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356
a
b
M.L. Welton
c
Fig. 22.4 High-resolution anoscopy images of LSIL and HSIL after
the application of acetic acid. Biopsies of visualized lesions confi rmed
HRA appearances, and region biopsied is indicated with arrows in
images ( b ) and ( d ). Panels ( a ) and ( b ) demonstrate anal LSIL in the
distal rectal mucosa with subtle punctate vessel changes. The
geography of the lesion is emphasized in the left frame with a black
lesion. If the underlying hemorrhoidal tissues are disrupted,
this is generally controlled without diffi culty using cautery
alone. Very rarely I have had to control hemorrhoidal hemorrhage with a chromic catgut ligature placed at the apex of a
hemorrhoidal cushion. Overall, I prefer the operating room,
at least initially, to offi ce-based therapies as I feel this allows
for better visualization and determination of extent of disease. I have often found disease along the hemorrhoidal column that would not have been identifi ed without the
relaxation and visualization provided by MAC local. The
relaxation of the sphincters allows for fl attening of the distal
rectal mucosa and improved lesion detection. Without this
improved visualization, I believe lesions are missed and this
results in the false impression that lesions have “returned”
when in fact the lesion is persistent and was never adequately
addressed in the fi rst place.
d
border . ( c , d ) Distal rectal mucosa where HSIL is visible. The left
image has the lesion highlighted with a black border focusing the
reader on the serpiginous, cerebriform vessels and the outline of the
entire lesion. The right image demonstrates the mosaic pattern created
by blood vessels in an acetowhite background (With permission from
Welton and Raju [
45 ] )
Dealing with Recurrence
When lesions do recur, they may be treated in the offi ce with
trichloroacetic acid or infrared coagulation (IRC). As noted
above, some recurrences are best treated in the operating
room. More importantly, we, and others, have experienced
excellent control of HSIL and minimal progression to cancer
with this approach [ 6 , 8 , 9 , 12 ].
Issues around HRA and cautery destruction that have discouraged more widespread adoption are the incorrect belief
that all lesions recur (so why treat them in the fi rst place and
risk complications like nonhealing wounds or stenosis) and
the patients experience signifi cant pain (see above for this
myth buster). Furthermore, reimbursement is poor, especially given the time and effort required to develop and hone
the new skill set necessary to visualize and treat these lesions.
22 Anal Intraepithelial Neoplasia (AIN)/High-Grade Squamous Intraepithelial Lesion (HSIL)
357
Our group and others have shown that despite initial recurrences, HSIL can be cleared in ~80 % of patients and progression to cancer can be signifi cantly diminished (Pineda
and Goldstone) [ 6 , 8 , 9 , 12 , 20 ]. This is done through tar-
geted destruction in the operating room with follow-up
destruction in clinic as needed. Admittedly, the patients do
experience postoperative pain. Yet, this can be largely controlled with sitz baths (in a bathtub fi lled to the chest),
LMX-5 % topical lidocaine cream, and a narcotic agent. I
have found that the warm bath and LMX-5 % are the most
effective methods of pain relief.
Coding
Reimbursement continues to be a challenge with no specifi c
code available for the diagnosis and treatment of anal dysplasia. A trial code is available for HRA itself, but since I do
this in the operating, I am not using that code alone. I use the
codes for diagnostic anoscopy and destruction of condylomata – extensive. When I am destroying HSIL in the distal
rectal mucosa, I am coding for transanal destruction of rectal
neoplasia. I also note use of the operative microscope, but
this is reportedly routinely included in diagnostic anoscopy.
Follow-Up
Follow-up anal cytology is a critical component of a successful program. The timing of the cytologic sampling is undefi ned and is even changing in the gynecology literature. My
current practice is to see patients back 1 month after surgery
to review pathology and see how they are progressing. If
they were found to have HSIL and I felt I was able to completely clear the disease, I see them back in 6 months for a
digital rectal exam and anoscopy in the offi ce. If they are not
involved in high-risk behaviors where I am concerned for
persistence, inoculation or re-inoculation, I recommend a
follow-up anal cytology at 1 year after treatment. If they are
at high risk or continue to engage in high-risk behaviors, I
recommend follow-up anal cytology and HRA at 1 year. If
the patient is immunosuppressed from chronic disease or
medication to control chronic illness, then more frequent
follow-up (i.e., 3–6 months) is typically warranted with anal
exams, anal cytology, and HRA as needed. These decisions
are all informed by the patient’s particular risk factors including the burden of disease, the severity and type of their
immune-compromised state, the pace of their disease, the
adequacy of my evaluation, and complicating associated
anal pathology. Otherwise, if there was a normal examination, I recommend that surveillance be extended to every
other year. Importantly, if I was unable to clear the disease at
the fi rst treatment, I will bring them back to the operating
room in 3 months to complete treatment and then proceed
with follow-up as detailed above.
Topical Agents
I have no personal experience with the dispensing of topical
agents such as 5-FU and imiquimod. I have been referred to
patients previously treated with imiquimod and have seen
some remarkable responses. One memorable patient had
documented circumferential HSIL, and we were unable to
get him into the OR for 4 months. At surgery there was no
documentable disease. Anecdotally, the vast majority of my
patients have not experienced such an impressive response.
This less favorable, and likely more generalizable, impression is supported in the literature; though, there certainly are
responders which leaves many to feel it is worth having in
the armamentarium [ 31 ]. To defi ne its role more clearly as an
adjunct to surgery, a trial with standardized surgical intervention would be necessary.
An initial study of topical 5-FU reported some early success, with 6 of the 11 patients experiencing a reduction of
dysplasia on HRA [ 32 ]. Unfortunately almost ¾ of the
patients experienced mild-to-moderate perianal pain and irritation. The benefi ts of this treatment approach over cautery
destruction remain to be elucidated. I can envision a scenario
where a topical medication such as 5-FU is added to a follow- up protocol following initial cautery destruction of
extensive disease to minimize local recurrences. Yet, its use
in conjunction with or as a replacement of TCA or IRC has
not been explored.
Infrared Coagulation
Infrared coagulation (IRC) has proven to be an effective
tool in the outpatient setting and has demonstrated ease of
use in the hands of surgeons and primary care physicians
alike [ 8 , 12 , 33 ]. IRC is used in this scenario as an offi ce-
based ablative device and has been typically touted to be
associated with less pain compared to other destructive
techniques. I have not found this to be true. Rather, I have
found the claims to be diffi cult to substantiate once an adequate volume of experience is acquired. Destroying tissue
in the anorectum generates pain no matter the technique.
Managing the amount of tissue destruction and the depth of
destruction is the most important operator-dependent factor. Managing patient expectations and providing adequate
education and postoperative pain management instructions
improves patient satisfaction. Like all techniques used to
treat high-volume disease in high-risk patients, IRC has a
reputation for high recurrence rates, but retreatment can
eradicate HSIL [
8 , 12 ]. Recurrences may more accurately
358
M.L. Welton
be characterized as persistence after an initial staged treatment that is appropriately focused on maintaining function
while preventing cancer.
Vaccination
The advent of the quadrivalent vaccine has lent a new wrinkle
to the discussion of both treatment as well as prevention and
raises the specter that someday treatment of anal dysplasia
and condylomata will be of historical interest only. Thus far,
the vaccine has proven safe and effective in women, leading
to decreased cervical infection and dysplasia rates [ 34 – 36 ].
Additionally, reports have demonstrated its safety and effectiveness in men in preventing anogenital HPV and external
perianal condylomatous disease as well as preventing anal
dysplasia in high-risk men who have sex with men (MSM)
[ 37 ]. It also prevents HPV disease in HIV (+) children [ 38 ].
To date, vaccines have been largely untested in individuals
over 26 years of age. Some have argued that they should be
used even after exposure because the patient may not have
been exposed to one of four subtypes in the quadrivalent vaccine and, therefore, would still receive benefi t. I withhold a
blanket recommendation and suggest it be discussed with
each patient individually. My bias is it has no proven effi cacy,
and I tend not to recommend unless part of a trial.
Special Situations: The HIV (+) Patient
It is well known that HIV (+) men and women are at an
increased risk for anal HSIL regardless of sexual practices
[ 39 , 40 ]. HIV positivity interferes with the response to the
HPV, and persistent infection is more common. HIV (+)
MSM are at the highest risk for development of anal cancer
and appear to be at highest risk for progression of HSIL to
cancer. HIV (−) men are at somewhat less risk but still signifi cantly increased risk over the rest of the population [
Condylomatous disease may be a marker for more signifi cant disease, as MSM have at least four serotypes present
when tested. This data would support that HIV (+) and HIV
(−) MSM should be evaluated with anal cytology and HRA.
The initial cytology and HRA should be performed at an initial evaluation. The subsequent frequency of performing
either or both tests is dictated by risk factors as outlined
above.
2 ].
Anal Cytology and Screening/ Surveillance Intervals
The frequency of anal cytology with or without HRA may be
debated. More frequent anal Pap smears would seem to be
indicated, while managing uncontrolled or previously
untreated disease now under control much like more frequent colonoscopies are oftentimes recommended in patients
with extensive polyps seen and treated on the fi rst endoscopic examination. Once the anal dysplasia is cleared, again
like colonic polyps or cervical dysplasia, the screening interval should be determined by the individual’s risk factor
assessment. We would not recommend the same colonoscopy frequency for a patient with a family cancer syndrome
or a 20-year history of ulcerative colitis as we would for a
patient with no risk factors. Likewise, HIV (+) MSM
involved in high-risk behaviors warrant the most frequent
evaluation, while a 20-year-old heterosexual with
low- volume perianal condylomatous disease would warrant
the least frequent surveillance, if any.
In the cervix, the benefi t of Pap smears is actually found
through the cumulative sensitivity of repeat testing. This is
considered safe in large part due to the documented slow
progression rate to cancer rates of 30–50 % in 30 years [ 28 ].
As stated, while the progression rate of anal HSIL to cancer
is still undefi ned, it maybe be at a slower rate in the general
population than the rate seen in the cervix and most likely
varies signifi cantly across patient populations with differing
risk profi les [ 41 ]. The fi ndings of higher than expected anal
dysplasia rates in HIV (+) women and HIV (−) women suggests the progression rate is quite low (i.e., more remain in
the dysplastic state without progressing to cancer) [ 42 ].
However, the incidence of anal cancer in MSM indicates that
this group progresses at an alarming rate [ 21 , 22 ] and should
be screened accordingly. Further, very recent data would
suggest an acceleration in both groups supporting the importance of close monitoring of this evolving topic.
While this may seem straightforward, in reality the addition of HRA to the monitoring protocol is equally problematic. If a provider has the ability to treat anal dysplasia in the
offi ce, then visualization in the offi ce with HRA after an anal
cytology might be benefi cial. In those instances, if the provider noted a low volume of HSIL, he/she might biopsy and/
or destroy the lesion at that visit. In other circumstances, the
HSIL could be biopsied and treatment in the operating
arranged. In yet other practice groups with low-risk individuals, with low-risk behaviors, where follow-up might not
need to be as rigorous or in those practices where HRA is not
available in the offi ce, the cumulative sensitivity of anal
cytology would seem to be acceptable. As with cervical disease, where an abnormal Pap smear is an indication for colposcopy, once the anal cytology is abnormal, the patient
would need evaluation and treatment with HRA. We have
documented progression to cancer in patients with known
untreated HSIL, but we have not seen progression in patients
under surveillance from completely normal Pap smears to
cancer without interval abnormal Pap smears [ 9 ]. Therefore,
in this practice setting, HRA may not be needed at all.
22 Anal Intraepithelial Neoplasia (AIN)/High-Grade Squamous Intraepithelial Lesion (HSIL)
359
My bias is continued surveillance at an interval dictated
by patient-risk factors appears indicated in MSM as is there
does not appear to be a peak incidence of dysplasia at age 30
as is seen in women with cervical disease. Rather, in MSM
with anal dysplasia, the disease evidence of HPV infection
and dysplasia persists and incidence rates do not decrease
raising the concern that this is associated with the continued
increase in incidence of cancers seen in MSM [
42 ].
Final Thoughts
Key Concept : While treatment recommendations may be
variable , in general , HRA and targeted destruction of HSIL
are effective means to control these lesions and minimize the
chance of progression to malignancy .
A major challenge for those seeing patients with anal
HSIL is who to treat. The management decisions are idiosyncratic and appear counterintuitive at times. For instance,
low-risk patients with low-volume disease that is easily
managed are often treated with ablative therapy, while highrisk patients with circumferential disease are observed. The
argument supporting this decision is “we don’t know the
natural history of HSIL,” “we don’t know who will progress,” and “if anal HSIL is so prevalent, then why don’t we
see more progress to cancer.” I agree we don’t know who
will progress and do feel that the progression rate overall
must be low. However, not knowing who will progress
doesn’t suggest we shouldn’t treat. If this were the case, we
shouldn’t treat cervical dysplasia, colonic polyps, and ulcerative colitis with dysplasia, ductal carcinoma in situ, or
Bowen’s disease.
Take this scenario, for example. The traditional recommendations of many for the incidental fi nding of Bowen’s
disease in a hemorrhoidectomy specimen is reoperation with
random biopsies and wide local excision of all disease based
on intraoperative frozen sections [ 10 ]. One is left to ask, do
we really know the natural history of untreated Bowen’s disease? Is this more aggressive approach truly benefi cial to the
patient? I prefer to treat HSIL found incidentally after a hemorrhoidectomy in the operating room where I perform HRA
and targeted destruction of all visualized disease, which is
usually quite minimal. Furthermore, I do not feel compelled
to enter an elderly but otherwise healthy 75-year-old patient
successfully treated in this fashion into a surveillance program. Am I wrong not to follow these traditional recommendations? My own data suggest no, although this highlights
our limitations of lacking high-level data to base decisions
upon. The paper often cited for how we should treat Bowen’s
disease reports upon 47 patients [
institution was based on 247 patients selected out of our
patient population with circumferential disease – the worstcase scenario. In these patients, our progression rate, 1.2 %,
10 ]. The report out of my
was lower than reported in the literature for traditional treatment recommendations for Bowen’s disease, which ranges
from 2 to 6 % [
Another common complaint is there is a lack of data to
support HRA and targeted destruction. In reality, we now
have multiple studies suggesting a lower rate of progression
to cancer in patients who are treated with HRA and targeted
destruction. Furthermore, we have data to support untreated
HSIL progresses to cancer [ 9 , 12 , 13 ]. HRA with targeted
treatment of HSIL is clearly an effective means to preventing
progression to anal cancer in the patients who are at highest
risk. If it works in these patients, it would seem that HRA
and targeted destruction in lower-risk patients would be successful as well. Some of these patients are easy to get into the
system as well. Women who are receiving anal Pap smears or
Pap smears following appropriate guidelines would be easy
to screen with anal cytology. Women have always had a
higher rate of anal cancer than men, and therefore, the potential benefi t seems clear. It would be easy to add an anal cytology to the surveillance plan.
Finally, it is interesting that many clinicians say “I don’t
do HRA, so I send them to someone who does” rather than
learning how to perform HRA. Are those same physicians
referring rectal cancers to centers with a robot or to surgeons
who perform single-incision surgery? Or, as I believe is the
case, are they learning this new technology? If so, where is
the data for the benefi t? Are they adopting technology before
any long-term studies prove benefi t? While I do believe
patients should be referred to centers of excellence, I do not
believe this to be the case for just HSIL and HRA. I do think
it should apply equally to rectal cancers, colon cancers,
infl ammatory bowel disease, and complicated perianal diseases, but I do not hear physicians clamoring for this. Is the
difference that industry is driving “the need” for robotic surgery and laparoscopic surgery and no driving industry exists
for HRA? Is it the lack of billing codes that adequately refl ect
the increased training? While we may never know the
answers to these latter questions, it is time that we, as providers caring for these patients, come full circle to learn the necessary skills to best manage this disease.
43 , 44 ].
Summary Pearls
Anal cancer rates continue to increase and affect both men
and women. HSIL, the precursor lesion, is readily identifi ed
with HRA. Lesions may be ablated with multiple agents –
IRC, TCA, and electrocautery. Yes, pain will occur; however, the pain is equivalent to, or less than, that associated
with a hemorrhoidectomy. You can easily learn HRA, and
the tools necessary to practice HRA are readily available.
The procedure can be performed in the offi ce for low- volume
disease or as an outpatient procedure in an operating room
360
M.L. Welton
for those with high-volume disease or associated anal pathology. Treatment with HRA-directed ablation and follow-up
anal cytology, digital rectal exams, and HRA is an effective
method of controlling HSIL and decreasing the progression
rate to anal cancer. Colorectal surgeons and providers caring
for these patients should be comfortable performing HRA
and offer this treatment within their regular practice.
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45. Welton ML, Raju NL. Anal cancer. In: Beck DE, Roberts PL,
Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD, editors. The
ASCRS textbook of colon and rectal surgery. 2nd ed. New York:
Springer; 2011. p. 337–57.
Chronic Anal Pain
Richard P. Billingham and Amir L. Bastawrous
2 3
Key Points
• Causes of discomfort in the anal area are common
and diverse.
• Chronic anal pain must be differentiated from more
common acute causes of anal pain.
• Common acute causes of anal pain include thrombosed external hemorrhoids, anal fi ssure, and perianal abscess/fi stula.
• Chronic anal pain is less common than the acute
problems mentioned, but may be identifi ed and
treated with a careful, systematic approach.
• The broad differential diagnosis for chronic anal
pain should include less common causes including
pelvic fl oor dysfunction, neurogenic, infectious,
and neoplastic conditions.
Introduction
Pain in the anal area is a common disorder. It is often of short
duration and is brought to the attention of a physician or other
healthcare provider relatively soon after onset in some patients.
Others languish due to ignorance, anxiety, and embarrassment.
Patients may often ignore the pain. The discomfort is particularly disturbing to patients because the anus is a sensitive region
and diffi cult for most individuals to visualize themselves.
These conditions are generally readily diagnosed by the practitioner, in that they are easily seen or detectable on physical
R. P. Billingham , MD, FACS, FASCRS (*)
A. L. Bastawrous , MD, MBA, FACS, FASCRS
Department of Colorectal Surgery , Swedish Colon
and Rectal Clinic, Swedish Hospital Medical Center,
Swedish Cancer Institute , 1101 Madison, Suite 510,
Seattle, WA 98104, USA
e-mail: rbham@u.washington.edu; amir.bastawrous@swedish.org
examination and often can be identifi ed and cured. Any discussion of chronic anal pain must also detail acute anal disorders.
These, if left undiagnosed or untreated, can become chronic
and diffi cult to manage. So, before detailing chronic anal pain,
we present a brief review of causes of acute anal pain.
Acute Anal Pain
Key Concept : Common things occur commonly . Initially , ask
about and look for a thrombosed external hemorrhoid , anal
fi ssure , or abscess with acute anal pain .
Most of the acute anal pain seen by physicians in this situation represents one of the three diagnoses: thrombosed
external hemorrhoid, anal fi ssure, or abscess/fi stula of the
perianal or ischiorectal area. Often simply asking the proper
questions and listening to the patient can make the diagnosis.
The time course, relationship to bowel habits and associated
symptoms usually make the diagnosis of these common
complaints, often prior to even examining the patient.
Generally, the combination of history and physical examination is enough to confi rm the diagnosis.
Thrombosed External Hemorrhoid (Fig. 23.1 )
Thrombosed external hemorrhoids will usually present
acutely after a bout of straining, constipation, or diarrhea.
The pain will be associated with a swelling that is painful to
sit upon. The time course is usually 1 week or less for the
pain if untreated and a few weeks for the clot to be absorbed.
When symptomatic, offi ce excision of the external hemorrhoid containing the clot—rather than making an incision
through the external skin to enucleate the clot—gives both
better short-term relief of pain and prevents recurrence at the
site of that particular hemorrhoid. When there is hemorrhoidal crisis, with circumferential thrombosis of all or most
of the external hemorrhoids, treatment should be performed
in an operating room setting (Fig. 23.2 ).
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_23, © Springer Science+Business Media New York 2014
363
364
R.P. Billingham and A.L. Bastawrous
Fig. 23.1 Thrombosed external hemorrhoid
Fig. 23.3 Anal fi ssure and sentinel tag
self-medicate with over-the-counter remedies for many
months without success. The gold standard treatment is lateral internal sphincterotomy. Most patients (and physicians)
prefer to fi rst try conservative measures (i.e., bulking agents,
sitz baths, calcium channel blockers, glyceryl trinitrate, botulinum toxin) before sphincterotomy. Anal fi ssures, even
after a competently performed lateral internal sphincterotomy,
may occasionally persist as causes of pain if the fi ssure does
not heal. Management options for persistent fi ssure include
botulinum toxin injection, contralateral internal sphincterotomy, or cutaneous advancement fl ap down into the anal
canal.
Fig. 23.2 “Hemorrhoidal crisis,” with circumferential thrombosis of
internal and external hemorrhoids
Anal Fissure (Fig. 23.3 )
Acute pain that occurs after every bowel movement, particularly a bout of hard constipated stools, and is sometimes
associated with spotting of blood, is typical of an anal fi ssure. Fissures are normally diagnosed clinically by their
classic appearance involving visible internal anal sphincter
fi bers, rolled edges, sentinel pile, and hypertrophied internal
papillae (when chronic, see Fig.
seen as a superfi cial tear in the anoderm. Anal fi ssure pain
can become chronic if not treated and may also be a result of
associated sphincter spasm. The chronicity is typically not
from the fi ssure being refractory in these situations but rather
long lasting due to lack of treatment. Patients at times try to
23.3 ). Acutely they may be
Anorectal Abscess/Fistula (Fig. 23.4 )
Abscesses, which are commonly treated with antibiotics
alone in the primary care arena or emergency department in
the mistaken hope that they will resolve, invariably need surgical drainage if they don’t drain spontaneously. For smaller,
superfi cial perianal abscesses, drainage can generally easily
be done in an offi ce setting, using local anesthesia. It is our
practice to remove an ellipse of skin overlying the abscess, to
ensure a large enough opening to provide adequate drainage,
and to delay premature cutaneous healing, which results in
early recurrence of the abscess. The practices of “breaking
up loculations,” or “packing the wound so it will heal,” are
unnecessary and potentially detrimental by obstructing
egress of purulence. It is suffi cient to place a gauze pad over
the wound. Larger abscesses, such as ischiorectal and/or
horseshoe abscesses, are best treated in the operating room,
using similar principles. Recurrence of abscess or persistence of drainage after operative treatment almost always
indicates a fi stula in ano. A fi stula is itself rarely a cause of
23 Chronic Anal Pain
365
Fig. 23.4 Perianal abscess
anal pain. However, persistent drainage can cause pruritus
which itself may be irritating and be thought of as chronic
pain.
Fig. 23.5 Perianal Crohn’s disease (Courtesy of W. Brian Sweeney,
MD)
Acute or Chronic Anal Pain
Key Concept : Several other disease processes may present
with acute or chronic anal pain ; however , most are still easily diagnosed with a thorough history and clinical examination . Radiographic and endoscopic ancillary tests are
required in select scenarios .
Less common conditions, which are less obvious than the
above, but may produce either acute or chronic discomfort,
include:
Anal Crohn’s Disease (Fissures,
Fistulae) (Fig.
While even simple fi stulae can sometimes cause pain, generally from undrained components of abscesses related to their
origins, this is more likely to be the case with anal Crohn’s
disease and more complex fi stulae. Furthermore, there may
be pain from associated infl ammation of the anus and rectum
(proctitis). Evaluation is typically best performed with an
examination under anesthesia, with emphasis on avoidance
of fi stulotomy, placement of setons through the known fi stulae, and a careful search made for undrained areas, which
can be opened and drained. Patients with anal Crohn’s disease often have chronic anal pain related to unrelenting
infl ammation and irritation. Sphincter spasm is common as
well. These patients are not usually candidates for sphincterotomy and may heal poorly from anal procedures.
23.5 )
Hidradenitis Suppurativa (Fig. 23.6 )
Hidradenitis suppurativa is a smoldering, uncomfortable
cutaneous condition, arising from one or more of the sebaceous glands of the perineum. It is thought to represent a
disorder of sebaceous gland metabolism, with similar lesions
in the axillae and groins. When attempting to differentiate
hidradenitis from other sources of perineal pathology, it is
often helpful to perform a detailed examination of the skin
adjacent to the anal verge. As this small circular area is
devoid of hair and glands, disease in this location is not
hidradenitis. Doxycycline, clindamycin, and Kefl ex are the
most common antibiotics used, when given long term, for
management of these lesions, while nonsteroidal antiinfl ammatory drugs and immunosuppressants. For larger,
more painful or nonresponsive lesions, conservative excision
is often curative. At times, operative drainage of an acute
cutaneous or deeper abscess is indicated [ 1 ].
Pruritus Ani (Fig. 23.7 )
While the anus is a particularly sensitive region, discrimination of sensations is not always clear. Patients can report
itching, burning, and pain symptoms interchangeably.
Though the predominant symptom in pruritus ani is itching,
pain can be reported, and in severe cases, tiny linear and
radial ulcerations are typically seen on a bed of lichenifi ed,
366
R.P. Billingham and A.L. Bastawrous
Fig. 23.6 Hidradenitis suppurativa
Table 23.1 Initial management of pruritus ani
Diminish local
trauma
Diminish perianal
moisture
Avoid soap, scrubbing, and scratching
Use damp toilet paper to gently pat the anal area
clean. Do not use “baby wipes,” etc.
1. Use a small amount of cotton, and/or some
corn starch powder, applied to the anal area,
and kept there all day to absorb moisture
2. Consider seepage of mucus or fecal matter as
a possibly ongoing source of moisture.
Possibilities include frequent stools, especially
loose stools, diminished sphincter tone, or
prolapsing hemorrhoidal or rectal mucosa.
3. Avoid creams, ointment, and other emollients
which serve only to keep the area moist and
are counterproductive
characteristics can diminish irritation and requires much less
perianal cleaning after bowel movements. This can be
achieved with decreasing excess water intake and/or increasing dry fi ber in the diet, such as by using fi ber tablets or
wafers (Table 23.1 ).
There are a few rare patients who suffer from chronic irritation bordering on pain despite following the advised bowel
and hygiene instructions. For pruritus symptoms which persist despite patients’ strict adherence to these guidelines,
consider biopsy to rule out other conditions such as lichen
sclerosus et atrophicus, Bowen’s or Paget’s disease, or similar entities, which may require dermatologic referral and/or a
different therapeutic strategy.
Fig. 23.7 Pruritus ani
chronically irritated skin. Pain from this source must be distinguished from anal fi ssures, ulcers of an infectious nature,
or other common sources of anal pain as described above.
Pruritus ani generally responds to discontinuation of chemical and mechanical irritants such as use of soaps or shampoos, salves, hemorrhoid creams or fl ushable wipes,
excessive scrubbing, excessive wiping with dry toilet paper,
and scratching. The latter—avoidance of scratching—is
often the most diffi cult for patients, though absolutely
required to stop the cycle of perpetual itching and irritation.
In addition, efforts should be made to avoid perianal moisture, which is thought to perpetuate the process. Use of
creams and ointments generally is counterproductive for this
reason. Recommendations of cotton or cornstarch to keep
the area drier during the day are often helpful. Also, if stools
are loose and/or frequent, attention to normalizing these
Retrorectal Tumors
Because of the rarity of these lesions, and consequentially
the failure to consider these in the differential diagnosis,
delays in diagnosis occur more commonly than not. While
these are often palpable on deep digital examination, a CT or
MRI is necessary to further characterize them as benign or
malignant and to plan therapy even if palpable. In general,
biopsy is not routinely required, and virtually all of these
require resection. A more detailed discussion is presented in
Bailey et al., Colorectal Surgery (Fig. 23.8 ) [ 2 ].
Bicycle Seat Issues
Serious cyclists may experience pain and/or numbness in the
ischial tuberosities, perineum, or genitalia. It is worthwhile
to inquire about this and other similar avocations that may
require prolonged sitting in the evaluation of a patient with
symptoms of this nature. The condition is usually related to
pressure on perineal nerves. Numerous adjustments in seat
design and position are available to prevent or treat such
issues [
3 ]. In addition, anti-chafi ng creams are routinely