Canad. M. A. J. 674 JACKSON: RECTAL DIsoRmERs May 1, 1955, vol. 7.2

COMMON RECTAL DISORDERS septum may easily be ascertained. In a word, much information may be derived from this ex- C. COLIN JACKSON, M.D., M.Sc., amination if it is done with finesse which would Vancouver, B.C. not be otherwise obtained. The value of these studies may be estimated only when it is ap- IN ORDER to discuss this topic in any degree of preciated that at least one out of every 20 detail the subject matter will be limited to those of my readers is harbouring what is to be con- disorders most commonly seen and treated by sidered a pre-malignant lesion within easy reach the general practitioner. These are hlemorrhoids, of an ordinary sigmoidoscope. anal ulcer, perianal , and pruritus Hxmorrhoids.-Internal and external haemor- ani. It is not my intention here to review the rhoids are part of the price we have paid for current literature on these subjects, but to pass assuming the upright position. The valveless over briefly the most pertinent signs and symp- plexus of veins of the superior hoemorrhoidal toms and mention a practical management in gr-oup lies loosely in a bed of connective tissue. each case. It is to be hoped that certain long- These veins undergo elongation, dilatation and held views will be relegated to the category of tortuosity from proximal pressure, whether this proctological mythology. be due to a gravid uterus,_ rectal cancer, chronic that I would like to preface these remarks with or of the liver. I feel the vitally important emphasis that with ano- inflammation plays a part in'the etiology as rectal complaints a thorough history and physical sections of internal haemorrhoidal tissue invari- examination be taken. Examination of the distal ably demonstrate inflammatory cells and phlebitis bowel and anus should include inspection, palpa- of these veins. The inflammatory process most tion, digital examination, and anoscopic and likely originates in the crypts at the pectinate sigmoidoscopic studies. This investigation may line. These wayward receptacles of contamination be supplemented by barium enema with air are the progenitors of most of the pathology to contrast, stool examination for blood, ova and be mentioned in this paper. It is readily under- parasites, and biopsy if necessary. We may easily standable that the above condition results in a be betrayed into diagnostic pitfalls by too sug- sense of weight, tenesmus or a "bag-of-worms" gestive symptoms, obviating the necessity of feeling. Because of the constant passage of stool, thorough investigation. It has often been said these haemorrhoids may enlarge until they pro- that a sigmoidoscope is just as important as the lapse, often having to be replaced manually but after each evacuation. Great pain may be ex- stethoscope in the doctor's armamentarium, this the carefully inserted gloved finger is the least perienced if the sphincter mechanism grasps expensive and most readily available instrument diseased tissue in its vice-like grip and strangula- at our disposal. I believe it pertinent here to tion may ensue. However, most frequently spot- The finger ting of blood or frank ha?morrhage is complained elaborate. on the digital examination. the should not be roughly thrust into the rectal of, due to traumatic ulceration into haemor- ampulla and quickly withdrawn if it does not rhoidal vein. collide with a bulky tumour. Nothing is gained With regard to treatment, I believe anything by this crude examination and indeed the doctor- short of haemorrhoidectomy is a compromise as patient relationship may be violently disturbed far as cure is concerned. However, it is realized as a result. The digit should be advanced slowly that many patients cannot afford the time to into the , taking several minutes if neces- undergo such a procedure and the injection of sary. In this way any muscular spasm may be sclerosing agents may be employed, particularly relaxed with little discomfort to the patient. The if the haemorrhoids are not too large. Of course exploring finger should then travel round the these solutions should never be injected into rectal lumen in search of small adenomata or external haemorrhoids or used in any case where larger growths. Extraluminal landmarks may associated fissure, abscess or fistula exists. With easily be palpated and any lesions associated reference to the surgical approach, two prin- with them noted. On slowly withdrawing the ciples should always be kept in mind. Adequate finger, the area of the dentate line should be skin bridging should be left between haemor- palpated carefully for focal points of tenderness rhoidal wounds, be it the normal anoderm or or induration. The integrity of the intramuscular skin grafts from the perianal area. It is evident Canad. AM. A. J. Mlay 1, 1955, vol. 72 JACKSON: RECTrAL DISORDERS 675

your patient will think of you in a derisive way- at least once daily. Fissure-in-ano.-Perhaps the most painful lesion of the ano-rectum is that of or anal ulcer. About 85%v of these appear in the posterior mid-line, 10% in the anterior mid-line, and the rest circumferentially. The typical complaint is that of pain following a bowel movement, which inay last from minutes to hours and is most devastating to the morale. These patients will often have their evacuation in the evening as the severity of a morning movement will keep them from their employment. The ulcer most com- monly is associated with a sentinel pile of Brodie, which is simply an (edematous at the. caudal end of the ulcer (Fig. 3). Proximallv a hypertrophic papilla may be in evidence. The base of the ulcer rests directly on the external sphincter. Although venereal disease, tuberctulous Fig. 1.-External heemorrhoids with marked prolapse of inlternal hwamorrhoids. ulcer and carcinoma must be kept in mind in the differential diagnosis, the microscopical ex- amination, darkfield study, serological tests, and Frei test will be negative. No other treatment in the whole of proctology is more gratifying to the patient than the surgi- cal excision of the chronic anal ulcer. Often the postoperative pain is much less severe than that caused by the initial lesion. I deprecate the use of topical medication in these chronic cases. Even iD acute fissuring, frequent sitz baths will relax She muscles and promote more healing than the topical panaceas of the detail man. Divulsion of the muscle accomplishes nothing and indeed may help spread the infection into the perianal tissue. Cauterization may be done under anaesthesia and, although it completely destroys the ulcer, the incidental fibrous tissue formation prevents proper healing. Although we may temporize with acute fissure, only complete Fig. 2.-Postoperative appearance having employed trtue excision with sphincter incision will eradicate skin for skin bridges. the chronic ulcer. from Fig. 1 that an ordinary haemorrhoidectomy ABSCESS AND FISTULA will fall short of a cure because of the remaining ha morrhoidal tissue beneath the skin bridges. The site of origin of these pyogenic processes In this case, the anoderm and underlying dis- is again the crypt at the dentate line. Infection eased area is also removed and perianal skin spreads through the ductal systems leading to brought down to make healthy skin bridges them and ravages the perianal or perirectal (Fig. 2). tissue. As a fistula is the final stage of progres- Secondly, these patients should be seen fre- sion of an abscess, these two will be discussed quently throughout the postoperative period and together. With an abscess, the pain is constant, digital examination done. The most beautiful throbbing and boring, not sharp and lancinating surgical dissection will come to naught if left as in fissure. The patient is often unable to sit. to the scar contraction of nature. It is then that Inspection of the anus may not reveal the true 676 JACKSON: RECTAL DISORDERS Canad. M. A. J. May 1, 1955, vol. '2

Fig. 4.-Sites of involving perianal and peri- rectal tissue: supralevator and infralevator. (From H. E. BacoR. Anus, Rectztm and Signmoid Colon. Vol. 1.) Fig. 3.-Chronic anal fissure. Note sentinel pile of Brodie. (From H. E. Bacon. Anus, Rectum and Sigmoid Colon. Vol. 1.) actually relaxes rather than contracts in response to impending frcal evaluation. These pernicious character of the lesion, as the abscess may be abscesses and fistulx cannot be combated by situated deeply or point toward the rectum. The anamic attempts at cure or recurrence is sure to various sites may be explained by reference to result. Fig. 4. The blueprint for cure of IDIOPATHIC and fistula depends upon one's knowledge of the This condition is a perianal itching due to intricate anatomy of the part. Incision and drain- causes of which the diagnostician is ignorant. age of the abscess may be followed in subse- Our knowledge of the process responsible is quent days or weeks by fistulectomy, as a fistula extremely limited. However, it may be brought invariably develops. However, if it is obvious about by obesity or pregnancy, due to hydration from which crypt the abscess developed, drain- of the skin, or by senile changes. Altered meta- age of the abscess may accompany fistulectomy bolic states such as uraemia, or pre- at one operation, thereby shortening hospitaliza- icteric states and jaundice may be responsible tion and lessening expense. In my experience no for some cases. infestation is a com- patient has developed septicaemia with this latter mon cause, particularly in children and young treatment if drainage is complete. Whether parents. Very often pruritus ani is merely a the one-stage or two-stage procedure is used, manifestation of a more generalized skin condi- we must not procrastinate in draining the tion such as seborrhoeic , atopic purulent material, as pus will track to the op- dermatitis, , or allergic eczematous con- posite side or often above the levatores ani with tact dermatitis from nail polish, toilet tissue, any delay. The employment of is a clothing or sanitary napkins. The "caine" drugs useful adjunct in the treatment of these pyogenic are particularly notorious here. The cause in processes, but they should never be used as a some cases is a mycotic infection, especially in substitute for surgery. older persons. Itching often accompanies a Although one should maintain respect for the lymphoblastoma. From a proctological point of anal musculature (the guardians of one's social view, a draining fistula, hbemorrhoids or fissure prestige), one should not be too wary in incising may be associated with perianal irritation but the sphincter, since it is the maintenance of the does not cause the idiopathic pruritus ani about anatomical relationship of the anus to the which I am speaking. If a psychic disturbance rectum by the levator sling which plays a major is present, it should be dealt with as it is when part in continence. The phobia of the internal associated with any other disease entity. How- sphincter is I believe unfounded, for this muscle ever, psychoses in themselves plav no part in Canad. M. A. J. RECTAL 677 May 1, 1955, vol. 72 JACKSON: DISORDERS

TABLE I. TABLE Il. %

POSSIBLE CAUSES OF PRURITUS ANI. SUGGESTED THERAPY FOR PRURITUS ANI.

1. Hydration of the skin: (a) obesity; (b) pregnancy. T'reatment 2. Senile changes. 1. Anal hygiene (e.g. Tuck's). 3. Altered metabolism; (a) uramia; (b) diabetes; (c) pre- 2. Avoidance of spicy foods and alcohol. icteric states. 3. Antihistamines q.i.d. 4. Pinworm infestation and mycotic infections. 4. Sedation. 5. Skin conditions: (a) seborrhceic dermatitis; (b) atopoc 5. Silver nitrate Yj% aqueous solution (sitz baths). dermatitis; (c) psoriasis; (d) allergic eczematous 6. Shake lotion (antipruritic lotion). : (1) nail polish; (2) toilet tissue; Rx. menthol ...... 1Y2% (3) clothing or sanitary napkins; (4) "caine" drugs. phenol ...... - % 6. Proctological disorders. zinc oxide...... talc. .... aa 15.0 glycerin .10.0 the etiology of this condition. It is true they alcohol...... water ...... aa 40.0 may aggravate pruritus ani but they do not play Sig. To be applied p.r.n. with tips of fingers or soft a role in its genesis. brush. 7. Grenz ray (low voltage x-radiation). The more intense our investigation of these 8. Anorectal surgery. causes, the better will be our results. A careful examination of the patient's skin the "cloverleaf" and "ball" procedures are no surface to rule out the presence of other areas of guarantee of cure and the embarrassment of skin disease might assist in diagnosing the cause recurrence following surgery should limit its use. of pruritus ani. Rule out the presence of an in- SUMMARY creased non-protein nitrogen, sugar, or bilirubin in the blood by the necessary tests. In older I would like to stress that with ano-rectal com- persons if the pruritus ani persists the blood plaints the history and physical examination should be examined to avoid missing a blood should be complete. The sigmoidoscope is an dyscrasia. Skin scrapings may be examined for easy instrument to master and I advocate its mycotic infection and the cellophane swab tech- more general use following digital examination nique used to diagnose pinworm infestation. and anoscopy. Haemorrhoids, fissure, fistula-in- If a specific entity is not found, we must re- ano, abscess and pruritus ani have been dis- member that other diseases may be adequately cussed, with the management in each case. controlled even though the etiology is unknown. RESUME Antihistamines may be employed q.i.d. and Tout symptome se rapportant la rnegion ano-rectale chloral hydrate at bedtime. Shake lotions con- doit etre le sujet d'une anamnese minutieuse et d'un examen physique complet, comprenant le toucher rectal taining methol, phenol, zinc oxide, talc, glycerin, et la sigmoidoscopie. S'il est necessaire, on peut proce'- water and alcohol give relief as do sitz baths der ensuite au lavement baryte, 'a la recherche des parasites et du sang dans les selles et meme 'a la biopsie. containing silver nitrate at proper dilution. The Les hemorrhoides s'accompagnent souvent de phlebite use of ointments is discouraged because the comme le demontre la presence de cellules inflam- matoires dans les coupes anatomo-pathologiques. Elles petrolatum base raises the local temperature, peuvent devenir tres douloureuses s'il y a prolapse et thereby aggravating the condition. This situa- etranglement par le sphincter. L'hemorrhoidectomie est le seul traitement valable, l'injection de substances tion is also brought about by tight clothing. sclerosantes ne pouvant aider que les cas benins. Une Bowel hygiene should be stressed to these des lesions anales les plus douloureuses est sans doute la fissure. L'exerese chirurgicale est encore la meilleure people, and cotton or Kleenex substituted for mesure a employer, si on desire eviter les tissus toilet tissue. The use of "Tucks" following cicatriciels fibreux resultant de la thermocauterisation. L'incision et le drainage d'un abces ano-rectal peuvent evacuation is beneficial. X-ray treatment with etre suivis quelques jours ou quelques semaines plus tard filtered radiation should be discouraged because d'une fistulectomie, puisque invariablement fistule il y aura. Cependant, s'il est possible de determiner de quelle of the potential overdosage with resulting crypte l'abcees a pris son origine, les deux operations avascularity. scarring and ulcer formation due peuvent se faire dans la meme intervention. Si le drain- age est complet, il n'y a pas de risque de septicemie. to excessive depth dosage. Apart from this, it is Les antibiotiques dans ce cas ne peuvent remplacer la difficult to protect the sex organs adequately. chirurgie. Le prurit anal est d'etiologie inconnue. I1 semble ac- The Grenz ray on the other hand is a super- compagner l'obesite', la grossesse ou la vieillesse. On ficial ray, and good results may be obtained with doit s'assurer qu'il n'existe pas de seborrhee, dermatite, psoriasis ou allergie par contact. Les oxyures sont souvent no local damage. en cause chez les enfants. On doit aussi examiner les The surgical approach should be used only formules sanguines et determiner l'azotemie, la glycemie et le taux de bilirubine. L'auteur enumere quelques in the most resistant cases. Operations such as traitements symptomatiques. M.R.D.