COVER ARTICLE

Common Anorectal Conditions: Part I. Symptoms and Complaints JOHN L. PFENNINGER, M.D., The National Procedures Institute, Midland, Michigan GEORGE G. ZAINEA, M.D., Midland, Michigan

Anorectal symptoms and complaints are common and may be caused by a wide spec- trum of conditions. Although most conditions are benign and may be successfully treated by primary care practitioners, a high index of suspicion for should be maintained, and all patients should be appropriately investigated. Inspec- tion, palpation and anoscopic examination using an Ive’s slotted anoscope provide adequate initial assessment. usually represents a self-perpetuating itch- scratch cycle and is uncommonly due to infection. The history, as well as the physical examination, can distinguish anal due to , fissure, abscess, cancer or proctalgia fugax. The most frequent causes of rectal bleeding are hemorrhoids, fis- sures and polyps. Diagnoses associated with difficulty in passing stool can range from to fecal incontinence. (Am Fam Physician 2001;63:2391-8.)

atients frequently consult an estimated 138,000 new cases of can- primary care physicians be- cer of the colon, or anus will be cause of concerns about or diagnosed; these cancers will cause the symptoms related to the death of more than 57,200 adults each anorectal area. Although year in the United States.1 In nonsmok- Pmany anorectal conditions are benign ers, colorectal cancer is the leading cause and easily treated, patients may delay of death from cancer. seeking medical advice because of Colorectal cancer may present as rectal embarrassment or fear of cancer. Thus, bleeding and coexist with a benign con- both malignant and nonmalignant con- dition such as hemorrhoids. Every pa- This is Part I of a two-part article ditions often present as advanced dis- tient with anorectal symptoms, espe- on common anorectal condi- ease, requiring more extensive treatment cially those with rectal bleeding, must tions. Part II, “Lesions,” will and causing greater patient distress than have an assessment that includes, at a appear in the next issue. if conditions had been adequately diag- minimum, digital rectal examination nosed and managed at an earlier stage. and visual inspection by anoscope. Conversely, both patients and physi- Increasing access to primary care physi- cians should be aware of the need for cians leads to earlier detection of colo- adequate assessment of all anorectal rectal cancer.2 symptoms because of the high incidence Current American Academy of Family of colorectal cancer. The average Ameri- Physicians (AAFP) and American Can- can is estimated to have a one in 18 life- cer Society (ACS) guidelines call for time risk of developing colorectal can- screening of all patients for colorectal cer.1 This risk is equal for men and cancer beginning at 50 years of age in the women and increases with age. In 2001, general population and 40 years of age in those with risk factors or a family history of the disease.3 Family physicians can A high index of suspicion for cancer should be maintained when play a major role in the prompt recogni- tion of cancer and appropriate manage- investigating all anorectal symptoms. ment of other anorectal conditions. All clinicians can and must perform a basic

JUNE 15, 2001 / VOLUME 63, NUMBER 12 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2391 15 cm of the (Figure 1).The The evaluation of all anorectal complaints should include valves of Houston are not true valves but are observation, palpation and anoscopic examination. prominent mucosal folds. The dentate or pectinate line divides the squamous epithe- lium from the mucosal or columnar epithe- lium. Four to eight anal glands drain into the examination to appropriately treat or refer crypts of Morgagni at the level of the dentate patients with anorectal complaints. After line. Most rectal abscesses and fistulae origi- proper evaluation, the majority of nonmalig- nate in these glands. The dentate line also nant anorectal conditions can be treated by delineates where sensory fibers end. Above the primary caregiver. (proximal to) the dentate line, the rectum is supplied by stretch nerve fibers but not pain Anal/Rectal Anatomy nerve fibers. This allows many surgical proce- The anus is the outlet to the gastrointesti- dures to be performed without anesthesia nal tract, and the rectum is the lower 10 to above the dentate line. Conversely, below the

Middle valve of Houston

Levator ani muscle . Superior valve of Houston

. .

. Inferior valve of Houston

Columns of Morgagni Dentate line . . . . Internal . . plexus . . Internal sphincter

Anal gland . External . hemorrhoid plexus

Anal crypts (of Morgagni) External sphincter ILLUSTRATION BY MYRIAM KIRKMAN-OH FIGURE 1. Rectal anatomy.

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Pruritus ani is more likely to represent a chronic itch/scratch cycle than infection.

all 360 degrees around the , and any palpable mass must be defined. Because of the redundant mucosa, small tumors may not be visualized even with the anoscope but can often be detected by palpation. The final step in the initial office examina- FIGURE 2. Ive’s slotted anoscope with intro- tion is usually anoscopy. Although many ducer. types of anoscope are available, the best visu- Used with permission from the National Procedures alization is provided by the Ive’s slotted Institute, Midland, Mich. All rights reserved, 2001. anoscope (Figure 2). A lubricant is applied to the entire unit, and it is inserted gently. The dentate line there is extreme sensitivity, and introducer is removed and one quarter of the the perianal area is one of the more sensitive mucosa is visualized as the anoscope is slowly areas of the body. The evacuation of bowel removed. The instrument is then rotated 90 contents depends on action by the muscles of degrees and reinserted. This is done four both the involuntary internal sphincter and times to visualize the entire circumference of the voluntary external sphincter. the anal canal. The currently available plastic anoscopes are smaller and do not provide the Anorectal Examination view of the larger Ive’s scope. Although prepa- Anorectal assessment consists of inspec- ration with an is not usually necessary tion, palpation and anoscopic examination. before anoscopy, it can improve visualization The patient can be positioned in the left lat- and may be aesthetically more acceptable to eral decubitus position for this examination the examiner and to the patient. and for almost all anorectal procedures. This Further examination using flexible sigmoi- position is much more comfortable for the doscopy and/or colonoscopy may be indicated patient than the traditional head-down “jack- in individual patients. Even if endoscopic knife” position, yet still allows adequate visu- examination includes retroflexion of the scope alization and access for the examiner. to inspect the anal canal, optimal visualization The glutei must be spread to provide ade- is obtained with the Ive’s slotted anoscope. quate visualization of the anus. If necessary, the patient can assist by raising the right Common Anorectal Symptoms gluteal area with the right hand to better PRURITUS ANI expose the perianal area. Inspection alone can Pruritus ani is an extremely common reveal fissures, fistulae, perianal dermatitis, symptom and is associated with a wide range masses, thrombosed hemorrhoids, condy- of mechanical, dermatologic, infectious, sys- loma and other growths. temic and other conditions (Table 1). Regard- Unless the patient is experiencing extreme less of the etiology, the itch/scratch cycle pain, a digital examination should always be becomes self-propagating and results in performed. In males, the prostate should be chronic pathologic changes that persist even palpated in addition to digital assessment of if the initiating factor is removed. the anal canal. The finger sweep must include When pruritus ani becomes chronic, the

JUNE 15, 2001 / VOLUME 63, NUMBER 12 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2393 The pattern of pain helps differentiate from hem- orrhoids and other conditions.

perianal area becomes lichenified and appears white with fine fissures (Figure 3). Although older texts emphasized parasitic infestation, this is a rare cause of pruritus ani except for pinworms (Enterobius vermicularis) in chil- dren. Many patients believe pruritus ani is FIGURE 3. Perianal dermatitis caused by caused by poor hygiene and are overzealous in chronic pruritus ani. their attempts to clean the perianal area. Used with permission from the National Procedures Excessive cleaning, and particularly the use of Institute, Midland, Mich. All rights reserved, 2001. brushes and caustic soaps, aggravates the sen- sitive tissues and exacerbates the condition. Successful treatment of pruritus ani Many patients have an underlying eczema- depends on recognizing the condition, ruling toid-type skin. The perianal area can be highly out other potential diagnoses, addressing pre- sensitive to perfumes, soaps, clothes, fabrics, cipitating or exacerbating conditions and dietary intake and superficial trauma. relieving the itch/scratch cycle. Many patients

TABLE 1 Conditions Associated with Pruritus Ani

Systemic illness Mechanical factors (continued) Dermatologic factors (continued) Diabetes mellitus Atopic dermatitis Hyperbilirubinemia Tight-fitting clothes Lichen planus Leukemia Allergy to dyes in toilet paper Lichen sclerosis Aplastic anemia Intolerance to fabric softener Contact dermatitis Thyroid disease Skin sensitivity from foods Infections Mechanical factors Tomatoes Erythrasma (Corynebacterium) Chronic Caffeinated beverages Intertrigo (Candida) Chronic constipation Beer Herpes simplex virus Anal incontinence Citrus products Human papillomavirus Soaps, deodorants, perfumes Milk products Pinworms (Enterobius) Over-vigorous cleansing Dermatologic conditions Scabies Hemorrhoids producing leakage Psoriasis Local bacterial abscess Prolapsed hemorrhoids Seborrheic dermatitis Gonorrhea Alcohol-based anal wipes Intertrigo Syphilis Neurodermatitis Medications Anal papilloma Bowen’s disease Colchicine Anal fissure Various squamous disorders

Adapted with permission from Zuber TJ. Diseases of the rectum and anus. In: Taylor RB, ed. Family medicine: principles and practice. 5th ed. New York: Springer-Verlag, 1998:792.

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The pattern of pain helps differentiate anal fissure from hemorrhoids and other conditions.

then either abate until the next bowel move- ment or continue, usually to a lesser degree. The pain of anal fissure is frequently accompa- nied by bright red rectal bleeding and often begins after a hard, forced bowel movement. The acute onset of pain with a palpable FIGURE 4. External hemorrhoid after seven mass is almost always due to a thrombosed days of thrombosis. external hemorrhoid (Figure 4). This intense Used with permission from the National Procedures pain typically lasts 48 to 72 hours and then Institute, Midland, Mich. All rights reserved, 2001. subsides spontaneously but may take several days to abate. Internal hemorrhoids, because scratch excessively during sleep and are they start above the dentate line, are not unaware of their actions. An antihistamine painful even if prolapsed or thrombosed. such as hydroxyzine hydrochloride (Atarax) Similarly, rectal cancer seldom causes pain taken before bedtime is often quite helpful unless it is extremely advanced because of the because it provides both antipruritic and innervation of the rectal area. Anal cancers sedative effects. Topical corticosteroids are more commonly cause pain after invasion of usually necessary to control pruritus ani but the sphincter muscle. Anorectal pain that must be limited to short-term use to avoid begins gradually and becomes excruciating thinning of the perianal tissues. This, in itself, over a few days may indicate infection. A can lead to more pruritus. Topical 5 percent localized area of tenderness could signal an xylocaine ointment (Lidocaine) can also abscess. Anal pain accompanied by fever and reduce the itching sensation and break the inability to pass urine signals perineal sepsis cycle. It should be noted that uncomplicated and is a medical emergency. hemorrhoids rarely cause pruritus ani. Only Proctalgia fugax is a unique anal pain. hemorrhoidal tags that are inflamed or asso- Patients with proctalgia fugax experience severe ciated with poor hygiene may produce pruri- episodes of spasm-like pain that often occur at tus. Any pruritic lesion that persists after ade- night. Proctalgia fugax may only occur once a quate treatment should be biopsied. year or may be experienced in waves of three or four times per week. Each episode lasts only ANAL PAIN minutes, but the pain is excruciating and may A careful history focusing on the nature of be accompanied by sweating, pallor and tachy- the pain and its relationship to bowel move- cardia. Patients experience urgency to defecate, ments frequently provides the diagnosis of yet pass no stool. pain in the anorectal area. Aching after a bowel No specific etiology has been found, but movement can occur with internal hemor- proctalgia fugax may be associated with spastic rhoids. Pain during bowel movements that is contractions of the rectum or the muscular described as “being cut with sharp glass” usu- pelvic floor in . Other ally indicates a fissure. This pain is most unproven associations are food allergies, espe- intense during the bowel movement and usu- cially to artificial sweeteners or caffeine. Reas- ally persists for an hour or so afterward. It may surance that the condition is benign may be

JUNE 15, 2001 / VOLUME 63, NUMBER 12 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2395 The most common causes of rectal bleeding in patients who TABLE 2 visit primary care physicians are hemorrhoids, fissures and Causes of Bright Red Rectal Bleeding and Occult Blood in the Stool polyps.

Bright red rectal bleeding Occult blood Hemorrhoids helpful, but little can be done to treat proctal- Diverticula Gastric ulcer gia fugax. Medications are not helpful since the Regional Gastric carcinoma episode is likely to be over before the drugs Ulcerative become active. Sitting in a tub of hot water or, Infectious colitis Arteriovenous (entero-hemorrhagic) malformation alternatively, applying ice may provide symp- Carcinoma Esophageal tumor tomatic relief. A low dose of (Val- Polyps ium) at bedtime may be beneficial in cases of Arteriovenous malformation Hiatal frequent and disabling proctalgia fugax. Intussusception Duodenal ulcer Fistula ‘LUMP’/PALPABLE MASS Fissure Polyps When a palpable mass is discovered in the Chronic solitary ulcer Carcinoma anal area, the patient may be concerned about Diverticula cancer or assume the mass is a hemorrhoid. Anal or perineal “lumps” may be due to a wide range of conditions including condy- loma, molluscum contagiosum, hemorrhoids RECTAL BLEEDING (thrombosed, tags or prolapsed), polyps, sen- Many conditions can cause rectal bleeding tinel tags related to fissure, or cancer. Full (Table 2), but all cases of rectal bleeding must assessment, including a detailed history, be evaluated and the cause identified. Even the inspection, palpation, anoscopy and, in some occasional finding of blood on toilet paper cases, biopsy, sigmoidoscopy or colonoscopy, after a bowel movement (“wipe hema- is needed to define the exact nature of these tochezia”) must be taken seriously.4 Signifi- lesions. Rectal masses will be further dis- cant pathologic conditions such as cancers cussed in part II of this article. and polyps can bleed intermittently. A study of patients presenting to family physicians5 found the most common causes of rectal The Authors bleeding to be hemorrhoids, fissures and polyps (Table 3). The authors of that study JOHN L. PFENNINGER, M.D., is medical director of the National Procedures Institute in Midland, Mich., clinical professor of family medicine at Michigan State University Col- concluded that if one of these common con- lege of Human Medicine in East Lansing and medical director of the Medical Proce- ditions were identified as the probable site and dures Centers, P.C., also in Midland. In addition, he is the editor of Procedures for Pri- cause of bleeding, colonoscopy and other mary Care Physicians. Dr. Pfenninger graduated from the University of Michigan Medical School, Ann Arbor, and completed residency training in family practice at the investigations were not usually necessary. University of Utah, Salt Lake City. He is board-certified in family practice. Indications for further investigation include GEORGE G. ZAINEA, M.D., practices colon and rectal surgery in a multispecialty sur- older age, significant family history of bowel gical group, MidMichigan General and Vascular Surgery, P.C., which is affiliated with disease or cancer, and nonresolution of the MidMichigan Medical Center in Midland, Mich. He completed medical training in gen- bleeding after treatment of the condition that eral surgery at McAuley Health Center in Ann Arbor. Following a residency, he was granted a fellowship in colon and rectal surgery at the Henry Ford Hospital in Detroit. is presumed to be the source of bleeding. Total colon examination is mandated if rectal Please address correspondence to John L. Pfenninger, M.D., National Procedures Insti- tute, 4909 Hedgewood Dr., Midland, MI 48640 (e-mail: [email protected]). bleeding is accompanied by systemic symp- Reprints are not available from the authors. toms, if there is a clinical suspicion of proxi-

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mal disease and when the cause of rectal predispose to this problem, and it is a com- bleeding cannot be readily established. mon complication of anorectal procedures as a result of reflex spasm of the anal sphincter. DIFFICULTY PASSING STOOL The patient may present with acute abdomi- The term constipation can have a variety of nal pain or chronic large-. meanings. Patients may use the term to indi- Rectal examination reveals hard, bulky stool. cate the lack of an urge to defecate, a Medical therapy is usually attempted first in decreased frequency of bowel movements, an otherwise ambulatory patient. Careful difficulty in passing hard scybalous stools, the administration of one or two (Fleet) sensation of incomplete evacuation or pro- into the bolus to soften and hydrate the stool longed straining at toilet. In general, consti- should be followed one hour afterward by the pation is regarded as fewer than three bowel administration of a mineral oil enema to assist movements per week in a person consuming in passage of the softened stool. at least 19 g of fiber daily. This condition can Manual disimpaction is required in most be due to diet, medications, functional distur- patients. This may require a circumanal block bances, endocrine and metabolic disorders, of the anal musculature with local anesthetic. collagen , central or periph- A four-quadrant field block allows for com- eral neuromuscular disorders or colonic iner- plete muscle relaxation and a painless disim- tia. It is imperative that the clinician rule out paction. After disimpaction, a bowel program obstructing lesions or painful anal lesions.6 that includes the use of a laxative, stool soften- ers and/or enemas should be initiated to pre- vent recurrence. If impaction recurs, it is Fecal impaction can present with either important to rule out an anatomic cause of constipation or fecal incontinence (“over- obstruction such as an anal or rectal stricture flow”). It is common in bedridden or nursing or tumor. home patients or after a cerebral vascular acci- dent and is the most common gastrointestinal FECAL INCONTINENCE disorder occurring in patients with a spinal Fecal incontinence is the inadvertent pas- cord injury. Medications such as narcotics sage of flatus, liquid or solid stool. Normal continence depends on many interrelated fac- tors, including stool volume and consistency, colonic function, rectal compliance, rectal TABLE 3 sensation and sphincter function. Patients Causes of Gastrointestinal Bleeding may be partially or completely incontinent. It in Adults* is important to rule out fecal impaction with overflow before seeking a pathophysiologic Hemorrhoids Colorectal cancer cause for uncontrolled passage of liquid stool. Fissures Ulcerative Patients at risk for fecal incontinence include Polyps Gastritis Diverticula disease the elderly, mentally ill and parous women, Peptic ulcer Systemic disease particularly those with a history of sphincter damage during delivery. *—Listed in order of frequency. Fecal incontinence with significant decrease Information from Trilling JS, Robbins A, Meltzer D, in sphincter tone can be caused by any prior Steinhardt S. Hemorrhoids: associated pathologic anorectal operative procedure or birthing conditions in a family practice population. J Am injury. Obstetric injury can include direct Board Fam Pract 1991;4:389-94. sphincter disruption (usually anterior) or injury to the pudendal nerves. Not uncom-

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monly, these may occur simultaneously. Neu- to neuropathy is treated with bulking and ropathy, particularly that associated with dia- antimotility agents. Pelvic floor strengthening betes mellitus, can result in fecal incontinence. with biofeedback is also a useful modality. Other causes include rectal prolapse, diarrheal states, radiation injury to the rectum and The authors thank Pat Wolfgram, medical librarian overflow fecal incontinence secondary to at the MidMichigan Medical Center, for research assistance, and Kay Pfenninger and Diane Bair for impaction. secretarial support. Digital examination of the patient with fecal incontinence includes palpation for muscle REFERENCES defects of the sphincter, assessment of resting 1. Greenlee RT, Hill-Harmon MB, Murray T, Thun M. and squeeze pressures of the sphincter, and Cancer statistics, 2001. CA Cancer J Clin 2001; testing of the sensory anocutaneous reflex. 51:15-36. 2. Roetzheim RG, Pal N, Gonzalez EC, Ferrante JM, Stroking the skin of the anal area, usually with Van Durme DJ, Ayanian JZ, et al. The effects of the end of a paper clip, should cause a contrac- physician supply on the early detection of colorec- tion (“wink”) of the anal musculature. In tal cancer. J Fam Pract 1999;48:850-8. 3. Smith RA, von Eschenback AC, Wender R, Levin B, selected cases, additional studies may include Byers T, Rothenberger D, et al. American Cancer anal manometry to objectively measure Society guidelines for the early detection of cancer: sphincter pressures, endo-anal ultrasonogra- update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J phy to morphologically visualize the sphincter Clin 2001;51:38-75. searching for discrete defects, and electro- 4. Helfand M, Marton KI, Zimmer-Gembeck MJ, Sox myelographic or pudendal nerve terminal HC. History of visible rectal bleeding in primary 7 care population. Initial assessment and 10-year fol- motor latencies to assess denervation injury. low-up. JAMA 1997;277:44-8. Fecal incontinence can seriously impair or 5. Trilling JS, Robbins A, Meltzer D, Steinbardt S. restrict normal activities and complicate the Hemorrhoids: associated pathologic conditions in a family practice population. J Am Board Fam Pract care of already frail patients. Treatment is gen- 1991;4:389-94. erally directed at the underlying cause and 6. Wexner SD, Dailey TH. The diagnosis and surgical minimizing symptoms. Discrete muscle in- treatment of chronic constipation. Contemp Surg 1988;32:59-64. juries are usually best treated by surgical 7. Blatchford GJ. The evaluation of incontinence. sphincter repair. Fecal incontinence secondary Semin Colon Rectal Surgery 1997;8:61-72.

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