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    Current Diagnosis

    • While most anorectal complaints are caused by a benign process, it is important to be mindful that the etiology can be a malignancy or other serious medical condition, such as anorectal Crohn’s disease.

    • A thorough, focused history is often the most helpful diagnostic tool for patients with anorectal complaints.

    • In patients where no etiology for bleeding is found or where there has been a change in bowel movements, a further diagnostic work- up should be performed.

    • Pain is the predominant symptom with anal fissure, thrombosed external hemorrhoids, and anorectal abscess but is not prominently featured with internal hemorrhoids.

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    Current Therapy

    • External thrombosed hemorrhoids are treated with evacuation in their early development (< 72 hours) but with expectant, supportive management only in their subacute phase.

    • Most internal hemorrhoids can be treated with outpatient treatments, including measures to normalize bowel movements and hemorrhoidal banding or injection therapy.

    • Anal fissures are treated conservatively with medical therapy but require operative therapy in a minority of cases.

    • Anal fistula repair techniques have variable success rates; it may require multiple procedures to treat anal fistula effectively.

    A number of conditions cause anorectal symptoms, but the majority of patients present with a complaint of “hemorrhoids.” Most anorectal conditions can be diagnosed with a focused history and physical examination. Treatment is aimed at the relief of symptoms, education of the patient, and prevention of further symptoms. Although most anorectal complaints are caused by a benign process, it is important for clinicians to be mindful that in some cases the etiology can be a malignancy or other serious medical conditions, such as anorectal Crohn’s disease.

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    A thorough, focused history is often the most helpful diagnostic tool for patients with anorectal complaints. Clinicians should inquire about pain, itching, discharge, extra tissue or a lump, and bleeding. It is particularly important to understand the patient’s bowel habits with respect to constipation or diarrhea as well as any change in defecatory habits. Other relevant history items include previous anorectal procedures and related medical conditions such as Crohn’s disease, malignancy, sexually transmitted diseases, or immunosuppression.

    Pain is an important symptom to elicit from patients. In most cases, pain is the predominant symptom with anal fissure, thrombosed external hemorrhoids, and anorectal abscess. Although discomfort from internal hemorrhoids can cause aching, soreness, or itching in the setting of tissue prolapse, internal hemorrhoid disease is most often painless. In contrast, external hemorrhoids that are acutely thrombosed cause pain that is acute in onset, severe, and constant.

    Fissure pain is often described as a tearing sensation or the feeling of “razor blades” during bowel movements that can continue for more than an hour following defecation. Patients with anal fissures might also express a fear of having bowel movements because of pain.

    Anorectal abscess is often associated with pain, and patients can also present with an acute lump and sometimes fever.

    Anal discharge and difficulty with anorectal hygiene are also common complaints. The discharge associated with prolapsing internal hemorrhoids might contain mucus or small amounts of stool. In contrast, an anorectal fistula or abscess can spontaneously drain with associated purulent and blood-tinged output.

    When a patient has bleeding, specific details to inquire about include color (bright red versus dark blood), amount, frequency, and length of time. When no etiology for bleeding is found, further screening should be performed. Patients who are younger than 50 years and who have no other risk factors should undergo flexible sigmoidoscopy. A colonoscopy should be done when patients are 50 years of age or older who have abdominal pain, anemia, change in bowel habits, a family history of polyps or colon cancer, or a personal history of polyps or colon cancer.

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    Although the prone jack-knife position allows the greatest exposure, the left lateral decubitus position with the knees up is preferred by patients and usually allows adequate exposure for the anorectal examination. It is critically important to have sufficient lighting with a self-lighted anoscope or a headlight as well as adequate instrumentation to perform the anoscopy. An adjunctive test that can also be helpful in patients where mucosal (hemorrhoidal) or full- thickness rectal prolapse is suspected is to have patients bear down on the commode and then to examine externally.

    The perianal skin is the skin immediately surrounding the anal verge (Figure 1). Perianal inspection includes careful examination of the surrounding skin for excoriation, an external draining orifice in the case of an anorectal fistula, lichenified skin with chronic irritation, other dermatitis, and the presence of perianal lesions. The anal verge is the entrance to the anal canal and is defined by the intersphincteric groove. There is frequently a clear demarcation between hair-bearing and non–hair-bearing skin in this location. Careful retraction of the buttocks can help to visualize an anal fissure located at the anal verge and extending into the anal canal.

    FIGURE 1    Anatomy of the anal canal.

    A digital rectal examination is helpful for assessing resting and squeeze anorectal tone, palpating the prostate in men, assessing for rectocele in women, detecting any palpable anorectal lesions, and evaluating for tenderness within the anal canal or at the level of the levator ani muscles at the anorectal ring. Anoscopy is used to visually examine the anal canal, which is between 4 and 5 cm in length starting at the anal verge and extending to the top of the anorectal ring (top of external sphincter and levator ani muscles). Within the anal canal is the dentate line, which acts as a landmark anatomically and is located approximately 2 cm from the anal verge. The dentate line represents the transition from squamous epithelial lining of the anus to the columnar epithelial lining of the rectum. Sensation above the dentate line is mediated by autonomic fibers and results in a relative lack of sensation in comparison to the highly sensitive, somatically innervated tissue below the dentate line. The dentate line is also the location of the crypt anal glands from which anorectal abscesses and fistulas originate.

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    Hemorrhoids are the anal vascular cushions that are present as normal structures in everyone. In the case of internal hemorrhoids, these cushions are arteriovenous channels that have overlying mucosa, submucosal smooth muscle, and supportive fibroelastic connective tissue. It is believed that internal hemorrhoids function by aiding with fine control of fecal continence of liquids and gases.

    Internal hemorrhoids enlarge and become symptomatic as fixation by submucosal smooth muscle and connective tissue becomes disrupted and loosens. This results in a sliding or prolapsing of the anal canal lining and further engorgement of the internal hemorrhoid tissues.

    Common exacerbating factors include constipation, diarrhea, aging, and increased abdominal pressure that can occur with chronic straining, pregnancy, heavy lifting, and decreased venous return.

    Internal hemorrhoids are typically staged on a scale from I to IV based upon the extent of prolapse (Table 1).

    Table 1

    Staging of Hemorrhoidal Disease

    Grade Description
    I Protrude only inside the lumen; seen only with the anoscope
    II Protrude during defecation; reduce spontaneously
    III Protrude during defecation; require manual reduction
    IV Permanently prolapsed and irreducible

    Internal hemorrhoids, when symptomatic, most commonly present with painless bright red bleeding or prolapsing tissue (Figure 2).

    Patients describe bleeding with or after bowel movements. Other symptoms include itching and leakage of mucus in the setting of tissue prolapse. Pain is rarely a prominent symptom except in the case of mixed hemorrhoid disease, when there is a thrombosed external component, or in the case of stage IV incarcerated hemorrhoids.

    FIGURE 2    Prolapsing (grade III) hemorrhoids, with a  prominent external component on the right and two sites of recent bleeding seen on the left.

    The central principles for conservative treatment of internal hemorrhoids and for long-term prevention of worsening symptoms are the normalization of bowel habits and avoidance of straining.

    Ideal bowel habits include having regular, soft, and formed stool resulting in minimal straining with elimination. An ideal diet should have high fiber content along with sufficient fluid intake. A total of at least 30 g of fiber per day is generally recommended. For the majority of patients, this is most easily achieved with the addition of a fiber supplement such as psyllium. Other medical treatment of hemorrhoids includes local anesthetic topical ointments, which relieve symptoms but do not improve the hemorrhoids, and steroid ointments, which symptomatically improve itching and irritation but also thin and atrophy the overlying tissue if used regularly.

    Internal hemorrhoids might benefit from further treatment in the setting of persistent prolapse or bleeding. Injection sclerotherapy works through shrinking and scarring the internal hemorrhoid by injecting a sclerosing agent (most commonly phenol in olive oil). Alternatively, infrared coagulation may be administered at the apex of the hemorrhoid. Both procedures have moderate effectiveness but are considered to be less effective than rubber-band ligation, which is widely used in the office setting, with good results.

    Rubber-band ligation requires the use of a rubber-band ligator (either suction type or ligator with clamp) and is performed by placing a rubber band around excess hemorrhoidal tissue at the apex of the hemorrhoid. Rubber-band ligation works by strangulating and cutting off blood flow to the hemorrhoid and by creating a scar that helps to fix tissue into place. The band must be placed well above the dentate line to prevent pain. Most patients experience a sensation of pressure with the procedure. Rarely, this procedure can cause significant pain, bleeding, or a vasovagal reaction. In general, only one or two band applications are performed in the same setting to prevent excessive pain or a vasovagal reaction.

    Surgical treatment for hemorrhoidal disease should be considered in patients with stage III or IV internal hemorrhoids. Surgery is also a consideration in cases where office procedures and conservative treatment have been ineffective or when internal hemorrhoids are circumferential. In the United States, most hemorrhoidectomies continue to be performed using a closed technique, where the hemorrhoid is excised and the defect sutured closed. More recently, stapled hemorrhoidectomy (sometimes called hemorrhoidopexy) has been introduced. The stapled technique appears to work best in cases where patients have more circumferential disease and is performed by excising the rectal mucosa and disrupting blood flow, thereby shrinking hemorrhoidal tissue and lifting the prolapsing tissue into the anal canal. Although stapled hemorrhoidectomy has been demonstrated to be effective and on average less painful, it does not address any external hemorrhoidal component, costs significantly more money, and has been associated with rare but severe complications, including pelvic sepsis.

    External hemorrhoids are generally painless, except in the case of thrombosis, and normally appear as more prominent external perianal tissue or painless skin tags. Thrombosed external hemorrhoids, in contrast, are associated with severe pain and a prominent external lump but not with bleeding or fever. On examination, an external thrombosed hemorrhoid appears as a prominent, blue, and firm perianal lump. It is also not uncommon for multiple hemorrhoids to thrombose. Patients who present within 72 hours of the onset of symptoms benefit from an evacuation of the thrombosed clot using local anesthetic (Figure 3). In contrast, patients who present after 72 hours should be treated expectantly with conservative supportive care, including sitz baths, normalization of bowel habits with fiber or stool softener, and pain management. The natural history in these cases is for the thrombosed clot to gradually be reabsorbed within several weeks.

    FIGURE 3 Incision and evacuation of an external  thrombosed hemorrhoid. A, A local anesthetic is injected into the subcutaneous surrounding tissue and at the base of the hemorrhoid. B, The skin over the hemorrhoid is lifted and a small elliptical excision of skin is  made. C, The thrombotic clot is evacuated. Additional dissection is sometimes needed in the subcutaneous tissue to extract the clot. D, The appearance of the evacuated area. The incision is left open and the skin heals by secondary intention.

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  6. 6
    Anal Fissure

    An anal fissure is a tear in the anoderm extending proximally into the anal canal and initially resulting from a traumatic bowel movement. Fissures typically occur in the setting of constipation or frequent bowel movements. Although most superficial fissures resulting from trauma to the anorectal region will heal, some patients have prolonged symptoms, causing them to seek medical attention. The pathophysiology of anal fissures is still not completely understood but is related to local ischemia caused by hypertonia of the internal sphincter. The great majority of anal fissures are located at the posterior midline; some also occur at the anterior midline (Figure 4).

    Lateral fissures are rare and can be associated with anal malignancy, anorectal Crohn’s disease, HIV, syphilis, or tuberculosis. In these cases, a biopsy should be strongly considered to confirm the diagnosis.

    FIGURE 4    Distribution of the location of anal fissures.

    Patients who present with anal fissure most often have a tearing pain that is associated with bowel movements and that continues after defecation and bright red bleeding with bowel movements. Physical examination demonstrates a tear in the anoderm with exposed internal sphincter upon retraction of the buttocks. Chronic cases also demonstrate a sentinel tag overlying the distal aspect of the fissure.

    Conservative treatment for acute anal fissures includes the normalization of bowel habits to minimize recurrent trauma to the anoderm and sitz baths for comfort. In cases in which the fissure is chronic or unresponsive to conservative treatment, topical therapy to relax the internal sphincter (i.e., a “chemical sphincterotomy”) is prescribed. Classically, nitroglycerin ointment (0.2%–0.4%)1,2 has been used but is associated with significant headaches and lightheadedness. Diltiazem ointment (2%)1 is a commonly used alternative without associated side effects. Either ointment can be applied topically two to three times per day for approximately 8 weeks. Reported healing rates are similar and range from 40% to 100%. An alternative agent that can be used for chemical sphincterotomy is botulinum toxin A (Botox), which can be injected in the office or operating room with a single application into the internal sphincter. Although botulinum toxin A appears to be as effective as topical therapy, it is significantly more expensive.

    Surgical internal sphincterotomy is the most effective treatment for resolution of anal fissures but is associated with a risk of fecal incontinence, particularly in women, elderly patients, or others at risk for impaired continence. This procedure is performed in the outpatient setting and should be considered in cases where more- conservative dietary and medical treatments have failed. Internal sphincterotomy is performed by dividing the internal sphincter laterally, which prevents the formation of a keyhole defect with stool leakage, which can occur with the posterior division of the internal sphincter muscle. This procedure can be performed with an open approach (incising mucosa and exposing muscle) or a closed approach (using landmarks and then blindly dividing muscle) and can be full thickness (entire internal sphincter) or tailored (partial thickness and length). Most surgeons perform a tailored sphincterotomy from the level of the top of the fissure distally, with partial division of the internal sphincter muscle to decrease the risk of postoperative fecal incontinence.

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    Anorectal Abscess and Fistula

    Anorectal abscess is most commonly a self-limited process thought to result from obstruction and infection of anal glands located in the crypts along the dentate line. Clinicians should be aware that perianal Crohn’s disease, trauma, and malignancy can cause anorectal abscess or fistula. Anorectal abscesses typically manifest with acute pain in the perianal area, acutely painful defecation, an indurated painful area, or fever. Most anorectal abscesses manifest with pain and swelling either superficially at the anal verge or deeper within the ischiorectal fossa. These patients have obvious tenderness, induration, or fluctuance on external and/or digital examination. In contrast, patients with intersphincteric abscesses have severe pain but minimal findings on external examination and are only suspected on digital rectal examination.

    The mainstay of therapy is surgical drainage. Superficial abscesses can be drained using local anesthesia, but more-extensive infections typically require general anesthesia. When the abscess is fluctuant and appears easily accessible, an incision and drainage with a local anesthetic can be considered in a motivated patient. Important principles in draining an anorectal abscess include keeping the patient comfortable, using aspiration with a large-bore (14- or 16-gauge) needle to help in the event of difficult localization, using a cruciate incision to ensure adequate drainage, and keeping the incision near the anus to keep any potential fistula tract as short as possible. After the abscess is drained, the area is allowed to heal by secondary intention. Patients are given analgesics and encouraged to take sitz baths. When the abscess is large and extensive, sometimes drainage tubes, débridement, or additional dressing changes are required.

    In a majority of patients, drainage of the anorectal abscess is sufficient. However, in one-third of patients, these do not heal and form a fistula with the external opening beyond the anal verge and the internal opening within an infected crypt gland at the dentate line.

    These continue to drain purulent material from the external opening, and some patients continue to have signs and symptoms of infection. The tract of the fistula is most often predicted with Goodsall’s rule.

    Goodsall’s rule states that an anterior fistula follows a radial tract to the internal opening, typically at the anterior midline. In contrast, a posterior fistula follows a curvilinear path to the internal opening at the posterior midline. Anorectal fistulas are defined by their anatomy and path relative to the sphincter muscles and are classified typically as superficial, intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric, as classically described by Parks (Figure 5). In most cases, patients can proceed directly to the operating room for initial definition of the anatomy and placement of a seton (a length of suture or other material that is looped through the fistula), which helps to allow drainage of infection within the tract, prevents recurrent infection, and allows the fistula to mature. Recurrent and complex fistulas may be better defined anatomically with the use of magnetic resonance imaging or endorectal ultrasound.

    FIGURE 5    Classification of anal fistulas. Abbreviations: ES  =extrasphincteric; IS = intersphincteric; S = superficial; SS = suprasphincteric; TS = transsphincteric.

    Superficial, intersphincteric, or low transsphincteric fistulas can be treated with simple fistulotomy, which opens up the fistula tract and allows the tissue to heal by secondary intention. This, however, can result in impaired fecal continence, particularly if the fistula involves a significant amount of sphincter muscle.

    Following this, a variety of methods can be used to repair the fistula. One classic technique is the use of a cutting seton, where a taut seton is progressively tightened over several weeks or months to form a scar in place of the fistula and muscle. A cutting seton may be painful, and the scar is associated with impaired continence in some cases. Fibrin glue has been proposed as a method to repair a fistula, but the long-term recurrence rate is high (> 85%). Fistula plugs have also been proposed as a method to heal the fistula tract by repairing the internal opening and providing a scaffolding for fibrosis to occur. Although short- and medium-term success is reported to be approximately 30%, long-term results are not known.

    Endorectal advancement flaps are the most well-established method to repair an anal fistula. With this technique, the internal orifice is closed and healthy tissue is brought down over the internal fistula opening to allow the area to heal. This procedure can be technically difficult: failure most commonly results from ischemia of the flap, and repeat flap procedures are often not anatomically feasible owing to scarring and fibrosis. Success rates have been reported between 50% and 80%.

    A new procedure has been developed for transsphincteric and suprasphincteric fistulas called ligation of intersphincteric fistula tract. This has been reported in about a dozen centers as a method to treat transsphincteric fistulas and is performed by closing the internal opening and ligating and removing the intersphincteric portion of the fistula tract through an intersphincteric approach. Although long-term results are still unknown, reports are favorable (on the order of 80%) for the short-term success of this technique; a multicenter trial is ongoing.

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    Bleier J.I., Moloo H., Goldberg S.M. Ligation of the intersphincteric fistula tract: An effective new technique for complex fistulas. Dis Colon Rectum. 2010;53:43–46.

    Christoforidis D., Etzioni D.A., Goldberg S.M., et al. Treatment of complex anal fistulas with the collagen fistula plug. Dis Colon Rectum. 2008;51:1482–1487.

    Jayaraman S., Colquhoun P.H., Malthaner R.A. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev. (4):2006 CD005393.

    Nelson R. Nonsurgical therapy for anal fissure. Cochrane Database Syst Rev. (4):2006 CD003431.

    Nelson R.L. Operative procedures for fissure in ano. Cochrane Database Syst Rev. (1):2010 CD002199.

    Parks A.G., Gordon P.H., Hardcastle J.D. A classification of fistula-in-ano. Br J Surg. 1976;63:1–12.

    Shanmugam V., Thaha M.A., Rabindranath K.S., et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. (3):2005 CD005034.

    Wang J.Y., Garcia-Aguilar J., Sternberg J.A., et al. Treatment of transsphincteric anal fistulas: Are fistula plugs an acceptable alternative? Dis Colon Rectum. 2009;52:692–697.

    1  Not FDA approved for this  indication.

    2  May be compounded by  pharmacists.

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