Our goals were to evaluate current diagnostic and therapeutic methods and establish guidelines for subspecialty referral. Medline was used to search for articles on each of these five topics, with an emphasis on recent literature (1990-98). The guidelines of the American College of Colon and Rectal Surgeons on hemorrhoids and fissures were reviewed [5,6].
1.3 Normal Anatomy of the Anorectal Area
figure shows the normal anorectal anatomy. Pain from a source above the dentate
line is visceral; from a source below the dentate line it is somatic. The anal
verge is the distal boundary of the anal canal, where the walls of the anus
normally come in contact .
2. Five Common Anorectal Problems
2.1.1 Hemorrhoids are dilated arteriovenous channels in the anal canal.
Internal hemorrhoids are located proximal to the anal verge, are covered by rectal mucosa and are supported by longitudinal muscles. They can be graded as 1st through 4th degree (Table 1).
External hemorrhoids are located distal to the anal verge, are covered by skin, and have no support by external muscles.
2.1.2 Internal hemorrhoids
In the anal canal, the three internal hemorrhoidal complexes are located in the right anterior, right posterior, and left lateral positions.
Hemorrhoids are thought to occur as a result of shearing forces during defecation which damage the supporting muscles and allow prolapse of hemorrhodial tissue.
The three major symptoms of hemorrhoids are bleeding, prolapse and pain. A feeling of incomplete evacuation of the stool is a less common symptom. A common classification of internal hemorrhoids and their treatment appears in (Table 1).
Bleeding is the most common symptom of internal hemorrhoids. It can be manifest by blood on the toilet paper when wiping after a bowel movement or blood on the outside of the stool. Occasionally, there will be blood spurting or dripping into the toilet bowl after defecation. The blood is usually bright red in color and bleeding is usually painless.
Another common symptom relates to protrusion of prolapsed hemorrhoids, since internal hemorrhoids can protrude after defecation. Although pain is uncommon, prolonged prolapse can cause an aching pain in the anal area.
2.4. Diagnosis of Internal Hemorrhoids (Table 1)
Since internal hemorrhoids are in the internal anal canal, they are not visible on external anal exam unless they are chronically prolapsed (grade IV) see (Table 1). Anoscopy or sigmoidoscopy detects hemorrhoids, but requires expertise for their recognition.
The "toilet test" is an
easy and effective way to detect internal hemorrhoids which prolapse. The rationale
is that straining is usually required for hemorrhoids to prolapse. Patients
are often reluctant to strain while being examined on a table. However, on a
toilet, patients can strain without embarrassment.
The method is as follows: have the patient strain while sitting on a toilet. After straining, have the patient lean forward, while you position a handheld mirror directed at the anus, with a flashlight directed at the mirror to better visualize the area
hemorrhoids which prolapse will be seen easily. If they bleed during this examination,
the test can be diagnostic of bleeding hemorrhoids.
2.5. Further Evaluation
Painless rectal bleeding requires evaluation and exclusion of other disorders before being assumed to be hemorrhoidal. In patients with rectal bleeding and hemorrhoids, additional pathology is found 30% of the time, (including colon cancer and colon polyps) . Age and other clinical criteria will determine the degree of evaluation needed. Patients with colon cancer should have a full colon evaluation to screen for colorectal cancer. In addition, patients older than 50 merit a full colon evaluation.
2.6.1. The first line therapy is to soften stools so they are easy to pass. Bulk laxatives, bran cereal or a higher fiber diet are the most effective ways to produce softer more bulky stool ("toothpaste consistency") which reduces straining during bowel movements. Fiber supplements have been shown to reduce bleeding from internal hemorrhoids in a controlled randomized trial . Stool softeners are often recommended but have no proven efficacy for hemorrhoidal symptoms. Increase in water consumption (6 glasses a day) and exercise are of no proven benefit but are not harmful. Topical products have no proven benefit.
2.6.2. Nonsurgical hemorrhoid ablation. If symptoms persist after first line therapy, hemorrhoid ablation can be considered. The goal of treatment is fibrosis of the submucosa with fixation of the anal epithelium to the underlying sphincter. The methods are all low risk office procedures but require special training. Specific therapies include: rubber band ligation, infrared, direct or bipolar coagulation, cryotherapy, injection sclerotherapy, and laser therapy.
126.96.36.199 Rubber band Ligation (RBL)
The major indications for this procedure are hemorrhoidal bleeding and symptomatic second or third degree hemorrhoids.
Through an anoscope, internal hemorrhoids are visualized, and a rubber band is placed on the mucosa overlying the hemorrhoid (above the dentate line)
Subsequently, the tissue
sloughs leaving an ulcer at the site. Fibrosis results in fixation of the mucosa
and submucosa. Often two to three sessions are required to complete treatment.
Mild post procedure pain is common, and usually relieved with warm sitz baths and analgesics.
Bleeding usually occurs at 7 to 10 days post procedure when the necrotic hemorrhoid sloughs. It is not usually significant.
Complications of the procedure are uncommon. They are pain, bleeding, and rarely perineal sepsis.
Infection- Perineal sepsis* This is uncommon but can be life threatening if not recognized and treated promptly. Early symptoms are fever, a marked increase in anal pain, and urinary retention.
* Urgent referral for surgery is indicated to prevent fatal infection and sepsis
Infrared coagulation (IRC), and direct current or bipolar coagulation devices are used to treat bleeding internal hemorrhoids. This causes local inflammation with scarring of mucosa and submucosa.
Local application using specific anal probes. The procedure requires training to develop expertise.
Direct current (DC) and bipolar (BP) current devices are equally effective in trials involving small numbers of patients [9,10]. Neither technique had major complications, but pain and ulcers can develop. In one study DC current took longer and was associated with more pain . Compared to rubber band ligation, coagulation is easier to perform, but efficacy and complications rates are similar.
Rapid freezing causes mucosal and submucosal fibrosis. Because it is cumbersome, and severe pain is frequent, this procedure has largely been abandoned.
188.8.131.52 Injection sclerotherapy (IS)
Needle injection of sclerosants (sodium tetradecyl sulfate or phenol) causes necrosis with painful ulceration. Bacteremia can occur as a complication. Published success rates are 60 - 80%.
184.108.40.206 Laser therapy
Laser therapy is effective, but requires expensive, laser equipment and shows no benefit over other techniques such as rubber band ligation.
Which procedure to choose?
Success rates from coagulation (bipolar or direct current) and rubber band ligation are excellent with similar efficacy and complication rates. Bipolar devices may be easier to use.
A meta analysis of nonsurgical techniques (RBL, IRC, and IS) for grade 1 and 2 internal hemorrhoids showed equal efficacy of RBL and infrared coagulation (IRC), with less efficacy of injection sclerotherapy .
IRC requires more sessions than RBL, but RBL was associated with more post-procedure pain. These authors were concerned with the risk of cellulitus post RBL, and recommended IRC, because there are fewer complications. However, the American Society of Colorectal Surgeons (ASCRS) practice guidelines state that RBL is the treatment of choice for first and second degree hemorrhoids .
In conclusion, RBL and IRC are equally effective, but decision making should consider risks, local expertise, cost and convenience. Injection sclerotherapy is less effective .
2.6.3. Surgical Hemorrhoid Ablation
Hemorrhoidectomy is reserved for some third degree hemorrhoids and for fourth degree hemorrhoids. A meta analysis showed RBL and surgical hemorrhoidectomy to be equally effective for treatment of third degree hemorrhoid . The authors recommend RBL as the first choice, as it has fewer complications. The surgical approach can be reserved for treatment failures.
The ASCRS guidelines recommend hemorrhoidectomy for: 1. Failure of conservative therapy (grade 3 hemorrhoids); 2. Severe symptoms and signs due to hemorrhoidal disease (grade 4 hemorrhoids)
2.7. Routine Evaluation Prior to Referral
Anorectal exam including external exam, digital rectal exam, and anoscopy.
2.8. Patients for Referral The following are indications for referral:
2.8.1 Referral to gastroenterologist
When sigmoidoscopy is indicated by age or concurrent factors, referral to a gastroenterologist or a specialist with expertise in the procedure and interpretation of its results is indicated. When the diagnosis is uncertain, it may be best to refer for full colon evaluation by colonoscopy. An alternative full colon evaluation can be performed by flexible sigmoidoscopy and barium enema, but this combination of procedures will be less sensitive than colonoscopy.
In patients over age 50, a full colon evaluation is indicated. When concomitant symptoms are present, such as diarrhea, constipation or a change in bowel habits, a full colon evaluation is indicated.
When an abnormality is detected on barium enema, such as mass, polyp, colitis or stricture, colonoscopy is indicated for further evaluation.
When an abnormality is detected on flexible sigmoidoscopy, (i.e. mass, polyp, colitis) colonoscopy may be indicated for further evaluation.
2.8.2 Referral to colorectal surgeon
When hemorrhoidal symptoms are unresponsive to medical therapy, surgical referral is appropriate.
When colorectal cancer has been detected on sigmoidoscopy or barium enema, surgical referral is indicated.
3. External Hemorrhoids
External hemorrhoids are dilated submucosal arteriovenous channels distal to the dentate line. These are venules of the inferior hemorrhoidal plexus.
When supporting tissues in the anal canal weaken, usually as a result of straining at defecation, venules become dilated. An intravascular clot in the venule results in a thrombosed external hemorrhoid. Constipation or diarrhea can aggravate these symptoms.
Thrombosis of an external hemorrhodial vein causes acute perianal pain with a palpable tender, bluish lump at the anus.
Other symptoms can include
itching, a burning sensation, and swelling.
External anal examination diagnoses external hemorrhoids. The presence of a palpable tender bluish lump is diagnostic of a thrombosed external hemorrhoid
Digital rectal exam should
be deferred since it will usually be too painful for the patient and adds nothing
to the diagonosis.
An external hemorrhoidal tag is fibrotic tissue adjacent to the anus, usually at the site of a prior thrombosed external hemorrhoid
They are of no significance,
although they can become secondarily inflamed.
If the patient presents within 24 - 48 hours of thrombosis, excision of the thrombus can give immediate relief of pain. The hemorrhoid is incised after infiltration of local anesthesia, and left open to heal. Sitz baths for 15 - 20 minutes are recommended twice daily for 7 - 10 days.
If evaluated 48 hours or more after thrombosis, treatment with Sitz baths twice daily for 7 - 10 days is recommended. Topical preparations may soothe the pain, but have no proven efficacy in accelerating healing.
Nitroglycerin ointment shows promise in patients with acute hemorrhoidal thrombosis .
Normally, nitric oxide (NO) release results in internal anal sphincter (IAS) relaxation.
Exogenous nitroglycerin releases nitric oxide which relaxes the IAS.
Preliminary studies in acute hemorrhoidal thrombosis show dramatic pain relief within minutes,lasting 4 - 6 hours but a randomized controlled trial has not been done. The treatment is low risk and inexpensive and may be an alternate to incision of the hemorrhoid.
Initial diagnosis: External anal exam is diagnostic.
4. Anal Fissure
An anal fissure is a superficial linear tear in the squamous lining of the distal anal canal between the anal verge and the dentate line. It is usually in the vertical axis of the anus. Fissures are most common in the posterior midline (90%). Those in the anterior midline more commonly occur in women. Acute fissures are more common in young people but can occur at any age. Initially a fissure is superficial. Chronic fissures may become deep and may even expose the circular muscle fibers of the internal anal sphincter. The edges of a fissure may become indurated, and spasm of the sphincter is common.
Secondary changes include
sentinal tags (or piles) (This
can also be seen with a fistula) and hypertrophied anal papillae.
4.2. Classification: A fissure can be classified as primary or secondary
4.2.1 Primary fissures usually occur as a result of local trauma associated with defecation. Resultant high pressure of the internal anal sphincter causes ischemia which may lead to persistence of fissuring. They are usually in the midline (posterior 90%, anterior 10%). Fissures can also result from diarrhea due to inflammatory bowel disease, postoperatively or after local anal procedures.
4.2.2 Secondary fissures are due to a variety of conditions. These include Crohn's disease or ulcerative colitis, prior anal surgery, and AIDS. Infections such as syphilis, tuberculosis, chlamydia, gonorrhea and herpes simplex virus, and anal cancer can present with an anal fissure.
Secondary fissures are usually lateral or anterior, and are less likely to be in the posterior midline. They can be multiple and always require further evaluation.
Sharp anal pain with and after defecation, lasting from several minutes to hours is the most common symptom. There may be small amounts of bright red blood, or an anal discharge. Pruritus and swelling are less frequent symptoms.
External anal examination is the key in diagnosis. An exam is performed as follows: spread the buttocks apart with gentle traction. A fissure or crack is usually seen in the anal canal
. Palpate with a Q-tip
to reproduce the pain. A fissure can be seen as a painful depression at the
anal margin, usually midline. Pain may prevent a full examination or may require
examination under anesthesia. If not visible, palpate gently after applying
a topical anesthetic ointment such as lidocaine jelly. The sphincter may be
spastic. Anoscopy to exclude other pathology may need to wait until the fissure
has healed. An acute fissure usually heals within 6 weeks. If it lasts longer,
it becomes a chronic fissure.
Unlike an acute fissure, a chronic fissure is usually associated with an edematous skin tag (sentinel pile) located distal to the fissure, and/or an enlarged anal papillae proximal to the fissure
Chronic fissures are often
deep and involve the internal sphincter.
Therapy of fissures is directed at breaking the cycle of hard stools, pain and reflex spasm of the sphincter. Healing of acute fissures occurs with 2 - 4 weeks of treatment, but the recurrence rate is 25% .
Treatment of fissures should include softening the stools (bulk laxative, high fiber diet). Warm Sitz baths for 15 -20 minutes three times a day decrease the internal anal sphincter pressure and relieve pain. The follwing therapies are of no proven benefit in accelerating healing: topical ointments (may soothe pain), suppositories, and injection of anesthetics. Long term topical steroid containing creams or ointments (> 2-3 weeks) should be avoided. There are several new approaches which aim to reduce internal sphincter pressure and thus decrease pain. These include nitroglycerin cream and botulinum toxin .
4.2.3 Nitroglycerin ointment
Applied before and after bowel movements may alleviate pain.
The mechanism of action is that nitroglycerine releases nitric oxide, a vasoactive mediator which relaxes the internal anal sphincter. Preliminary studies in anal fissure patients show dramatic pain relief within minutes, lasting 4 - 6 hours [13,14,15,23]. However, randomized controlled trials are needed to confirm this finding. Headaches are a frequent side effect but usually do not limit therapy. The nitroglycerin ointment used for heart disease is 2%, and while widely available, should be mixed with a neutral ointment in a 1 to 5 ratio before application.
4.2.4. Botulinum toxin injection
Botulinim toxin is the neurotoxic product of Clostridium botulinum. It causes inhibition of acetylcholine release with resultant reversible paralysis of the internal anal sphincter . Paresis lasts for weeks, allowing fissures to heal. However, therapy is expensive and invasive. Side effects include transient incontinence and perianal thrombosis. There are only a small number of studies; more experience is needed. However, it may be an alternative to surgery.
Contraindications to these therapeutic approaches are complicated anal fissures, large sentinal piles, scarring, fistula, and abscess.
For chronic fissures there are three options for therapy: surgery, direct coagulation probe and botulinum toxin injection. The surgical approach is sphincterotomy. Direct coagulation probe has been shown to be effective in a small open trial but it is expensive . It is a possible alternative to surgery. Botulinum toxin injection has been evaluated in a small number of studies. A recent publication comparing botulinum toxin and topical nitroglycerin ointment for chronic anal fissures showed both treatments to be an effective alternative to surgery. Botulinum toxin was more effective than nitroglycerin ointment. 
Indications for referral
A chronic or refractory fissure or a complicated fissure with scarring, incontinence, fistula or abscess should cause referral to a colorectal surgeon or general surgeon. Patients with complicated fissures associated with scarring, incontinence, fistula or abscess should also be referred to a surgeon.
Secondary fissures may need further evaluation to diagnose and manage underlying disease, thus referral to gastroenterologist or colorectal surgeon may be indicated.
Evaluation prior to referral
Anoscopy and digital rectal examination should be performed. Therapeutic trials of fiber supplements, nitroglycerin ointment or cream, and Sitz baths for 2 weeks may also be advisable.
5. Perirectal Abscess
Perirectal abscesses are usually acute though chronic abscesses can occur. Abscesses are usually due to obstruction of the anal glands at the dentate line which leads to infection and abscess formation. Less common causes are anal fissures, trauma, or Crohn's disease. The infection can travel superiorly, inferiorly or circumferentially around the anus.
The four most common sites for abscesses are:
Perianal 40 - 50
Ischiorectal 20 - 30
Intersphincteric 20 - 25
Supralevator 5 - 7
5.2. The most common symptoms of a perirectal abscess are swelling of the buttocks, pain which is usually continuous, profound, and increases with bowel movements.
With an abscess close to the surface (e.g. perianal or ischiorectal), there may be erythema and swelling over the buttock. Some abscesses are less obvious on exam and may require rectal exam to detect tenderness, fullness, and mass.
Differential diagnosis of abscess includes infection (cellulitis, tuberculosis, and LGV (lymphogranuloma venereum)) infection, as well as Crohn's disease, pilonidal disease, inflammatory skin disease (e.g. hidradenitis suppurativa), anal cancer, and trauma.
Immediate drainage is indicated, with a radially oriented incision. Healing within 2 weeks is typical though fistula may result in 50% of cases
The role of
antibiotics is unclear. They are indicated for: systemic infection, diabetic
patients, immunosuppressed patients, and patients with prosthetic heart valves.
5.5. Indication for referral
Anal fistula, chronic abscess and pelvic sepsis are indications for referral. Ischiorectal or supralevator abscesses should be further evaluated. Intractible symptoms such as drainage and recurrent abscess are also indications for referral.
Referral: A general or colorectal surgeon will perform an exam under anesthesia and consider possible fistulotomy.
5.6. Evaluation prior to referral:
Digital rectal exam and Anoscopy should be performed.
6. Pruritus Ani
6.1 Definition. Pruritus ani is the insidious onset of perianal itching, burning or discomfort. Symptoms often cause scratching, which results in friability and tender blistered skin. It is more common in men than women, and is idiopathic in 50 - 90% of cases.
6.2 Contributing factors include the following:
a) Hygiene: Local warmth and moisture cause epidermal cells to swell. Scratching removes dead cells but also damages skin and promotes pruritus. Friction and overcleaning can aggravate pruritus. Anal seepage/incontinence can contribute to damage as well.
b) Diet - Possible associations include caffeine containing drinks, highly spiced foods, coffee, chocolate, citrus fruits, and tomatoes.
c) Local or systemic diseases which can contribute to pruritus ani are prolapsing hemorrhoids, skin tags, fistula, fissures, lax sphincter (incontinence), diarrhea, diabetes mellitus, sexually transmitted diseases, vaginal or rectal discharge, and anal cancer.
d) Psychogenic factors such as obsessive compulsive disorder can cause pruritus ani.
e) Finally, radiation therapy and many skin diseases (allergic dermatitis from medications, contact dermatitis, pin worms, warts, scabies, eczema, lichen planus, lichen sclerosus, psoriasis, fungal infection (usually Candida), seborrhea, Paget's disease, and Bowen's disease) can all cause pruritus .
6.3. Diagnosis - Physical exam in early stages shows only erythema.
In the later stages, chronic changes include raw, oozing areas of skin and lichenification of skin.
Further evaluation is indicated to exclude secondary causes or associated conditions. If age > 50, do flexible sigmoidoscopy or colonoscopy to exclude anorectal or colon cancer.
Therapy - none of proven efficacy
Diet modification can be tried to remove specific foods listed above.
Local therapy should be recommended to keep the area clean and dry by putting cotton balls (not synthetic fiber balls) in the gluteal folds. Avoiding soap is very helpful and important. Topical cornstarch or powder can be helpful. Topical lotions are probably of no benefit and may aggravate or cause contact dermatitis [19,20].
Indications for referral:
Referral to dermatologist if skin disease suspected.
Referral to gastroenterologist for anorectal manometry if sphincter dysfunction or incontinence is present.
Evaluation prior to referral:
Counselling regarding hygiene and diet see above.
7. Anal Warts
Anal warts are caused by human papilloma virus (HPV) infection. HPV is the most common sexually transmitted disease, and its incidence is increasing. There are over 70 different types of these small non-enveloped viruses; 34 are known to affect the anogenital area.
HPV types 6 and 11 are "low risk" types associated with benign genital warts. HPV types 16 and 18 are "high risk" types associated with genital intraepithelial neoplasia and squamous cell cancer of the anus or cervix. Mixed infections are common, and typing of HPV has no role in clinical management.
External anal warts are visible and may cause: itching, bleeding, pain and a mass effect
warts are often asymptomatic but may cause anal discharge or bleeding
Physical exam is essential for diagnosis. On external perianal exam, the lesions are pink-white, verrucous, or "cauliflower-like" in appearance.
Anoscopy is essential to diagnose internal warts. Internal warts have the same appearance as external warts. They are usually at or just proximal to the dentate line.
7.4. Differential diagnosis includes condyloma lata (syphilis), keratoses, nevi, bowenoid papulosis (carcinoma in situ) and Buschke-Lowenstein tumor.
7.5. Treatment Despite therapy recurrence is frequent (50% after 1 year) after all types of therapy because HPV persists in surrounding skin and in deep lesions. The following therapeutic modalities can be used:
7.5.1. Topical therapy This is most effective for small external lesions and can include podophyllin . Repeat applications are needed. This is contraindicated in pregnancy. It is not for internal anal use because it can not be applied effectively.
Five percent 5-fluorouracil cream is available but not FDA approved for this indication. Because there is 6% systemic absorption it may be useful to prevent recurrence in immunocompromised individuals in whom recurrences are even more frequent. It is contraindicated in women of childbearing age .
Topical acids (e.g. trichloroacetic, bichloroacetic) can used in anal canal. They will result in necrosis and sloughing of the condyloma.
7.5.2. Cryotherapy This can be used for internal and external lesions.
7.5.3. Intralesional or Systemic Interferon Interferons (naturally produced proteins with antiviral, antitumor and immunomodulatory action), have been useful in selected patients. Their use is associated with frequent side effects and their overall efficacy and place in therapy are unknown.
7.5.4. Surgery can include fulguration or excision.
Cautery and laser have equal efficacy. However, laser is more expensive.
7.5.5. When to refer
Symptomatic, and refractory to topical therapy
Internal anal lesions
To rule out anal cancer
Large external collections