Office Management of Common Anorectal Problems

A gastroenterologist discusses anorectal examination technique and details the assessment and treatment of hemorrhoids, fissures, and functional proctalgias.

By Lawrence J. Brandt, MD, MACG, FACP

Anorectal problems are among the more common disturbances of the gastrointestinal tract. The exact incidence of hemorrhoids, for example, is not known precisely, but it is estimated to be 10% to 25% of the adult population. Levator ani syndrome and proctalgia fugax are believed to affect 6% and 14%, respectively, of adults. Other common problems are anal fissures, fistulas, and abscesses, all of which can be seen daily in a busy practice. Because these problems are so common, it is important for the clinician to know how to examine the anorectum, make an accurate diagnosis of any existing conditions, and render appropriate care.
 

EXAMINING THE ANORECTUM

Physical findings are often more important than the history in anorectal diseases, because the lesions responsible for complaints are easily examined and because patients tend to be imprecise and guarded in their description of such problems. Specific questions should be asked regarding stool habits—for example, the presence or absence of diarrhea, constipation, fecal incontinence, rectal discharge or bleeding, anal or rectal pain, prolapse, anal irritation and pruritus, genitourinary complaints, and abdominal pain. The patient's general health, constitutional symptoms, sexual habits, previous illnesses, and operations also should be discussed.

It is particularly important to remember that a rectal examination is viewed by patients as a distinctly unpleasant and embarrassing ordeal. Sensitivity and gentleness are imperative. It is also important to let the patient know in advance what you are going to do. The patient should be examined in the left lateral position with appropriate draping to ensure privacy. While it may be preferable to have a chaperone present, especially when examining a patient of the opposite sex or one who has had intimacy issues or a history of sexual abuse, this often is not practical.

Inspection is the first step in examining the anorectum. Discoloration or asymmetry of the buttocks is readily seen. The anus should be inspected for symmetry, wetness or fecal soiling, irritation, perianal fistulas and abscesses, prolapsed or thrombosed hemorrhoids, and mass lesions. Asking the patient to bear down may result in the prolapse of anorectal lesions; it will also make it possible to assess pelvic floor integrity.

Palpation follows inspection. The buttocks should be felt for tender masses, which may represent abscesses or even tumors, and also for fistulous tracks. The perianal area is then palpated; tender areas adjacent to or underneath fistulas may represent abscesses. Before a finger is inserted into the anus, a dollop of lubricant should be placed on the tip of the finger. The finger is then stroked across the anus, depositing the lubricant into the anal opening, and inserted into the anal canal.

The inner aspects of the internal and external anal sphincters and the intersphincteric groove may be palpated. Approximately 80% of the resting pressure of the anus is due to the internal sphincter. When the patient is asked to tighten the anus or bear down, anal pressure increases, largely reflecting contraction of the external anal sphincter. At the upper end of the anal canal is the puborectalis sling, the major organ of continence and part of the pelvic floor. When the patient bears down, it is normal for the examining finger to be displaced anteriorly as the puborectalis sling contracts.

The finger should be swept around the circumference of the bowel. The mucosa can be felt for irregularities, strictures, and masses. The prostate gland in a male and the uterine cervix and corpus in a female may be palpated. A palpable mass or firmness felt anteriorly in a woman may be a tampon, and occasionally it may be necessary to examine the vagina as well as the rectum to evaluate anorectal complaints. Metastases from gastric or transverse colon malignancies may drop to form a ridge called Blumer's shelf on the pelvic peritoneum. The sacrum and coccyx as well as presacral tumors are also palpable. The examining finger should be inspected on withdrawal for blood, mucus, or pus.
 

TWO TYPES OF HEMORRHOIDS

Hemorrhoidal tissue is present in infancy and remains as an integral part of the continence mechanism. Hemorrhoidal cushions consist of venous plexuses and arterial vessels with numerous arteriovenous and portosystemic communications, embedded in a stroma and tacked onto muscular fibers (Treitz's muscle) within the submucosal space. Vascular cushions normally surround the anal canal in the right anterolateral, right posterolateral, and left lateral positions. Clinically significant hemorrhoids form as these vascular cushions slide off their muscular attachments. These anatomic positions of hemorrhoids are important to know because masses thought to be hemorrhoids that occur in other than these positions are likely to be neoplastic, infectious, or inflammatory in origin.

External hemorrhoids. These dilated venules of the inferior hemorrhoidal plexus cause pain only when they are acutely thrombosed. Internal hemorrhoids. These cause painless bleeding that usually is best managed by modifying the diet to reduce roughage and condition the stool.

There are two major types of hemorrhoids: external and internal. External hemorrhoids are dilated venules of the inferior hemorrhoidal plexus arising below the dentate line and covered by squamous mucosa (see image above, left). A skin tag is a fold of skin arising from the anal verge; it is the end result of thrombosis of an external hemorrhoid. External hemorrhoids are usually small, do not itch, and cause pain only when they are acutely thrombosed. Internal hemorrhoids are submucosal vascular tissue located above the dentate line and covered with transitional and columnar epithelium (see image above, right). The major symptoms of internal hemorrhoids are painless bleeding and a bloody, mucoid discharge often associated with their prolapse. Depending on the extent of prolapse and ease of reduction, internal hemorrhoids are classified from first to fourth degree (see box below).

The basis of all definitive hemorrhoidal treatments is to affix the sliding hemorrhoidal tissues back onto their muscular attachments. Treatment of external hemorrhoid problems is rarely surgical. Moreover, bulky but asymptomatic hemorrhoids should be left alone. Treatment is directed toward symptom control, not appearance.

External skin tags should be cleansed thoroughly after bowel movements with wet toilet tissue or witch hazel-impregnated pads (for example, Tucks). Their irritation during sports activities, such as horseback or bicycle riding or jogging, can be minimized by applying small amounts of petroleum jelly beforehand to reduce friction. Extremely large overlapping external tags occasionally contribute to itching and an inability to keep the anus clean and dry; in these cases, surgical excision may be helpful.

Large external hemorrhoid-like lesions may in fact be the granulomatous inflammatory masses of tissue of Crohn's disease called "elephant ears" (see image below). Such lesions must not be surgically removed as if they were hemorrhoids because the area may not heal well and may drain for prolonged periods of time.

Hemorrhoid-like lesions of Crohn's disease. These granulomatous inflammatory masses, called "elephant ears," must not be treated as hemorrhoids.

PRESENTATION OF HEMORRHOID THROMBOSIS

Hemorrhoid thrombosis typically presents as a painful, tender swelling resembling a grape at the anal verge. This usually involves just one or two of the three normally positioned hemorrhoid cushions; a painful mass in another location should raise diagnostic concern. Treatment of thrombosis should parallel clinical severity. If the patient is relatively asymptomatic or is seen several days after the acute thrombosis, nothing need be done other than to reassure the patient that the condition will resolve within two to three weeks. A stool softener is often helpful. Any obvious offending physical activity should be avoided, such as weight lifting or bicycle riding. For moderate symptoms, immediate nonsurgical measures to reduce the pain and swelling should suffice. Magnesium sulfate solution (in approximate relative amounts of one-half cup to a pan of cool water), either as a sitz bath or as compresses, can help arrest the swelling for the first day or two. This is preferable to hot baths, which may be more helpful in resolving swelling days later.

Oral analgesics, including narcotics, can be used for sustained pain control, which topical anesthetic agents such as lidocaine rarely provide. Meperidine and the combination of oxycodone with aspirin have far fewer anticholinergic side effects than codeine-containing analgesics (such as Tylenol #3), which may diminish both colon motility and anal sphincter relaxation, resulting in painful constipation or fecal impaction. Patients with hemorrhoid thromboses may present after the inflammatory response has peaked or the clotted pile has ruptured, producing a small gush of dark blood, which may continue to seep out for a day or two.

In some instances, the acutely thrombosed hemorrhoid is so engorged and painful that it needs to be lanced. This can easily be done in the office setting. A local injection of lidocaine and epinephrine is administered into the thrombosed hemorrhoid, and a scalpel blade is then used to make an incision along the long axis of the hemorrhoid. The incision is spread apart and a clamp is inserted to grasp and remove the thrombus, resulting in immediate pain relief. The area is then simply compressed with a gauze pad. A hemorrhoidectomy should almost never be done during the acute stage, particularly if the patient has not had prior hemorrhoid problems. It is surprising how completely the process usually resolves, without the need for any further treatment.
 

PROBLEMS WITH INTERNAL HEMORRHOIDS

The most common problem arising from internal hemorrhoids is painless bleeding, which is also managed nonsurgically in most cases. Minor bleeding, characterized by small amounts of blood on the toilet tissue and dripping into the toilet bowl, usually responds to the following: stool lubrication and softeners (for example, mineral oil and docusate sodium); measures to reduce coarse roughage in the diet (such as nuts, hard pretzels, and popcorn); bulk laxatives to ensure moister and more regular stool; and periodic mild cathartics, if needed.

Major internal hemorrhoid bleeding, such as blood spurting or dripping for minutes after a bowel movement, usually comes from the upper aspect of the internal hemorrhoid cushions. This area is more vascular than the portion of the anal canal below the dentate line, but not as richly innervated with pain fibers. The nonsurgical measures for minor bleeding may suffice here too, but they may need to be supplemented by endoscopic procedures to partially thrombose the upper redundant internal cushions, using either rubber band ligatures, sclerosant injections (usually with arachis oil containing 5% phenol), or various coagulation modalities, such as infrared, argon, or laser.

Office ligation of internal hemorrhoids was first introduced by Blaisdell in 1958 and modified with the use of rubber bands by Barron in 1963. Since then, and with the increasing use of flexible sigmoidoscopy and colonoscopy, rubber band ligation (RBL) has become the most common office procedure for the treatment of second- and third-degree hemorrhoids (see image below). Treatment of first-degree hemorrhoids may be more difficult because of the paucity of redundant tissue to be drawn into the banding device. It is inappropriate to use this method for fourth-degree hemorrhoids.

Rubber band ligation. This is the most common office-based treatment approach for second- and third-degree hemorrhoids.

Before this procedure, patients must be instructed to refrain from taking aspirin and other nonsteroidal anti-inflammatory drugs for five to seven days to avoid excessive bleeding. Rubber bands are placed on rectal mucosa just proximal to the internal anal cushion. Severe pain will result if they are placed on squamous epithelium, in which case they must be promptly removed. The number of bands that should be placed at each session is controversial; one to three is the usual range that is debated. Local anesthetic injection does not appear to reduce post-ligation discomfort. Sitz baths and acetaminophen are all that is usually required for pain relief afterward.
 

TRIALS INVOLVING RUBBER BAND LIGATION

In a meta-analysis comparing hemorrhoidal treatment methods, MacRae and McLeod reviewed 18 randomized controlled trials and found that RBL was better than sclerotherapy for all grades of hemorrhoids. Patients treated with sclerotherapy or infrared coagulation were more likely to require further treatment than those treated with RBL. Hemorrhoidectomy was shown to give better response rates but had a higher rate of complications and pain than did RBL. It was recommended that RBL be the initial form of management, with hemorrhoidectomy reserved for failures with conservative treatment.

Overall, success with RBL has been reported in 75% of first-degree hemorrhoids and 65% of second- and third-degree hemorrhoids, with recent series reporting a reduction in bleeding in 80% to 90% of cases. Repeat RBL treatments may be necessary, and a much-reduced amount or frequency of bleeding, rather than complete cessation of bleeding, may be an acceptable endpoint for successful treatment.

Complications of RBL may occur as with any other therapeutic procedure. Bleeding may result when the band and hemorrhoidal tissue are sloughed five to eight days after band placement. Such bleeding is rarely severe, but it may require balloon tamponade, epinephrine injection, or suturing. A more serious threat is sepsis. There have been five reported deaths from sepsis, two patients who developed life-threatening sepsis but recovered, and three cases of pelvic cellulitis following RBL. New or increased anal pain or difficulty voiding may herald sepsis. Intravenous antibiotics and surgical debridement are required. Pelvic cellulitis and sepsis are more apt to occur in immunocompromised patients.

Operative hemorrhoidectomy should be reserved for patients with heavy bleeding from very large and sensitive cushions that have not responded adequately to nonsurgical treatment, and for irreversible or complicated prolapse or herniation of the hemorrhoid cushion below the anal sphincters. In most cases, the prolapse occurs only during defecation, and the cushions either reduce spontaneously (with second-degree hemorrhoids) or can be easily pushed back up manually (with third-degree hemorrhoids), not to descend again until the next bowel movement. In such instances, surgery is not necessary. However, prolapse may become chronic with resultant excoriation, bleeding, mucus discharge, and minor fecal soiling. Hemorrhoids that cannot be returned to their rightful place are classified as fourth-degree. Regardless of whether surgery is performed for refractory bleeding or prolapse, the entire offending hemorrhoidal cushion or cushions and their vascular pedicles must be removed completely.
 

FISSURES: MOST LIKELY LOCATION

A fissure is a superficial longitudinal tear in the epithelial lining of the anal canal. The midline is the weakest structural point in the anal canal. Trauma to the canal (from constipation, for example) produces a fissure that is almost always located in the midline of the posterior wall of the canal or on either side of it. About 1% of fissures in men and 10% of fissures in women are located in the midline anteriorly, especially when related to postpartum injury in women.

Fissures that are multiple or lateral should raise concern about immunosuppression and also inflammatory, infectious, or neoplastic causes, such as Crohn's disease, tuberculosis, syphilis, or carcinoma. Quite often, the anal papilla immediately above the fissure becomes swollen due to inflammation and edema. This so-called sentinel pile may resolve or fibrose and persist as a skin tag (see image below).

Anal fissure. The hypertrophic papilla and so-called sentinel pile surrounding this fissure are typical complications.

Typically, the internal anal sphincter becomes spastic, an important observation with regard to current thoughts on the pathogenesis of anal fissure and one with great implications for treatment of this condition. Currently, ischemia is considered the most likely cause for fissure. There is a paucity of anal blood vessels, especially in the posterior midline, and it is believed that anal spasm further reduces blood flow. After a period of about four to eight weeks, a fissure can be considered chronic. Chronic fissures are typified by indurated edges with a visible subjacent internal anal sphincter and, in many cases, a hypertrophied skin tag.

Anal fissures present with pain during and after bowel movements, perhaps accompanied by bleeding and a mucopurulent discharge. Examination of the anorectum is very difficult to perform because of the associated anal spasm; the anus is closed tightly and the fissure may even be concealed. The spasm may be overcome with gentle and persistent traction, revealing first the sentinel skin tag, if it is present, and then the split skin. Palpation of the fissure is extremely painful and adequate evaluation of the anorectum may be impossible without intravenous sedation or anesthesia.
 

CONSERVATIVE THERAPY FOR FISSURES

Approximately 90% of acute fissures heal spontaneously or with conservative therapy, such as avoidance of constipation, increased fluid intake, stool softeners, and use of an anorectal analgesic. Recent therapies used in the United States and abroad to relax the anal spasm include topical nitroglycerin (0.2%), topical isosorbide dinitrate, diltiazem (30 to 60 mg or 2% gel), nifedipine (20 mg), topical bethanechol (0.1%), salbutamol and L-arginine gel, all several times daily, as well as botulinum toxin (discussed below). Depending on the method used, healing rates in the 60% range can be expected. Recurrence occurs in 15% to 30% of patients.

Because ischemia or poor perfusion of the posterior midline aspect of the anal sphincter may be a contributing factor in the failure of anal fissures to heal, topical vasodilators have been used as treatment options. One of the more commonly used therapies is nitroglycerin ointment. The 2% ointment used to treat angina can be diluted to 0.2% by mixing one part ointment with 10 parts petroleum jelly. Wearing a latex glove or finger cot, the patient inserts a dollop of the ointment into the anal sphincter; the finger protection is needed to prevent the absorption of nitroglycerin through the skin. At this 0.2% concentration, anal sphincter pressure can be reduced by at least 25%, with a resultant increase in anodermal blood flow. The main side effects of this therapy are headache and dizziness. Success rates range from 48% to 78%, with recurrence in about a third of patients.

Botulinum toxin binds to presynaptic nerves and prevents the release of acetylcholine. When injected directly into the internal sphincter, it results in a temporary chemical denervation of the muscle that lasts about three months. Cure rates with botulinum toxin injection range from 80% to 96%; relapse rates are less than 10%. Approximately 20 to 40 units are injected; the vials in which the medication is supplied contain about 100 units and cost about $500. The medication must be used within four hours of opening the vial. For the treatment to be cost-effective, several patients should be available at the same time to maximize the use of each vial's contents.

If an anal fissure has not responded adequately to nonoperative measures within one month of treatment or if the fissure is too painful and debilitating to await the results of such treatment, surgery is appropriate. The surgical procedure of choice in the United States is lateral internal sphincterotomy. This procedure can be performed by a skilled general or colorectal surgeon in an ambulatory setting and is often curative. Unfortunate sequelae, such as diminished control of flatus and minor fecal incontinence, occur in about 5% of cases. Reduction of resting anal sphincter pressure can also be accomplished by manual or balloon dilation, an approach more popular in the United Kingdom than in the United States. Dilation is thought by some to have a lower cure rate but also a lower incidence of adverse effects.
 

FISTULA-IN-ANO AND ABSCESS

A fistula is a communication between two epithelial-lined surfaces, such as the anal canal and the perianal skin (see image below). Fistula-in-ano usually is a manifestation of a more chronic disorder, whereas with an abscess the patient presents acutely. Both conditions typically have a common cause in an infection that begins in the anal glands and then tracks in various tissue planes. Most often, the fistula tracks from the mid-anal canal downward in the plane between the internal and external sphincters to the anal verge. Alternatively, the passage may be upward or through the external sphincter into the ischiorectal fossa.

Perianal fistula. Magnetic resonance imaging, as shown here, or endoscopic ultrasound can be used to determine the size and course of fistulas and abscesses involving the anal canal.

Anal fistulas are usually the result of perirectal abscesses that have previously drained spontaneously or have been surgically incised and drained. Perirectal abscess presents with pain and swelling in the anal region; the pain is often exacerbated by sneezing, coughing, or defecation. Cardinal signs of inflammation are present, and occasionally pus is seen exuding from an anal crypt. With a perianal abscess, a red, tender, localized, swollen mass is seen close to the anus. With an ischiorectal abscess, the entire perianal area or buttock may exhibit a brawny induration. With intersphincteric abscess, anal pain is persistent and inguinal lymphadenopathy may be present. With abscesses above the levator muscle, signs of peritoneal irritation and urinary bladder inflammation may predominate. The external opening of the fistula may be identified as a red elevation draining serosanguineous fluid. Sometimes the actual opening is inconspicuous and can only be seen when pus is expressed by gentle palpation of the area.
 

SITE OF ORIGIN OF THE FISTULA

The number and location of the external openings may give a clue to the site of origin of the fistula and can guide the clinician in probing the fistula's track. According to Goodsall's rule, if the opening is posterior to the coronal plane, then the fistula probably originates from the dorsal midline and its course will curve around to the midline. If the opening is anterior to this plane, it probably originates from the nearest anal crypt and its course will be straight. Induration is another reliable sign of track direction. Anal endoscopic ultrasound is a valuable tool in defining the anatomy of the anus and evaluating the size and course of fistulas and abscesses, as is magnetic resonance imaging (see image above).

A chronically infected Bartholin gland and a pilonidal cyst may be confused with an anterior and posterior fistula, respectively. Crohn's disease and hydradenitis suppurativa must be considered in a differential diagnosis, especially in patients with multiple fistulas and a so-called watering-can perineum. Actinomycosis and tuberculosis can also cause fistulas and abscesses.

Treatment of fistula-in-ano and perirectal or ischiorectal abscess is surgical, although antibiotics, sitz baths, and pain relievers can help contain the infection and provide some relief. A patient presenting with a mature fistula-in-ano may have painless purulent discharge around the anus and on underwear for weeks to months—obviously not a surgical emergency. Nevertheless, it requires surgical and gastroenterologic evaluation to determine its cause and appropriate treatment. Surgical fistulotomy or closure of the fistula by seton or tissue glue usually will cure the common fistula resulting from a crypt abscess or fissure, but will rarely cure a fistula due to Crohn's disease. Metronidazole, 6-mercaptopurine, and infliximab all have a success rate of approximately 80% in treating the perineal fistulas of Crohn's disease. Because fecal incontinence may result from the disease as well as its treatment, referral to a competent surgeon experienced in treating colorectal disorders is advised.
 

LEVATOR ANI SYNDROME AND PROCTALGIA FUGAX

Proctalgia or anorectal pain may be organic or functional. In the latter category, the two most common disorders are the chronic levator ani syndrome and proctalgia fugax. Levator ani syndrome must be differentiated from organic causes of chronic anorectal pain, such as coccydynia, tumors of the pelvis and cauda equina, endometriosis, and various gynecologic disorders.

Levator ani syndrome occurs in about 6% of the population, 29% of whom have sought medical attention for this complaint, a percentage similar to other functional bowel disorders. Symptoms of levator ani syndrome are a dull aching or pressure sensation in the rectum, usually lasting for several hours over a period of several months. Prolonged sitting or defecation may precipitate the pain, and some patients complain of tenesmus or difficult defecation. Digital rectal examination reveals a characteristic finding: asymmetric tenderness of a contracted levator ani muscle.

Diagnosis is suggested by history, physical examination, and the exclusion of other disorders that can cause anorectal pain. A causative role for anorectal dysmotility is controversial, although some patients have had elevated anal canal pressure with relief of pain when the pressure was reduced.

Therapy is directed at reducing anal canal and levator ani tension. Appropriate interventions include digital massage of the muscle, warm sitz baths, muscle relaxants, belladonna and opium suppositories, electrogalvanic stimulation, and biofeedback. Surgical division of the puborectalis muscle is to be avoided.

Proctalgia fugax has been reported in approximately 14% of the population, mostly in males. It is characterized by a sudden severe pain in the rectum lasting seconds to minutes. Attacks in the daytime are more common than attacks at night. In contrast to levator ani syndrome, patients are asymptomatic between attacks and have no characteristic findings on rectal examination. Uncontrolled studies suggest a role for psychosocial factors; profiles of patients with proctalgia fugax who have sought medical help are similar to those with irritable bowel syndrome who have also sought help, with a higher-than-control prevalence of anxiety, hypochondriasis, somatization, and perfectionist tendencies.

Therapy is mainly explanation of the disorder and reassurance. Benefit has been reported with clonidine, salbutamol, nitrates, diltiazem, caudal epidural blockade, and antidepressants, anxiolytics, and psychotherapy when appropriate.

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