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11 Pelvic Floor Dysfunction
Table 11.7 Summary of the main imaging tests with their indications and expected fi ndings
Investigation Indications Expected fi ndings
Defecography Diffi cult defecation/dyschezia
unresponsive to initial treatment
Fecal incontinence (pre-op
workup)
Rectal prolapse
Rectocele
Unexplained pelvic pain
especially when enterocele is
suspected
Anal endosonography Fecal incontinence
After sphincteroplasty if anal
incontinence persists
MRI defecography See defecography above
+
Evaluate global pelvic fl oor
dysfunction
Static MR Fecal incontinence
After sphincteroplasty if anal
incontinence persists
Internal rectal prolapse
Rectocele, enterocele, sigmoidocele
Pelvic fl oor descent
Paradoxical puborectalis contraction
Incomplete and prolonged contrast evacuation
Poor rectal stripping
External and/or internal anal sphincter defect
Abnormality of external and/or internal anal
sphincter thickness
Postoperative status
See defecography above
+
Enterocele
Genitourinary prolapse
Abnormalities of the levator ani muscle
See anal endosonography above + precise
evaluation of external anal sphincter atrophy
153
fl oor dynamics. Dynamic fl uoroscopic defecography began in 1964. High-resolution ultrasound
and cine-loop MRI have revolutionized our
understanding and management of pelvic fl oor
dysfunction (Collet et al. 2008 ).
11.4.4.5.1 Dynamic Fluoroscopic Defecography
It requires rectal opacifi cation with or without small
bowel and vaginal opacifi cation if applicable (to
rule out enterocele). In case of bladder dysfunction,
simultaneous cystography can also be performed.
11.4.4.5.2 Anal Endosonography
It is a good modality for evaluation of anal
sphincters specially to study the integrity of anal
sphincters.
11.4.4.5.3 Dynamic MRI Defecography
It provides all the information that a conventional
defecography provides. Better assessment of the
defecation is possible with a dynamic cine-loop
MRI. All the three compartments of the pelvic
fl oor are seen in real time. It is emerging as the
gold standard of pelvic fl oor imaging.
Table
11.7 shows compact utility of various
imaging modalities for pelvic fl oor dysfunction.
11.5 Causes of Anorectal Outlet Obstruction
The condition may be secondary to anismus,
rectal intussusception, rectocele, or idiopathic
megarectum.
11.5.1 Paradoxical Puborectalis Syndrome (PPR) or Anismus
Inappropriate contraction or non-relaxation of
the pelvic fl oor can result in pelvic outlet obstruction. This condition is called anismus. In 1964,
Wasserman described, “a type of stenosis of anorectum caused by spasm of a component of the
external anal sphincter muscle.” He called this
condition puborectalis syndrome. Since then, it
has carried many names like paradoxical external
anal sphincter, spastic pelvic fl oor syndrome,
obstructed defecation syndrome (ODS), rectoanal dyssynergia, abdominolevator incoordination, and abdominal pelvic asynchronism.
Preston and Lennard-Jones ( 1985 ) reported that
many patients with severe constipation are unable
to relax the pelvic fl oor voluntarily. Both the
external sphincter and the puborectalis inappro-
154
B.B. Agarwal and P. Sivalingam
priately contract when the patient strains to defecate. Anismus is a complex and poorly
understood entity. Its cause remains obscure. It is
suggested that the paradoxical contraction of the
striated muscles could be a refl ex activity or
could be due to voluntary suppression of the normal inhibitory process. Bartolo et al. ( 1983 ) con-
sider this condition a behavioral disorder with
lack of coordinated relaxation of the striated anal
sphincter during defecation. This theory is supported by the fact that anismus has been shown to
improve with yoga or biofeedback. Anismus can
be suspected on the history and physical examination. The paradoxical contraction of the external anal sphincter and puborectalis muscle can be
easily palpated by digital examination during
straining.
The symptom in anismus is obstructed defecation. The characteristic complaint is prolonged
and unsuccessful straining at stool, feeling of
incomplete evacuation, perianal heaviness,
tenesmus, hard stools, requirement of manual
assistance, and regular use of laxative and enema.
These patients are evaluated by a clinical scoring
system, the ODS scoring system, and graded
according to severity. The diagnosis of the condition requires a high index of suspicion.
Defecography and electromyography show the
characteristic features. In defecography (X-ray or
MRI), the anorectal angle may be narrow instead
of wide during straining. The patient may be
unable to defecate a rectal balloon during the rectal balloon expulsion test. In cine defecography,
patients with anismus are unable to evacuate the
barium. The anorectal angle in these patients
does not increase with evacuation but remains at
90°. The most common radiologic sign is a prominent and persistent puborectalis impression
noted in the lateral fi lms during attempts to evacuate the rectum. The other fi ndings suggestive of
anismus include an overly capacious rectum, a
long persistently closed anal canal, ballooning of
the rectum, and the presence of anterior rectocele. Electromyography shows a paradoxical rise
in electric activity during straining instead of the
expected inhibition of electrical activity.
Treatment of anismus is essentially nonsurgical. Biofeedback is a technique for training the
mind to control the somatic functions. Kawimbe
et al. ( 1991 ) advised their patients to perform
their own biofeedback at home using an anal plug
electrode attached to the EMG display or a loudspeaker every day, for at least 2 weeks. The anismus index was signifi cantly reduced. EMG-based
biofeedback is a valuable technique with 89 %
success rate in the treatment of anismus.
Biofeedback therapy is an attempt to retrain the
puborectalis muscle to allow adequate relaxation.
It is performed either at home or with the help of
a biofeedback therapist. The aims of retraining
are to relax the anal sphincter and to improve
recto-anal coordination and sensory perception.
The method of biofeedback therapy varies widely
between centers. However, there is no difference
in electromyography-based biofeedback therapy
when compared with manometry-based biofeedback therapy or visual versus auditory feedback.
Electromyography biofeedback training alone is
as effective as addition of balloon training. When
there is both prolonged colonic transit and outlet
obstruction constipation in a patient, treat the
pelvic fl oor problem with biofeedback before
considering major surgery for slow transit.
Biofeedback for outlet obstruction is more likely
to be successful in patients without evidence of
severe pelvic fl oor damage. The results of biofeedback are not infl uenced by age, sex, or duration of symptoms, but they are greatly infl uenced
by patient’s motivation and the willingness of the
patient for the treatment.
Partial division of puborectalis muscle (posterior or lateral) was advocated in an attempt to
treat this condition, but the results were not satisfactory. There is no medical or surgical therapy at
present for anismus that has proved to be consistently effective.
Botulinum toxin once feared as a paralytic
agent is now used for a variety of medical and
neurological disorder related to muscle spasm.
Botulinum toxin acts by inhibiting the release of
acetylcholine in the presynaptic region of the
neuromuscular junction. The duration of response
11 Pelvic Floor Dysfunction
155
varies from 1 to 3 months. Twenty-fi ve units of
botulinum toxin is injected into both puborectalis
muscles either by palpation or under electromyography guidance. It is found to be effective in
treating constipation secondary to paradoxical
puborectalis contraction. The response may be
dose dependent or may vary with the technique
of delivery.
11.5.2 Rectal Intussusception
Internal rectal intussusception (hidden procidentia) may be a preliminary stage of complete rectal
prolapse. The condition produces symptoms of
outlet obstruction such as sensation of incomplete evacuation, rectal fullness or pressure,
tenesmus, and perineal pain. It is common in
female. The condition can be diagnosed on rectal
examination. Sigmoidoscopy may reveal mucosal edema or hyperemia of the anterior rectal wall
for a distance of 8–10 cm. The most useful test
for diagnosis is defecography. The majority of
these patients can be treated medically with operative intervention reserved for special circumstances. Surgical intervention in the form of
excision of prolapsed rectal wall using stapler
[stapled transanal rectal resection (STARR)] is
used to treat ODS with intra-anal rectal wall prolapse (anterior, posterior, or both) or intussusception using PPH01 device. This procedure results
in correction of anatomical confi guration and
physiological restoration of anal canal function.
It also removes very effectively the bulged out of
the anterior rectal wall in females (rectocele), the
most common cause of incomplete evacuation.
Principle of the STARR procedure is to remove
excessive prolapse of the lower full- thickness
rectal wall in two stages (anterior and posterior),
thereby pulling up the anal canal and normalizing
its anatomy and function. In TRANSTARR multiple cartridges are used to remove prolapsed rectal wall in fragments. This instrument is a smaller
version of a contour stapler used for anterior
resection of the rectum. The complications of
STARR include bleeding, sepsis, perforation,
Fig. 11.8 Rectocele
rectovaginal fi stula, urgency, and tenesmus. The
overall results of this procedure are satisfactory
(Longo 2003 ).
11.5.3 Rectocele
Protrusion of the posterior vaginal wall, including the rectum, is referred to as rectocele
(Fig. 11.8 ). The symptoms are consistent with
those of recto-anal outlet obstruction. The diagnosis is made by bimanual or rectovaginal palpation. A pocket-like defect on the anterior wall of
the rectum, just above the anal sphincter, can be
easily made out. In defecography during straining, the apex of the defect moves anteriorly and
inferiorly pushing the stool further from the anal
opening. The classical fi ndings in rectocele are
necessary for digital vaginal maneuver for defecation. Defecography may demonstrate rectocele
with evidence of retained stool. In the absence of
severe symptoms, patients should be managed
conservatively like optimizing stool consistency.
Biofeedback may help to relax the pelvic fl oor
outlet. Surgery is reserved only for patients with
severe symptoms. The surgical treatment is transvaginal repair or STARR. The technique involves
plication of musculofascial defect in the anterior
rectal wall in a transverse fashion. Dyspareunia
may be the distressful complication. Underlying
constipation should be treated to prevent
recurrence.
156
B.B. Agarwal and P. Sivalingam
11.5.4 Idiopathic Megarectum
Megabowel can present as megacolon alone,
megarectum alone, megarectum and megasigmoid, or total mega large bowel. These patients
present with severe constipation and soiling
caused by fecaloma fi lling the rectum around
which liquid feces seep. Those with megacolon
can also have abdominal discomfort and swelling. Etiology is not clear. Majority of cases are
acquired due to long-standing constipation or
neurological disease (cerebral birth trauma, epilepsy, hydrocephalus) or degenerative diseases
affecting the autonomic nervous system, e.g.,
Chagas’ disease. In only few cases, the cause
can be adult Hirschsprung’s disease with a short
segment of aganglionosis. The rectal wall in
these patients has little elasticity and can easily
expand to accommodate large volume. Transit
study reveals marked stagnation in the rectal
lumen. Although impaired rectal sensation has
been noted, the level of pressure at which sensation occurs is the same. This suggests that the
nature of problem in megarectum is not the
impaired rectal sensation but lack of elasticity in
the musculature. A greater stretch is required
before suffi cient tension occurs and sensation
begins.
Diagnosis can be made from clinical examination showing large fecaloma in the rectum with
patulous anus. Plain X-ray shows gross dilatation
with increased transverse diameter. Barium
enema is useful after evacuation of fecaloma.
Both resting and squeeze rectal pressures are low.
Recto-anal inhibitory refl ex is usually absent.
Rectal sensation is always impaired. Fullthickness anorectal biopsy will verify the presence of ganglion cells.
Conservative treatment in the form of laxatives, suppositories, and enemas with the aim to
keep the rectum empty is helpful for minor form
of diseases. However, majority of patients need
surgical resection of dilated bowel, i.e., proctocolectomy, subtotal colectomy, rectosigmoid
resection, or resection of the rectum followed by
restoration of bowel continuity depending on the
extent. Staplers should not be used as the bowel
wall is thick in these patients.
11.6 Management of Pelvic Floor Dysfunction
Lifestyle modifi cation, dietary advice, and management of comorbid illnesses are very important
parts of any clinical approach to pelvic fl oor
dysfunction (Agarwal 2011 ). Given the evolution
in our understanding, imaginative approaches
that include traditional wisdom, dietary spice
management, biofeedback, and yoga have been
shown to be helpful in improving the quality of
life in pelvic fl oor dysfunction. These additional
modalities have been found to be helpful in
improving the postoperative quality of life of
patients also (Agarwal 2010 ).
11.6.1 Surgery for ODS: Stapled Transanal Resection Rectopexy (STARR)
Internal rectal mucosal prolapse with or without
rectal intussusception and rectocele has been
found to be the factor responsible for
ODS. Resection of this prolapsing segment without any luminal compromise by a transanal route
was reported by Dr. Longo for the fi rst time. He
described the procedure of STARR using two
layers of purse-string sutures as per the experience gained from stapled hemorrhoidopexy. We
described the STARR procedure using six parachute string-like suture placement in place of two
rows of purse-string sutures. This has made the
STARR procedure easier to perform with predictable donut harvest (Agarwal
2013 ).
11.6.1.1 Operative Procedure
The procedure is done under spinal or general
anesthesia in lithotomy position. Circular cutting and stapling devices (PPH01, manufactured
by Ethicon Endo-Surgery, Cincinnati, USA)
for the rectal resection are used. It is similar to
the one used for stapled hemorrhoidopexy, i.e.,
PPH03 except for the ability of PPH01 stapler to
take in thicker tissues. This is necessary because
STARR involves full-thickness rectal resection,
while the hemorrhoidopexy involves only mucosal resection.
11 Pelvic Floor Dysfunction
157
A circular anal dilator (CAD) is introduced
into the anal canal and secured in place with skin
sutures passed through the four slots in CAD. The
orientation of CAD is such that the slots are positioned at 12 o’clock position, 3 o’clock position,
6 o’clock position, and 9 o’clock position.
After securing the CAD, the internal rectal
prolapse/intussusceptions are checked by pushing in a “sponge on holder” and pulling it out
gently. This helps in identifying the prolapse and
the groove at the base of the recto-rectal intussusception. The prolapse is now to be resected in
two sequential parts in a hemi-circumferential
manner. Anterior hemi-circumference is done
fi rst. To pull the anterior half of prolapse into the
resecting/stapling unit of PPH01, the traction is
given by three parachute sutures. The sutures are
placed at the base of intussusception and are full
thickness. The fi rst one is placed at 12 o’clock
position and then 10 and 2 o’clock position parachute sutures are placed. To protect the posterior
hemi-circumferential rectal mucosa from being
bitten by PPH01, a spatula is introduced on the
rectal mucosal through the 6 o’clock slot in the
CAD. This protects the posterior half from any
entanglement in the jaws of PPH01. The free
threads of 10 o’clock suture and one arm of the
free thread of 12 o’clock suture are jointly pulled
through the left thread slot of PPH01. The
remaining arm of the free thread of 12 o’clock
suture and the two arms of the free thread of 2
o’clock suture are pulled through the right slot in
PPH01. Adequate traction is applied on the
threads to pull in the prolapse before the instrument is tightened, fi red, and removed as in a standard stapled hemorrhoidopexy. The same steps
are repeated in a mirrorlike fashion to complete
the posterior hemi-circumferential resection with
the fresh PPH01 instrument. The staple line is
examined for its integrity and hemostasis. This
can be reinforced by box-mattress sutures (as
designed by the author-mattress suture placed
across the staple line, being parallel to the staple
line with the two buried strips of mattress suture
being equidistant from the staple line) placed at
12, 3, 6, and 9 o’clock positions, using either
chromic catgut or synthetic absorbable sutures.
The sutures at 9 and 3 o’clock positions ensure
that the “dog-ear of tissue” left at the junction of
anterior and posterior resection is secured. This
ensures the recto-rectal anastomosis being
smooth, secure, and dry. Postoperative management is the same as for standard stapled hemorrhoidopexy (view the procedure at www.
endosurgeon.org ).
11.6.2 Pelvic Organ Prolapse Surgery with STARR (POPSTARR)
With the better understanding of pelvic fl oor
dysfunction on dynamic MRI defecography, the
surgical approach has become more precise. In
case of multi-compartmental pelvic fl oor failure,
STARR alone will address the posterior
compartment, leaving out the other two unaddressed. To address the anterior and middle compartment, an extraperitoneal prosthetic
suspension is done laparoscopically to string the
uterovaginal junction to the anterior abdominal
wall. The laparoscopic extraperitoneal sling for
the anterior and middle compartment is supplemented by the STARR procedure for the posterior compartment (view the procedure at www.
endosurgeon.org ).
11.7 Descending Perineum Syndrome
It is often associated with constipation disorder.
It is thought to be secondary to many years of
straining to evacuate stool and pelvic fl oor laxity
due to childbirth. Some believe that the straining
is often against a non-relaxing sphincter mechanism. Though it can be easily identifi ed on physical examination, its extent can be better
determined with defecography. It is defi ned when
the anorectal angle descends more than 3 cm
below the level of the ischial tuberosity. When
the descent is more than 1.5 cm of stretch (beyond
which pudendal nerve is seen), it causes progressive denervation of external sphincter mechanism
(striated muscle dysfunction), and the result is
incontinence (Park et al. 1977 ). Many of the
patients do not suffer from fecal incontinences,
158
B.B. Agarwal and P. Sivalingam
but instead report symptoms of progressive
obstructive defecation. The fi nding of abnormal
perineal descent alone is not an indication for
surgery. Treatment is mainly medical and aimed
at treating the presenting complaint of constipation with diet, laxatives or enema, and biofeedback therapy.
11.8 Functional Pelvic Pain Disorders
This entity includes those anorectal and pelvic
pain disorders where there is no underlying structural or specifi c pathology. Pudendal neuralgia
which refers to pain in the distribution of one or
both pudendal nerves is due to entrapment of
pudendal nerve between sacrotuberous and
sacrospinous ligaments and Alcock’s (pudendal)
canal secondary to trauma (cyclists or rowers)
and is not classifi ed among functional pelvic pain
disorders. It may manifest as vulvodynia, proctalgia, prostatodynia, and orchialgia. Pudendal
nerve latency is prolonged in these patients.
These patients are treated by neurolysis or pudendal nerve block under guidance of ultrasonography or computed tomography
These disorders are classifi ed into urogynecological conditions like painful bladder syndrome (cystitis) or chronic pelvic pain syndrome
(chronic prostatitis), levator ani syndrome,
and anorectal disorders (proctalgia fugax).
Coccygodynia (pain and tenderness in the coccyx) is a variant of levator ani syndrome. Pain
is the predominant symptom in these disorders
though they have associated defecation problem.
Symptoms may overlap as these organs are in
close relation to each other (Barry et al.
2008 ).
11.8.1 Levator Ani Syndrome
This syndrome is characterized by dull anorectal
pain which is constant, frequent, prolonged (for
hours to days), and often associated with tenderness of the levator ani on palpation. Pain is worse
in sitting than standing or lying down position.
The other names for this syndrome are puborectalis syndrome, pyriformis syndrome, levator spasm,
diaphragma pelvis spastica, and pelvic tension
myalgia. Its prevalence in the common population
is 6 % and is more common in women (Drossman
1993 ). The symptoms are due to spasm of the
et al.
levator ani, the pathophysiology of which is not
known. Association with psychosocial disorders
is also not clear (Anderson et al. 2008 ).
After excluding the other causes of pain (using
endoscopy, USG/MRI, defecography), treatment
is initiated with digital massage of the levator ani,
myofascial pelvic fl oor physiotherapy, sitz baths,
diazepam, and muscle relaxants (Oyama et al.
2004 ). Biofeedback therapy gives relief in some
patients (Heah et al. 1997 ). Sacral nerve stimula-
tion reduces severity of pain in patients with
chronic pain. Patients not responding may be
offered per rectal trigger point steroid (triamcinolone) injection. Associated depression should be
given due consideration and addressed accordingly (Dodi et al. 1986 ). Surgery should be
avoided.
Coccygodynia is a part of the levator syndrome
probably caused by spasm of the pubococcygeal
portion of the levator ani muscle. The pain is
directed to the coccyx, and classically the pain
exacerbates when the person rises from a sitting
portion. There is point tenderness of the coccyx
rather than the levator ani muscle. This condition is
treated with steroid injections. If there is no relief,
operative manipulation and injection therapy are
considered. Coccygectomy is rarely indicated.
11.8.2 Proctalgia Fugax
Unlike levator syndrome, proctalgia fugax is
defi ned by the sudden onset of severe pain in the
area of the anus and rectum lasting for several seconds but usually no more than a minute or two in
the absence of any organic disorder. Occasionally
it may last for up to 30 min. It occurs infrequently
(once in a month or less often). It is often precipitated by anxiety and stressful events. Its prevalence ranges from 8 to 18 % (Drossman et al.
1993 ; Thompson 1981 ). It rarely occurs before
puberty and equally in males and females.
The condition is secondary to spasm of the
rectum or pelvic fl oor muscles (Eckardt et al.
2004 ). Many patients may be anxious,
11 Pelvic Floor Dysfunction
159
perfectionists, and hypochondriac (Pilling et al.
1965 ). Hereditary form has also been reported
(Kamm et al. 1991 ; Celik et al. 1995 ). Since the
pain episodes are brief and infrequent, treatment
is impractical and prevention not feasible.
Patients need to be reassured. In patients with
frequent symptoms, inhalation of beta-2 adrenergic agonist (salbutamol) and alpha-2 adrenergic
agonist (clonidine) has been found to reduce
symptoms (Eckardt et al. 1996 and Swain 1987 ).
Patients with associated psychological disorders
should be treated accordingly.
Acknowledgment I am grateful to my colleague Dr.
Manish K. Gupta for making the various line diagrams in
this chapter based upon standard anatomical descriptions.
I am grateful to Nayan Agarwal and Pooja Pant for manuscript preparation.
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Perianal Dermatology
Iffat Hassan and Parvaiz Anwar Rather
1 2
12.1 Introduction
Knowledge about the dermatoses in the perianal
region is of paramount importance, as it is a
vital area for dermatologists, surgeons, and
internists, especially specialists in gastrointestinal diseases, because of its specialized anatomy
and physiology. Perianal dermatoses may occur
as a primary disease or secondary to systemic
disorders. They may comprise dermatoses ranging from benign eczematous processes to
advanced malignancies, and it is important to
distinguish common problems from those with
more serious pathology. This chapter gives a
brief overview of the dermatoses in the perianal
region laying emphasis on important clinical
aspects of use to the clinician. The perianal dermatoses have been described under the major
headings of infl ammatory dermatoses, infections, and benign, premalignant, and malignant
conditions. Besides these, an attempt has also
been made to dwell on some other relevant
aspects of perianal dermatoses.
I. Hassan , MD (*) • P. A. Rather , MD
Head Department of Dermatology , STD & Leprosy,
Government Medical College , Srinagar ,
Jammu and Kashmir , India
hassaniffat@gmail.com;
e-mail:
parvaizanwar@gmail.com
12.2 Structure and Function:
Special Features
The perianal region has numerous eccrine sweat
glands, apocrine glands, and variable number of
sebaceous glands, both in pilosebaceous units
and as “free” sebaceous glands. These anatomical and physiological considerations are important for the occurrence of various dermatoses in
the perianal area. The anus is meant principally
for the evacuation of feces from the gastrointestinal tract and the deep natal cleft is a special site
with abutting of mucocutaneous junctions of
anus and genitalia, and mucous discharges,
excreta, and moisture can be easily retained
within it leading to various perianal dermatoses.
The major dermatoses in the perianal area are
tabulated in Table 12.1 .
12.3 Infl ammatory Dermatoses
Infl ammation in the perianal area may result from
the coexistence of several factors including hemorrhoids, anal discharge, proctitis, presence of
fi ssures, or the effect of scratching. In all cases of
perianal and perineal infl ammation, the urine
should be tested, and skin swabs and scrapings
examined for organisms, especially tinea. Any
irregularity of the bowels that causes straining or
soiling should be evaluated and corrected.
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_12
161
162
I. Hassan and P.A. Rather
Table 12.1 Common dermatoses in the perianal area
1. Infl ammatory dermatoses
2. Infections
3. Benign, premalignant and malignant dermatoses
Contact dermatitis
Perianal dermatitis of the newborn
Seborrheic dermatitis
Atopic dermatitis
Psoriasis
Lichen simplex chronicus
Lichen sclerosus et atrophicus
Hidradenitis suppurativa
Crohn’s disease
Miscellaneous infl ammatory dermatoses
Other related conditions
Anal fi ssures
Anal fi stula
Pilonidal cyst/sinus
Pruritus ani
Folliculitis and furunculosis
Streptococcal dermatitis/perianal cellulitis
Perianal abscess
Ecthyma gangrenosum
Necrotizing infections
Common mycoses
Thread/pinworms
Sexually transmitted diseases
Miscellaneous infections
Hemorrhoids
Porokeratosis
Anal intraepithelial neoplasia (AIN)
Carcinoma of the anus
Extra-mammary Paget’s disease (EMPD)
Miscellaneous malignancies
4. Congenital and developmental abnormalities
5. Trauma in the perianal area
6. Chronic perianal pain
patients as a consequence of overzealous cleanliness with detergents, irritation by stools as in urinary or fecal incontinence, chronic diarrhea, or
bowel disease including tumors or infl ammatory
bowel disease, along with ingestion of spicy
foods or cathartics (Odom et al.
2000 ).
Allergic contact dermatitis (ACD) is type IV
delayed-type or cell-mediated hypersensitivity reaction occurring in a previously sensitized individual
after repeated contact with the allergen. Allergic dermatitis can have many causes, mainly neomycin,
“caine mix,” quinolines, lanolin, and ethylenediamine (Wilkinson et al. 1980 ). Other allergens
include biocide preservatives and fragrances in
moistened toilet tissue (Swinyer 1980 ; Van Ginkel
and Rundervoort 1995 ; De Groot et al. 1991 ), lido-
caine (Hardwick and King 1994 ), tetracaine (ameth-
ocaine) hydrochloride (Sanchez-Perez et al. 1998 ),
local anesthetics used in topical antipruritics for piles
(Lee 1998 ), and mitomycin C (Fisher 1991 ). The
role of food allergy in causing perianal symptoms is
debatable. Homosexual men may be susceptible to
condom hypersensitivity (Fisher 1987 ).
The clinical presentation can vary, but typically there is erythema and varying degrees of
edema, vesiculation, maceration, and oozing.
Symptoms include pruritus and/or a burning sensation in the affected area. Diagnosis is based on
detailed history taking, clinical examination, and
patch testing for ACD. Treatment is mainly based
on removal of irritant or allergen, topical or oral
corticosteroids, symptomatic treatment with antihistamines, and hydrophobic barrier creams for
long-term prevention of recurrences.
12.3.2 Danthron Contact Dermatitis
12.3.1 Contact Dermatitis
Contact dermatitis in perianal region, one of the
most common eczematous processes, can be
either primary irritant or allergic.
Primary irritant contact dermatitis is caused
by skin contact with an irritant resulting in
infl ammatory reaction in a previously nonsensitized individual. Irritant contact dermatitis is
seen in infants as diaper dermatitis and in older
This is a form of irritant reaction to the use of danthron as a laxative (Barth et al. 1984 ). Danthron
(1,8-dihydroxyanthroquinone) is reduced in the
large bowel to active agent 1,8-dihydroxyanthron,
which is chemically identical to dithranol, so causing “dithranol burn”-like reaction. There is a sharply
demarcated erythema corresponding to the area of
contact with feces. It is usually seen in Hirschsprung’s
disease or encopresis and sometimes in elderly
incontinent patients (Barth et al. 1984 ).
12 Peria nal Der matol o g y
163
12.3.3 Perianal Dermatitis
of the Newborn
Perianal dermatitis of newborn has been reported
to have an overall incidence of 5–20 % (Hidano
et al. 1986 ). The precise cause of perianal derma-
titis in the newborn remains unknown, and it is
assumed to represent an irritant response to fecal
constituents. Generally erythema of the perianal
skin makes its initial appearance during the fi rst 8
days of life and is confi ned to 2–4 cm diameter
zone around the anus (Pratt 1951 ). The affected
skin may be edematous and superfi cially eroded
in more severe cases. Perianal dermatitis may
sometimes be associated with primary irritant
napkin dermatitis or seborrheic dermatitis of
infancy. Attention to hygiene, emollient application, and a protective lubricant are important in
the management.
12.3.4 Seborrheic Dermatitis
Seborrheic dermatitis is a common eczematous
process with a predilection for areas with abundant pilosebaceous glands, such as the scalp,
nasolabial folds, and eyebrows, but can also
occur in the perianal area. The etiology has not
been fully elucidated, but possible association
with the yeast Malassezia furfur is opined. It is a
chronic condition characterized by pruritus and
greasy scaling together with erythema, edema,
vesiculation, maceration, and oozing of varying
degrees, often bilateral and symmetric. Diagnosis
is made mainly by clinical examination and less
commonly through the histological fi ndings on
biopsy and response to treatment. Topical application of mild to moderate potency corticosteroids along with antifungals is usually all that is
needed. Oral agents may be required in recalcitrant cases.
12.3.5 Atopic Dermatitis
Atopic dermatitis, the prototypical eczematous
skin disease, may involve perianal region especially in children, although more common sites
Fig. 12.1 Perianal and gluteal psoriasis
of involvement are the antecubital and popliteal
fossae, face, neck, chest, and wrists. The hallmark of atopic dermatitis is pruritus, which leads
to excoriations, with resultant scratching leading
to subsequent development of chronic changes of
lichenifi cation and even scarring. Atopic dermatitis passes through acute (erythema, edema, vesiculation, and oozing), subacute (crusting, scaling),
and chronic (hyperpigmentation, accentuation of
skin lines, and skin thickening) stages, with secondary bacterial infection. Treatment is commonly based on proper moisturization, topical
corticosteroid preparations, and oral antihistamines, but more severe cases can be treated with
oral corticosteroids, ultraviolet light, and topical
or oral immunosuppressants.
12.3.6 Psoriasis
Psoriasis is chronic, infl ammatory disease of the
skin, characterized by erythematous plaques with
hyperkeratosis, with the typical psoriasis plaque
being well circumscribed, red, and scaly, topped
by typically large, easily detachable, silver-toned
scales (Fig. 12.1 ). Psoriasis of the anogenital
region may look quite different from psoriasis at
other sites. In the intergluteal fold, the plaques
tend to be more humid and less scaly, with more
maceration and fi ssuring. Silvery scales are rarely
noticed on perianal lesions. Psoriasis in the perianal area may be diffi cult to treat.