Anorectal Disease

Ashley Cozart

Background

  • Benign and malignant causes share symptoms, often hemorrhoidal complaints.

Presentation

  • Perianal pain
    • Generalized: pruritis ani, less likely to be malignant
    • Localized: skin trauma, perianal abscess, perianal neoplasms, external hemorrhoids
  • Anal canal pain: anal fissure, anal cancer, anal ulceration (STIs), proctalgia fugax
  • Bleeding: anal fissures, internal hemorrhoids, anal cancer
  • Prolapsing tissue: prolapsing internal hemorrhoids, rectal prolapse
  • Pruritis: most likely idiopathic, inflammatory skin disorders (dermatitis, hidradenitis suppurativa, SCC), infections (STIs and Candida), systemic diseases (usually generalized; DM, cholestasis, thyrotoxicosis, HIV, etc.)
  • Perianal drainage: anal fistula, fecal incontinence, or other skin conditions (i.e. pilonidal cyst)

Evaluation

  • Visual inspection+ DRE + anoscopy/proctoscopy/colonoscopy
  • Anoscopy: eval of anal condylomata, neoplasms, internal hemorrhoids, anal fissures
  • Rigid proctoscopy: eval of rectal neoplasms, proctitis
  • Colonoscopy: eval of anal bleeding

Management

  • Internal hemorrhoids:
    • Low grade (I or II):
      • Dietary: water intake + fiber supplements +/- stool softeners
      • Lifestyle modifications: limiting seated and toilet time
      • Rx: topical anesthetics + steroids (intermittent short-term use), vasoactive agents (Prep H, Nitro), antispasmodic agents (ie. Nifedipine), sitz baths.
      • Refer to GI clinic or colorectal surgery clinic if refractory to 6-8 weeks of medical treatment
    • High grade (III or IV): refer to colorectal surgeon
    • If bleeding refractory to conservative management, refer for banding (colorectal surgery vs GI)
  • External hemorrhoids:
    • Thrombosed external hemorrhoids:
      • <72 hours- bedside incision and thrombectomy
      • >72 hours- operative intervention avoided since discomfort will likely improve.
      • If nonviable skin on exam- urgent surgical intervention
    • If not thrombosed, can treat like low grade internal hemorrhoids as stated above
    • If rectal bleeding associated with any type of hemorrhoid, refer for colonoscopy
  • Perianal abscess: consult surgery for urgent incision and drainage
  • Anal fistula: surgery
  • Anal fissure: treat w/ 1 mo of supportive measures (fiber, sitz bath, topical analgesic), topical vasodilator (nifedipine or nitroglycerin), and resolution of constipation. Surgery if refractory.
  • Anal cancer: treatment based on tumor location/histology
  • Rectal prolapse: Likely surgical repair (indications include sensation of rectal prolapse and fecal incontinence and associated constipation. Pelvic floor exercises (VUMC Pelvic Floor Therapy Clinic) if patients cannot undergo procedure.
  • Proctalgia fugax: reassurance for mild-intermittent, topical nitroglycerin if severefrequent
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