Anorectal Disease

Natalie Vellutini

Background

  • Benign Anorectal Disease: Structural (anal fissure, hemorrhoids, diverticula, rectocele, rectal prolapse), Infectious/Inflammatory (anorectal abscess, fistulas, proctitis), functional (dysynergic defecation, fecal incontinence, proctalgia).
  • Malignant Anorectal Disease: SCC (most common), adenocarcinoma, melanoma, NET.

Presentation

  • Anal canal pain: anal fissure, thrombosed external hemorrhoids, perianal abscess, proctitis, cancer, proctalgia fugax.
  • Hematochezia: internal hemorrhoids, anal fissures, diverticula, proctitis, anal cancer.
  • Anorectal pruritis: most likely idiopathic; otherwise, hemorrhoids, inflammatory skin disorders (dermatitis, hidradenitis suppurativa, psoriasis, IBD), infections (STIs, Candida, pinworm), SCC.
  • Localized skin changes of anus: anal fissure, perianal abscess, perianal fistula, perianal neoplasms, internal hemorrhoid prolapse, thrombosed external hemorrhoid.
  • Prolapsing tissue: internal hemorrhoids (radial folds), rectal prolapse (concentric circular folds), thrombosed external hemorrhoid, anal condyloma, malignancy.
    • Perianal drainage: infectious proctitis (STIs, IBD), hemorrhoids w/ mucous drainage, anal fistula/abscess, fecal incontinence, or other skin conditions (i.e. pilonidal cyst).
    • Constipation/Straining: pelvic floor dyssynergia, anal fissure, rectocele, IBD adhesions.

Evaluation

  • Thorough history (symptoms, bowel habits, OB/surgical hx, hx IBD) and DRE necessary for initial eval.
  • Consider anoscopy next if initial eval does not yield clear diagnosis. 
    • Any new rectal bleeding w/o recent colonoscopy → colonoscopy.
    • Defecation Disorders → anorectal manometry/balloon expulsion testing.
    • Occult perirectal abscesses, recurring perianal fistulas, Crohn’s → MRI Pelvis W & WO.

Management

  • Anal fissure: for acute anal fissure (<6 wk), treat w/ supportive measures (psyllium fiber, sitz bath) and treatment of constipation. If chronic, can use topical NTG, calcium channel blocker. Local botox injections vs. sphincterotomy last line. 
  • Internal hemorrhoids: Graded I → IV based on severity and degree of prolapse. 
    • Low grade (I or II): 
      • Conservative: fiber, adequate fluids, limiting toilet time +/- stool softeners. 
      • Rx: topical hydrocortisone (intermittent short-term use), vasoactive agents (Prep H, Nitro), phlebotonics, sitz baths.
      • Refer to GI clinic or colorectal surgery clinic if refractory to 6-8 weeks of medical treatment for consideration of rubber-band ligation vs. sclerotherapy.
    • High grade (III or IV): 
      • Recommend initial conservative measures (above).
      • Refer to colorectal surgery for excisional hemorrhoidectomy.
  • External hemorrhoids: 
    • Thrombosed external hemorrhoids: acute, painful, blue perianal mass. 
      • <72 hours- bedside incision and thrombectomy.
      • >72 hours- conservative management (see above), avoid operative intervention. 
      • If nonviable skin on exam- urgent surgical intervention.
  • Rectocele: Pelvic floor biofeedback therapy (VUMC Pelvic Floor Therapy Clinic) first line, then surgical intervention 
  • Rectal prolapse: Asymptomatic Grade 1-2 rectal prolapse does not require surgery, managed. conservatively/biofeedback therapy. Symptomatic Grade 3-4 requires surgical repair (indications include sensation of rectal prolapse and fecal incontinence and associated constipation). 
  • Perianal abscess/anal fistula: consult surgery for drainage or fistulotomy/seton placement; if related to Crohn’s, will also need medical management.
  • Defecatory Disorders: evaluate with ARM,BET; treat with pt. education/dietary modifications, pelvic floor biofeedback therapy, sphincterotomy, sacral nerve stimulation.
  • Proctalgia fugax: history of recurring episodes of rectal pain lasting > 20 minutes with tenderness to palpation of the levator ani muscles on exam and exclusion of other pathology (negative imaging/colonoscopy). Treat with pelvic floor biofeedback therapy + reassurance. For pain, topical nitroglycerin ointment (0.3%) and warm sitz baths. 
  • Anal cancer: Treatment based on tumor location/histology.
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