Anal & Rectal Pain It’s not just Hemorrhoids Greta Bernier, MD Colon & Rectal Surgeon Anal & Rectal Pain It’s not just Hemorrhoids No financial disclosures. I have hemorrhoids… …I can’t stand it anymore …They are getting worse …They hurt …I need surgery …My doctor said I should see a specialist Tell me about it… …What is your pain like? …Where is it? …When does it happen? …Do you have bleeding? …Do you feel external tissue? …Straining or difficulty with evacuation? So… is it a hemorrhoid? Mucosa Dentate Line Anoderm (Mucosa) Dentate Line (Anoderm) 1. External Thrombosed Hemorrhoids 1. External Thrombosed Hemorrhoids • Symptoms o Intense, acute onset, sharp pain, worsens in first ~48 h o Constant, unrelenting, difficulty sitting, pain with walking o New external swelling or mass o Possible bleeding, often with relief afterward •Exam o Blueberry, swollen, firm to rubbery, tender, ulcerated •Treatment o Sitz Baths, stool softeners, fiber supplement, pain medications o Clot evacuation –OR or clinic, within 72 hours 2. Fissure 2. Fissure • Symptoms •Razor blade, glass shard pain, bright red blood. • Occurs with BMs. •Pain may last few minutes or several hours. •Exam • Distal aspect of fissure noted with effacement of anal orifice •Very tender, difficulty with relaxation • Defer rectal exam • Typically anterior or posterior midline 2. Fissure •Treatment • Sitz Baths, stool softeners, fiber supplement •Avoid pain medications, concern for constipation • Topical Nifedipine, Diltiazem, Nitroglycerin +/‐ lidocaine • Surgical Management: Botox injection, sphincterotomy 3. Abscess & Fistula Dentate Line 3. Abscess & Fistula • Symptoms •Pain, swelling, cellulitis, fever • Difficulty with urination, rectal bleeding •Exam •Erythema, induration, cellulitis, fluctuance • Intersphincteric abscess: Inability to tolerate rectal exam without external skin findings •Treatment • Clinic or operative incision & drainage • Antibiotics •No packing, Sitz baths 3. Abscess & Fistula Dentate Line 4. Pelvic Floor Disorders / Dysfunction From the perspective of a colorectal surgeon… 4. Pelvic Floor Disorders / Dysfunction From the perspective of a colorectal surgeon… • Levator syndrome / spasm •Pain from spasm •Sharp to achy • Frequently after bowel movements •May worsen with laying supine •May last for hours • Proctalgia Fugax • Sudden rectal pain •Wakes from sleeping • Rectal spasm 4. Pelvic Floor Disorders / Dysfunction From the perspective of a colorectal surgeon… • Coccodynia • Tailbone pain • Worse with movement or manipulation •May worsen with bowel movements •1/3 of patients do not report preceding trauma •Outlet dysfunction constipation • Paradoxical puborectalis contraction • Pushing against a closed door • Incomplete evacuation • Pressure, aching 4. Pelvic Floor Disorders / Dysfunction From the perspective of a colorectal surgeon… • Levator syndrome / spasm • Proctalgia Fugax • Coccodynia •Outlet dysfunction constipation • Pudendal neuralgia •Rectocele, Prolapse 4. Pelvic Floor Dysfunction Levator Syndrome / Proctalgia Fugax / Outlet Dysfunction •Exam •No fissure or other anatomic abnormality on examination •Pain with palpation of puborectalis, lateral levators •Treatment • Bowel movement regulation: Fiber, water, dietary changes •Pelvic floor physical therapy with biofeedback • Medicated suppositories (i.e. diazepam, Flexeril) •Injection of anti‐inflammatory agent, local anesthetic, Botox (off label) 5. Sexually Transmitted Disease / Fungal Infection • Gonorrhea, Chlamydia, Herpes, syphilis, HPV, HIV… • Symptoms / Exam •Variable ‐ Pain, purulent drainage, bleeding, ulceration, warts •Treatment – dependent on pathogen Important to remember these in the differential diagnosis 6. Perianal skin irritation / maceration •Overly aggressive perianal hygiene •Chronic use of steroids, witch hazel or other topicals •Any of the prior diagnoses • Primary skin condition: psoriasis, warts 6. Perianal skin irritation / maceration •Exam: • Butterfly distribution • Papules •Rash • Flat or raised •Dry or wet •Treatment: •LESS IS MORE!!! • Stop topical medications • Barrier creams •Perianal hygiene Please don’t forget… Colorectal Cancer Anal Cancer Young Onset Colorectal Cancer • 11% of colon cancer diagnoses are patients <50 years old • 18% of rectal cancer diagnoses are patients <50 years old Young Onset Colorectal Cancer • 11% of colon cancer diagnoses are patients <50 years old • 18% of rectal cancer diagnoses are patients <50 years old International Agency for Research on Cancer – 2015 World Health Organization ‐Eating 50g of processed red meat per day increases risk of colorectal cancer by 18% ‐ Classified red meat as probable carcinogen ‐ Equivalent of 4 strips of bacon or 1 hot dog ‐ Increase lifetime risk from 5% to 6% in avgerage risk person Young Onset Colorectal Cancer • 11% of colon cancer diagnoses are patients <50 years old • 18% of rectal cancer diagnoses are patients <50 years old American Cancer Society –May 30, 2018 ‐Recommended colon cancer screening at age 45 ‐ “Simulation modeling of CRC incidence demonstrated favorable benefit‐to‐burden balance of screening at age 45” ‐ Current risk for CRC in those ages 45‐49 is nearly identical to the 50‐54 age group when age 50 was first recommended ‐ 51% increase in CRC in <50 age group since 1994 ‐ 2x risk if born in 1990 than those born in 1950 Young Onset Colorectal Cancer • 11% of colon cancer diagnoses are patients <50 years old • 18% of rectal cancer diagnoses are patients <50 years old When a patient isn’t improving or symptoms don’t add up… consider cancer Rectal exam or Refer Anal Cancer •Less common overall than colorectal cancer •1‐2% of all GI cancers • Incidence increasing •HPV associated • Bleeding, pain, swollen perianal tissue When a patient isn’t improving or symptoms don’t add up… consider cancer Rectal exam or Refer Anal & Rectal Pain 1. Thrombosed External Hemorrhoid 2. Anal Fissure 3. Anal Abscess and Fistula 4. Pelvic Floor Disorders: Levator Syndrome / Proctalgia Fugax / Coccygodynia / Pudendal Neuralgia 5. STDs / Fungal Infection 6. Perianal skin irritation / Skin Disorders 7. Malignancy Greta Bernier, MD [email protected] Thank you!.