Rectal PainDiagnosis and Treatment Dr. Darin Green Proctology Residency Program Director
Anal Fissures• Most common cause of rectal pain - “My hemorrhoids are killing me”• A fissure is a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus.• Typical symptoms of an anal fissure are extreme pain, out of proportion to the size of the lesion and rectal bleeding.• Patients often avoid having a bowel movement due to the pain.
Anal Fissure - Treatment• Stool softeners or antidiarrheals (immodium or lomotil)• Sitz baths• Hydrocortisone cream or suppositories• Canasa (mesalamine) suppositories• Nitroglycerine ointment• Dilatation• Cauterization• Surgery
Pruritis Ani• Pruritis Ani is an unpleasant cutaneous sensation characterized by varying degrees of itching and burning• There are many causes: - excessive moisture (sweating or moist sticky stools) - Loose or irritating stools - Fecal incontinence - Certain foods or beverages - Chewing gum with sorbitol - Skin conditions - Other anorectal conditions
Pruritis Ani• Physical findings include only minimal erythema and excoriations in the early stages to raw, red, and oozing or pale and lichenified skin with exaggeration of the radiating folds of anal skin in the later stages.• The treatment is directed at regaining a clean, dry, and intact perianal skin. - Reassurance - Inform the patient there is no significant underlyingpathology, treatment is mainly symptomatic and directed towarddecreasing moisture in the perianal area. - Education – Patients are instructed to cleanse the area several timesdaily especially after a bowel movement, no medicated soaps, Sitzbaths, hairdryer, the use of gauze pads or cotton balls - Dietary – No coffee, tea, colas, chocolate, beer, alcohol, or dairyproducts. Keep a dietary diary. - Local therapy – A barrier cream such as calamine or balneol - Dilute steroid lotion such as synalar, or hytone - More potent topical steroids for refractory cases or perianal psoriasis -Miscellaneous therapy – Shaving, antihistamines (atarax), oralsteroids, gloves
Thrombosed External Hemorrhoids• A thrombosed external hemorrhoid is the result of a rupturing blood vessel around the anal opening.• The blood leaks out and forms a clot• With or without edema• The cause is sometimes unknown but usually secondary to anything that increases the intra- abdominal pressure very quickly, such as lifting, straining, coughing, or pregnancy.
Thrombosed External Hemorrhoids• Will appear as a bluish or purple knot around the anal opening, usually left lateral or right lateral. If edema is present, the clot may not be as visible.• Treatment : Excision
Perianal Abscess• A perianal abscess is an infected cavity filled with purulent material found near the anus or rectum.• An abscess results from acute infection of a small gland just inside the anus when bacteria or foreign matter enters the tissue through the gland.• Symptoms will include pain, swelling, fever, malaise, and drainage.
Perianal Abscess• Treatment consists of draining the puss from the infected cavity by making an opening in the skin near the anus to relieve the pressure. This is usually done in the office setting but a large or deep abscess may require hospitalization• Antibiotics are not an alternative to incision and drainage.• I and D will not affect fistula formation.• 50% of perianal abscesses will develop a fistula.
Condyloma Acuminatum• Condyloma is caused by the HPV virus• Most commonly HPV 6, 11• HPV 16, 18 behave more aggressively and are more frequently associated with dysplasia and malignant transformation.• Are sexually transmitted• Virus may lay dormant for six to nine months
Condyloma Accuminatum• Almost all patients note visible perianal warts• 2/3 of patients will experience pruritis ani secondary to irritation of the warts or inability to cleanse the area properly or with the use of hydrocortisone cream• Treatment – topical / surgery
Perianal Condyloma with Subsequent Squamous Cell Formation
Perianal Crohn’s Disease• Often confused as “painful hemorrhoids”• May be presenting symptom for colonic Crohn’s disease• Presents ususally as edematous, erythematous perianal tag with ulceration or as perianal abscess• Treatment – Treat underlying colonic Crohn’s - Local treatment such as suppositories, creams and ointments - Ciprofloxacin/Flagyl - Remicade
Rectal Procidentia (Rectal Mucosal Prolapse)• Rectal procidentia is the protrusion of the entire thickness of the rectal wall through the anal sphincter.• Usually seen in elderly females with decreased pelvic muscle tone.• Usually presents with anal incontinence, discomfort, the sensation of incomplete evacuation and tenesmus• In later stages a permanently extruded rectum is noted• Usually diagnosed by a physical examination which will reveal a protruding large red mass with concentric folds.• A mild case of mucosal prolapse may present with no obvious prolapse but a very patulous anal opening.• Treatment is colorectal surgery referal
Squamous Cell Carcinoma• Squamous Cell Carcinomas of the anal margin resemble those occurring in skin elsewhere in the body.• They typically have rolled everted edges with central ulceration• Any chronic unhealed ulcer should be considered a potential squamous cell carcinoma until proven otherwise by biopsy.• Treatment usually consists of local excision for lesions less than 2 cm, larger lesions and lesions involving more of the anal canal may require radiation therapy or APR
Perianal Comedones (Giant Comedones)• Can occur around the perianal area• Usually present as large, yellowish, indurated nodules with hair extruding from them• Can sometimes become infected and therefore painful• Treatment – Expression of sebum like material - Excise lesion
Perianal Edema• Perianal Edema is the swelling of the tissue around the anal opening without thrombosis• May appear skin colored or slightly erythematous but no purplish color due to no thrombosis• Treatment – ice packs, sitz baths, topical ointments and excision• Commonly seen during and after pregnancy
Grade 4 Internal Hemorrhoids• Typically internal hems are not painful• Grade 4 hems are prolapsed internal hems that cannot be manually reduced.• Appear erythematous and edematous and will have radial grooves versus concentric rings• May become gangrenousTreatment : Immediate Surgical Removal