known side effects and are con- after application. sidered safe in pregnancy and in children. While the above treatise describes the various They could also be prescribed to the elderly ano-perianal pathologies in general, certain geo- patients. graphical and dietary factors, availability of ad- Senna, bisacodyl, sodium picosulphate, and vanced medical services and social circum- magnesium salts should be used with caution as stances that do influence the prevalence and pre- they could cause symptoms like bloating, colicky sentation of the disease have to be given due pain, and purging. Low doses of polyethylene weightage. In the developing countries, Tubercu- glycol and sodium phosphate could be used for losis (TB) is an important public health problem, intermittent lavage of the bowel. which also has an influence in the causation and Drugs like Cisapride, Mosapride, Itiopride, progression of ano-perianal sepsis. HIV is the and Docusates are known to improve intestinal most significant risk factor for progression from motility and could be prescribed for a prescribed subclinical infection with Mycobacterium tuber- duration. culosis to active TB31. For patients with intractable constipation, The prevalence of benign anorectal diseases in behavioral techniques to modify pelvic floor the general population from developing countries and intestinal function can be considered. has been difficult to establish, either because the Combination of bowel training, dietary man- individual diseases themselves were difficult to agement, and regular exercise could possibly characterize in surveys or because of bias in the help achieving a satisfactory relief from the selection of the survey population. In a randomly symptoms. selected population, more than 80 percent of the subjects with symptoms of benign anorectal dis- Role of “Hemorrhoid Creams” or order have not consulted a physician regarding Suppositories in Proctology their illness32. Fear of impotence following Ointments containing , xylocain, surgery and misplaced belief in herbal remedies amethocain, and cinchocain to relieve pain, are some of the reasons for not consulting a belladonna to alleviate sphincter spasm and sil- physician despite an advanced ano-perianal prob- ver nitrate to promote healing have all had been lem33. in vogue since long29. These mixtures are intro- A relatively low incidence of cancer, ulcera- duced either with the finger or through a short tive colitis, adenomatous polyps, and diverticu- rectal bogie to ensure a thorough application lar disease of the colon have been noticed in over the affected part of the anus. Recent re- these developing countries in comparison to the ports of topical application of Solcoderm, Ke- patients from developed nations34. Similarly, tanserin gel, a eutectic mixture of 5% Prilocain the causes of upper GI bleeding in children in and 5% Lidocain or combination of Policre- developing countries are different from those in sulen and Cinchocain (Faktu by Ranbaxy developed countries (variceal bleeding due to Crossland, India) has shown good symptomatic extrahepatic portal venous obstruction is the relief in anal pain. most common cause, while peptic ulcer is rare). Topical and isosorbide dinitrate However, the spectrum of lower GI bleeding is ointment, which at present are being used for similar to that of developed countries35. treatment of cardiovascular disorders, have been Traditional treatment is dispensed according to reported to be useful in the treatment of anal fis- the type of illness and is mainly used by adults. sures and acute strangulated internal hemor- Children are treated more quickly than adults. rhoids30. Cost of and distance from health services often The best practice of using these preparations is hampers use of modern medicine36. Interestingly, to insert them over an anal dilator, which also Khat chewing, a very common habit of the popu- helps relieve the sphincter spasm. Alternatively lation in Mediterranean region has been found to emollient suppositories containing some of the have a significant role in development of hemor- above preparations could be used with identical rhoidal disease37. Green banana is being used as results. an astringent in the treatment of hemorrhoids, The possible complication with such oint- while lotions prepared from essential oil like the ments and creams is local and systemic allergy myrrh are frequently used for application on he- and loss of the anal dilator in the rectum. Nitro- morrhoids.

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