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The five common symptoms of anal disease
1 Consultant Surgeon, Groote Schuur Hospital, Cape Town, South Africa
2 Professor of Surgery, Kingsbury and Groote Schuur Hospitals, Cape Town, South Africa
Corresponding author: A Boutall (boutall@icloud.com)
Pain
This is usually caused by:
• anal fissure
• peri-anal abscess
• prolapsed thrombosed piles
• peri-anal haematoma
• cancer invading the sphincters.
Anal fissure
This typically presents with pain on defecation and blood spotting on toilet paper. These symptoms are due to an ischaemic mucosal ulcer within a high-pressure sphincter. The fissure is usually visible at inspection of the gently distracted anus (Fig. 1). Defecation is exquisitely painful, ‘it’s like passing razor blades’, resulting in a cycle of fear of defecation, constipation, mucosal trauma and sphincter spasm. Digital examination is intolerable and should be avoided. Management requires laxatives, analgesia and internal sphincter relaxation, which can be achieved with a nitrate ointment or a limited internal sphincterotomy. Nitrate ointment applied to the anus at least 3 times daily for 6 weeks is appropriate first-line treatment. A mono-nitrate ointment avoids the side-effect of headaches associated with tri-nitrates. Persistent symptoms or atypical features, such as rolled edges or a lateral location, require examination under anaesthetic (EUA) and biopsy. Botox has not been shown to be superior to topical therapy.1
Fig. 1. Anal fissure
with sentinel tag.
Peri-anal abscess
These develop from an obstructed anal crypt gland at the dentate line. They are named according to their location: ischiorectal (ischio-anal), peri-anal or intra-anal. The symptoms are severe pain with point tenderness. Examination will reveal an obvious abscess or tender induration and swelling. An internal or submucosal abscess is an unusual variant, which is frequently missed because the peri-anal region appears normal. Digital examination is exquisitely painful and mandates EUA. The management remains incision and drainage, with antibiotics occasionally used as an adjunct to surgery in a few selected patients. An important point to remember when deciding to prescribe antibiotics is that, unlike other cutaneous abscesses, the causative organisms are enteric flora and not skin flora. Antibiotics that cover Gram-negatives and anaerobes (e.g. co-amoxiclav) are required.
Acutely prolapsed thrombosed piles
The primary symptom is severe pain, often requiring hospital admission. Examination reveals a tender, oedematous, haemorrhoidal mass protruding from the anus (Fig. 2), which is often circumferential and occasionally mistaken for a rectal prolapse. Treatment can be conservative or surgical. A randomised control trial comparing surgery to conservative management demonstrated that conservative management is appropriate for many patients.2
Fig. 2. Prolapsed thrombosed piles.
Peri-anal haematoma
This is caused by the rupture of a subcutaneous blood vessel in the peri-anal region and is sometimes incorrectly called an ‘external pile’. This purple pea-sized swelling is tender but not inflamed. It is easily managed by scalpel incision after instillation of local anaesthetic via an insulin syringe. Success is confirmed by the expression of a blood clot and a grateful patient. Scalpel incision should be reserved for acute lesions as delayed presentation results in a more diffuse swelling which is best managed conservatively.
Anorectal cancer
Occasionally a low-lying cancer arising from the anus or rectum can cause severe anal pain due to sepsis or sphincter invasion (Fig. 3). However, it is important to realise that the absence of pain does not exclude cancer. Any abnormality palpable in the anal canal must be regarded as cancer until proven otherwise. Internal haemorrhoids are not palpable on digital examination and are diagnosed with a proctoscope.
Fig. 3. Fistula with seton and abscess scar.
Prolapse
Three things may prolapse through the anus – polyps, the rectum and haemorrhoids, which are the most common. The treatment of prolapsing haemorrhoids is either rubber-band ligation as an outpatient or surgical removal in theatre. Surgical removal provides durable results, but at the cost of significant postoperative pain and the possibility of surgical complications. Rubber-band ligation is ideal for grade 2 and 3 haemorrhoids and generally provides excellent results, with very low morbidity (Table 1).3
Rectal prolapse is most commonly seen in elderly women and occasionally in young women, but is rare in men. The management is surgical, which can be via a perineal approach or an abdominal rectopexy, which is well suited to the laparoscopic approach.
Discharge
This is a symptom of anal fistula, mucosal/haemorrhoidal prolapse or incontinence, which is beyond the scope of this article. Hidradenitis and pilonidal sinus are not usually in the immediate peri-anal region but should also be considered.
Anal fistulae present a major proctological challenge. The primary symptom is a purulent discharge from an external peri-anal opening. It is painless unless associated with an underlying abscess. Fistulae result from a peri-anal abscess forming a granulation-lined tract between the anal canal and the peri-anal skin. The external opening is usually easy to identify and gentle pressure around the lesion will often produce a bead of pus. These lesions can be associated with a cycle of abscess formation, spontaneous drainage and persistent discharge. Diagnosis of a cryptoglandular fistula requires exclusion of Crohn’s disease, tuberculosis, or cancer. The majority of fistulae are superficial and can be laid open with the division of an inconsequential amount of sphincter. In complex fistulae this approach can result in incontinence and other strategies are required. These include long-term seton drainage and/or fistulae repair such as mucosal advancement flap (Fig. 4). A steady stream of new repair techniques is testimony to the demands of this challenging condition.
Fig. 4. Anal squamous carcinoma.
Bleeding
Bleeding per rectum (PR) is a common complaint, which can range from a few spots on the tissue to frank blood in the toilet. Haemorrhoids classically present with bright red painless bleeding. Fissures and bleeding due to excessive wiping (which causes micro-abrasions) will result in blood on the paper. Bleeding from the rectum or more proximally will present as altered blood mixed with the stool and mandates colonoscopy. The common causes are cancer, colitis, a diverticular bleed or angiodysplasia. The major problem with PR bleeding is trying to distinguish between those patients who can be safely diagnosed as having bleeding from haemorrhoids or another minor peri-anal complaint, and those with an underlying sinister cause. Unfortunately both cancer and haemorrhoids are common and can co-exist.
All patients with anorectal bleeding require a careful history, digital examination, proctoscopy and sigmoidoscopy. If the patient cannot tolerate this, then fissure or cancer is likely. A suspicion of cancer mandates an EUA. When a fissure is confidently diagnosed, an examination can be avoided at the first consultation. A failure of fissure to respond to topical therapy also mandates an EUA. Remember ‘piles are impalpable’.
Indications for colonoscopy in patients with rectal bleeding:
• no local cause identified
• a patient 50 years or older
• any alert symptoms:
• change in bowel habit • loss of weight • iron deficiency anaemia • family history of colorectal cancer.The yield of sinister pathology in patients under 50 is low. However, sinister findings are possible in this group and a high index of suspicion must be maintained.
Itch
Pruritus ani refers to itching of the anus. This troublesome symptom can be caused by many conditions but is most commonly self-inflicted. Over-zealous cleaning can cause micro-abrasions of the delicate peri-anal skin and removal of protective oils secreted by the anal glands, resulting in a cycle of inflammation, irritation and itch. History and examination will reveal any underlying pathology. Particular attention should be paid to a history of dermatological conditions and the use of potential allergens. Examination should focus on excluding anatomical abnormalities like mucosal prolapse, skin tags, etc.
‘The anus thrives on neglect’ is a useful adage when treating pruritus. Patients should be discouraged from repeated wiping and over-cleansing. Washing using a hand shower, sponge or cotton cloth should be encouraged. Soap, topical preparations, toilet paper and tight-fitting garments are discouraged.4
Conclusion
• Piles are impalpable.
• Digital examination is contraindicated in acute anal pain.
• Unexplained rectal bleeding requires colonoscopy.
• Peri-anal abscess requires surgery.
• Cancer and haemorrhoids can co-exist.
• Cancer can occur in the young.
• ‘The anus thrives on neglect.’
References
1. Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Colorectal Group. Published online 15 Feb 2012. [http://dx.doi.org/10.1002/14651858.CD003431.pub3]
2. Allan A, Samad AJ, Mellon A, Marshal T. Prospective randomised study of urgent haemorrhoidectomy compared with non-operative treatment in the management of prolapsed thrombosed internal haemorrhoids. Colorectal Disease 2006;8(1):41-45.
3. Shanmugam V. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Library Oct 2008 [http://dx.doi.org/10.1002/14651858.CD005034.pub2]
4. Schubert MC, Sridhar S, Schade RR, Wexner SD. What every gastroenterologist needs to know about common anorectal disorders. World Journal of Gastroenterology 2009;15(26):3201-3209. [http://dx.doi.org/10.3748/wjg.15.3201]
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