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358 The ASCRS Manual of Colon and Rectal Surgery
• Many patients who have tried fi ber without benefi t may benefi t
from judicious use of Imodium ® or Lomotil ® to lessen frequency
and fi rm up stools. Questran ® , in varied doses, has been helpful
in my practice to fi rm loose stools.
• Environmental factors should be altered as much as possible
with removal of irritants such as soaps, perfumes, dyes in clothes
or wiping tissues, alcohol- or witch hazel-containing agents,
and moisture.
• Dove ® is free of conventional soap and is the preferred bathing
agent.
• Bidets are not common in the United States, but detachable
shower heads are common and inexpensive and when equipped
with long tubing and handle may be a useful item for cleansing
the perianal skin and anal canal and eliminating soap residues
by fl ushing with water in the squatting position.
• Subsequent drying with a hair dryer can eliminate moisture,
and application of an athlete’s foot powder or barrier cream will
lubricate and prevent maceration of the skin in the cleft and
anal canal.
• Zeasorb ® is an alternate lubricating, drying agent in powder form.
Cornstarch is to be avoided because it is culture medium for yeast.
• Dilute white vinegar (1 tablespoon in an 8-ounce glass of
water) on a cotton ball is a cheap effective nonsoapy cleanser
that can be kept at the toilet when bathing is not handy.
• Burow’s solution, 1:40 (Domeboro ® tablet one in 12 ounces
of water, or one in 6 ounces for 1:20) is another nonirritating
cleanser that can be kept refrigerated in a plastic squeeze bottle
and used in lieu of soap or plain water.
• Balneol ® is a commercially available mineral oil-based preparation that can be kept in a pocket and squeezed onto toilet paper
to make a soothing cleansing agent when using public facilities.
• Doxepin (Sinequan ® orally) is available topically as an effective
antihistamine (Zonalon ® ), but orally is 1,000 times more potent
than diphenhydramine (Benadryl ® ) for elimination of itching and
may a useful adjunct at bedtime to avoid nocturnal scratching.
• Nocturnal scratching, of which the patient may be unaware,
is probably a signifi cant contributing factor in most cases of
idiopathic pruritus ani. Patients who are awakened by the urge
to scratch should be instructed to gently cleanse the area to
eliminate any fecal seepage and reapply their steroid or barrier
cream (whichever is in effect at the time) but not to scratch.
16. Perianal Dermatology and Pruritus Ani 359
• No data exist on the infl uence of clothes or other fomites on
pruritus, but from a practical standpoint, loose underwear that
allows air circulation and promotes dryness makes sense.
• Fresh clothes should be used daily that have been laundered
without perfume, perhaps with the addition of a small amount
of chlorine bleach to secure lowered bacterial counts.
• Patients who come to the offi ce with acute moderate to severe
changes of the skin are treated by application of Berwick’s dye
(combination of gentian violet and brilliant green) which has
alcohol content and stings, often relieving the itch.
– The dye is dried with compressed air or a hair dryer.
Benzoin tincture is applied over top of this as a barrier
and dried similarly. This preparation will stay in place for
several days if only water is used to cleanse and gives
excellent temporary relief of symptoms and allows
reepithelialization of broken skin.
– Berwick’s is suitable as an offi ce applied remedy but is
generally not for home application.
• Patients who have mild to moderate symptoms with minimal
skin changes will often respond to topical 1% hydrocortisone
cream which can be combined with menthol, 0.5–1.0%, and
topical antibiotics (gentamicin, clindamycin, or bacitracin) or
antifungals (clotrimazole, nystatin). This preparation is applied
at night and in the morning after bathing, being used daily until
symptoms subside.
• Patients with thickened skin and chronic moderate or severe
changes should be approached with higher intensity therapy,
with a medium or high potency steroid for a limited, defi ned
period of time (Table 16.8 ; nonsteroidal topical therapies are
listed in Table 16.9 ). It is important to prescribe brand names
when dealing with topical steroids because of the vehicle in
which it is delivered, and the particular salt matter as to potency
(Table 16.8 ). For instance, betamethasone as Diprolene ® is
more than 1,000 times more potent than Valisone ® cream, with
Valisone ® ointment somewhere in between.
• Emphasize to patients that a high-potency steroid should be
used for a limited period of time, generally 4–8 weeks.
• When normalization of the skin has been achieved, switch
them to a mild steroid such as hydrocortisone 1% or Locoid ®
0.1% with tapering frequency of application down to once or
twice a week or to total elimination.
360 The ASCRS Manual of Colon and Rectal Surgery
Table 16. 8. Relative potency of topical steroids (descending order).
Group 1 (most potent) Group 4
Betamethasone dipropionate 0.05%
(Diprolene
®
)
Clobetasol propionate 0.05%
(Temovate
®
)
Desoximetasone 0.05% (Topicort
LP ® )
Flurandrenolide 0.05% (Cordran
Group 2 Group 5
Desoximetasone 0.25% (Topicort
Fluocinonide 0.05% (Lidex
®
) Betamethasone valerate cream 0.1%
(Valisone
®
) Hydrocortisone butyrate 0.1%
(Locoid
®
)
®
)
Triamcinolone acetonide 0.1%
(Kenalog
®
)
Group 3 Group 6 (least potent)
Betamethasone valerate ointment 0.1%
(Valisone
®
)
Triamcinolone acetonide 0.5%
(Aristocort
®
)
Alclometasone dipropionate 0.05%
(Aclovate ® )
Hydrocortisone 1%
Table 16. 9. Nonsteroidal topical therapy for itching.
Berwick’s dye (crystal violet 1% + brilliant green 1% + 95% ethanol 50% +
distilled H
O q.s.ad. 100%) with benzoin barrier
2
Burow’s solution 1:40
Calmoseptine
Camphor
Capsaicin (Zostrix
®
®
(0.1–3%)
®
0.025%, Dolorac ® 0.25%)
Cold compress (ice cube)
Doxepin 5% (Zonalon
®
)
EMLA (eutectic mixture of local anesthetics)
Hot compress (120°F)
Macrolide topical agents (Tacrolimus and Pimecrolimus)
Menthol (0.125–1%)
Phenol (0.125–2%)
Pramoxine
Shake lotions (calamine + additives)
Topical “caines”
®
)
• Patients who have frankly eroded or denuded skin may benefi t
from topical antibiotics. Silver sulfadiazine cream to which
hydrocortisone or triamcinolone and menthol have been added
may be soothing and promote regrowth of epidermis over
ulcerated areas while suppressing the infl ammation that can
cause fi ssuring in the skin.
16. Perianal Dermatology and Pruritus Ani 361
Table 16. 10. Adverse reactions to topical steroids.
Skin atrophy with telangiectasia, pseudoscars, purpura, striae, spontaneous
bleeding
Tinea, impetigo, scabies incognito
Allergic contact dermatitis
Systemic absorption with adrenal suppression
Burning, itching, dryness from vehicle
Rebound worsening after withdrawal
• Skin atrophy is a serious problem with prolonged use of potent
steroids, but each of the steroid preparations differs in its
tendency to cause trouble.
– Creams cause comparatively greater atrophy than ointment
preparations containing identical ingredients.
– Newer, double-ester, nonfl uorinated steroids may prove
to be less atrophogenic than the older preparations.
– Macrolide topical immune modulators (tacrolimus and
pimecrolimus) seem to be free of the problem of skin
atrophy, a fact that enhances their appeal for use on the
apposed skin of the cleft. These compounds may have
some intrinsic antifungal activity as well.
– Table 16.10 lists the potential complications of topical
steroids, which are not to be taken lightly, and are all the
more important because they are preventable complications
of treatment excess.
Anal Tattooing
• Every practice has a small number of patients who respond
poorly to treatment and whose symptoms are severe enough to
alter life and happiness. These refractory patients may benefi t
from anal tattooing.
• A modifi ed anal tattooing technique consists of the intradermal
and subcutaneous injection of the following solution with the
patient under intravenous sedation in the prone jackknife
position: 10 mL 1% methylene blue + 5 mL normal saline +
7.5 mL 0.25% bupivacaine with epinephrine (1/200,000) + 7.5
mL 0.5% lidocaine.
• Certain individuals have found this sensation very disagreeable, so I am careful to warn them in detail before treatment.
17. Sexually Transmitted Diseases
A. Introduction
• Site and route of infection determine the symptoms caused by
Sexually Transmitted Diseases (STDs).
• Infections of the distal anal canal, anoderm, and perianal skin
are similar to lesions in other parts of the genitalia and perineum caused by the same organisms. These are typically the
result of anal receptive intercourse but in some instances represent contiguous spread from genital infections.
• Proctitis from sexually transmitted organisms is almost always
from anal intercourse.
• Current estimates are that less than 2% of adult males regularly
practice anal receptive intercourse and between 2 and 10% participate in homosexual activity at any point in their life.
• Between 5 and 10% of females engage in anal receptive intercourse “with some degree of regularity” and females seem to
be more likely than men to have unprotected anal intercourse.
• Diffi culty in correct diagnosis and appropriate treatment of
STDs of the anorectum is caused by several factors:
– The signs and symptoms of infection are more organ
related than organism related so that no symptom or
symptom complex or physical fi nding is diagnostic for
many STDs.
– The presence of more than one organism is not uncom-
mon, especially with anogenital ulcerations.
– Determining true pathogen from colonizing organisms
may be diffi cult.
D.E. Beck et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery, 363
DOI: 10.1007/978-0-387-73440-8_17, © Springer Science + Business Media, LLC 2009
364 The ASCRS Manual of Colon and Rectal Surgery
– Lastly, there is a lack of rapid sensitive diagnostic tests
for many STDs so that empiric treatment is frequently
required.
B. Overview of Anorectal Immunology
• The mucosa shed from the rectum contains immunoglobulin A
which traps foreign antigens and expels them with stool, preventing them from reaching the anorectal crypt cells.
• Cellular immunity is controlled by the Langerhans, or dendritic
cells which communicate with the T cells through a complicated mechanism and essentially prime the T cells to identify
foreign cells. This then allows the entire complement of cellmediated immunity to destroy that which is alien.
• It is known that whereas human papilloma virus (HPV)
increases Langerhans cells, human immunodefi ciency virus
(HIV) may damage their effectiveness. In addition, pathogens
such as HPV and herpes simplex virus (HSV) invade into the
host cell, combining with cellular elements or the genome,
thus evading surveillance mechanisms.
• HIV is known to deplete cell-mediated immunity by depletion
of T cells and destruction of Langerhans cells. This allows,
through unknown mechanisms, propagation of oncogenic
processes such as HPV to become dysplastic.
• Breakdown of the mucous complex protecting the rectum is
seen in various diseases contracted through anal intercourse.
The physical act of intercourse abrades the mucous lining and
delivers pathogens directly to the crypt and columnar cells
allowing for easy entry.
• In the case of recurrent viral attacks (HPV, HSV), it seems that
the level of functioning T cells may have an impact on recurrence of warts or herpes outbreaks.
• The mechanics of anoreceptive intercourse, as compared with
vaginal intercourse, almost always results in denuding of the
protecting cellular and mucous layer of the anus and rectum.
• Latex allergies, with condom use, may also be seen causing
severe invasive and erosive proctitis and should be in the differential of a caustic burn to the rectum after sexual anoreceptive
intercourse.
17. Sexually Transmitted Diseases 365
C. Diagnosis and Management
of Bacterial Pathogens
Gonorrhea
• Neisseria gonorrhoeae , the Gram-negative diplococcus
responsible for gonorrhea, is probably the most common bacterial STD affecting the anorectum.
• Peak incidence for all forms of gonorrhea is in the late teens
for females and early 20s for males. African-Americans have a
30-fold higher rate of infection than white Americans.
• Infection from N. gonorrhoeae occurs in columnar, cuboidal,
or noncornifi ed epithelial lined cells of the urethra, endocervix,
rectum, and pharynx and is frequently asymptomatic.
• The incubation period ranges from 3 days to 2 weeks.
• Untreated infection may lead to disseminated gonococcal
infection with transient bacteremia, arthritis, and dermatitis.
• Thirty-fi ve to fi fty percent of women with gonococcal cervicitis have concomitant rectal infection which is believed to be
from contiguous spread from the genital infection.
• A large percentage of patients who culture positive for rectal
gonorrhea are asymptomatic - up to 50% of males and 95% of
females. Asymptomatic rectal infection constitutes the main
reservoir of gonococcal disease in homosexual men.
• Symptomatic anorectal gonococcal infection results in pruritus, tenesmus, bloody discharge, mucopurulent discharge, and/
or severe pain.
• External inspection of the anus is generally unremarkable; however, nonspecifi c erythema and superfi cial ulceration may occur.
• Anoscopy reveals a thick purulent discharge, which classically
is expressed from the anal crypts as pressure is applied externally on the anus. Nonspecifi c proctitis may be present with
erythema, edema, friability, and pus.
• Diagnosis is confi rmed by culture on selective media (ThayerMartin or Modifi ed New York City) incubated in a CO 2 -rich
environment and Gram’s stain of directly visualized discharge.
The use of lubricants other than water may introduce antibacterial agents during anoscopy and decrease diagnostic yield.
• Nonculture detection of gonorrhea is being used more frequently especially in urethral and cervical infections. Nucleic
acid amplifi cation tests (NAATs) such as polymerase chain
366 The ASCRS Manual of Colon and Rectal Surgery
Table 17.1. Treatment of anorectal gonococcal infection. 14
One of the following as a single dose
Ceftriaxone 125 mg intramuscularly
Ciprofl oxacin 500 mg orally
Ofl oxacin 400 mg orally
Levofl oxacin 250 mg orally
Cefi xime 400 mg orally
reaction (PCR) and ligase chain reaction (LCR) and nonamplifi ed DNA probes provide sensitivities of greater than 95% but
do not provide antibiotic susceptibility data.
• The most current recommended treatment regimens from the
Centers for Disease Control (CDC) were published in 2002
and are listed in Table 17.1 .
• Concurrent HIV infection does not alter treatment for anorectal
gonorrhea. Because of the high rate of concomitant infection
with chlamydia, patients treated for gonococcal infections should
be given appropriate treatment for chlamydia at the same visit or
measures to rule out chlamydial infection should be taken.
• Routine follow-up at 3 months is no longer necessary because
current treatment provides near 100% effi cacy. Patients with
persistent symptoms after treatment should be followed and
cultured as should those treated with nonstandard antibiotics.
• Sexual partners from the past 60 days should be treated and
patient should abstain from intercourse until treatment is completed and symptoms resolved.
Chlamydia/Lymphogranuloma Venereum
• Chlamydia trachomatis is an obligate intracellular bacterium
that is sexually transmitted and results in clinical infections
that are similar to those caused by N. gonorrhoeae . Simultane-
ous infection with both organisms is common.
– Chlamydia is the most frequently reported STD in the
United States with an annual incidence of about 3 million
cases per year.
– Anorectal transmission of chlamydia is through anore-
ceptive intercourse although secondary involvement can
occur as a late manifestation of genital infection.
– The incubation period for chlamydia is 5 days to 2 weeks.
17. Sexually Transmitted Diseases 367
• Lymphogranuloma venereum (LGV) is caused by LGV serovars L1–L3
– Serovars D through K [non-LGV serovars] are respon-
sible for proctitis and common genital infections
(chlamydia).
– L1–L3 LGV serovars produce a much more aggressive
infection with perianal, anal, and rectal ulceration.
– Lymphadenopathy develops in draining nodal basins -
iliac, perirectal, inguinal, and femoral - several weeks
after initial infection. Large indurated matted nodes and
overlying erythema may produce a clinical picture similar to syphilis.
• Diagnosis of chlamydia as the causative agent in proctitis can
be diffi cult. Proper specimen collection increases diagnostic
yield and consists of a cotton or Dacron swab with an inert
shaft (plastic or metal).
– Tissue culture for chlamydia is relatively insensitive and
is not widely available because of cost and technical
requirements.
• Antigen detection by direct fl uorescent antibody (DFA) or
enzyme immunoassay DFA is highly specifi c, widely available, and does not require rapid transportation or refrigeration.
• The two recommended treatment regimens for rectal chlamydia (non-LGV) are azithromycin, 1 g orally as a single dose or
doxycycline, 100 mg orally, twice a day for 7 days.
• Treatment of LGV is with doxycycline or erythromycin for 21
days. In patients with HIV and LGV, prolonged therapy may
be required.
• Abstinence from sexual intercourse should last until 7 days
after treatment with azithromycin or completion of 7 days of
doxycycline.
Syphilis
• Syphilis is an STD caused by the spirochete Treponema pallidum
that can present in one of several progressive stages - primary
(chancre or proctitis), secondary (condyloma lata), or tertiary.
• The primary stage of anorectal syphilis appears within 2–10
weeks of exposure via anal intercourse. The chancre begins as
a small papule that eventually ulcerates.
368 The ASCRS Manual of Colon and Rectal Surgery
• Anal ulcers are frequently painful (in contrast to genital ulcers)
and without exudates. They may be single or multiple and
located on the perianal skin, in the anal canal, or distal rectum.
Differentiation from idiopathic anal fi ssures may be diffi cult.
• Painless but prominent lymphadenopathy is common.
• Untreated lesions in this stage will usually heal in several weeks.
• Hematogenous dissemination of untreated syphilis leads to a
secondary stage that occurs 4–10 weeks after primary lesions
appear. Nonspecifi c systemic symptoms from this infection
include fever, malaise, arthralgias, weight loss, sore throat,
and headache. A maculopapular rash is seen on the trunk and
extremities.
• Condyloma lata, another secondary manifestation, are gray
or whitish, wart-like lesions that appear adjacent to the primary chancre and are laden with spirochetes. Untreated, the
symptoms of syphilis usually resolve after 3–12 weeks - of
these patients, approximately one-fourth will have a relapse of
symptoms in the fi rst year. This is called early latent syphilis.
• Diagnosis in the primary or secondary stage is made by visualization of spirochetes on dark-fi eld microscopic examination
of scrapings from chancres.
• Positive nontreponemal tests should be confi rmed by a treponemal test such as the fl uorescent treponemal antibody absorption test (FTA-ABS), which remains positive for life.
• A single intramuscular injection of 2.4 million units of benzathine penicillin G is the treatment for primary and secondary
syphilis. Penicillin-allergic patients are treated with doxycycline (100 mg orally, twice daily for 14 days) or tetracycline
(500 mg orally, four times a day for 14 days).
• Partner notifi cation, testing, and treatment depends on stage
at diagnosis of the index case. At-risk partners include sexual
contacts (a) within the prior 3 months plus duration of symptoms for patients with primary syphilis; (b) within the prior 6
months plus duration of symptoms for patients with secondary
syphilis; and (c) within the prior year for those with early latent
syphilis.
Chancroid
• Chancroid is an ulcerating STD caused by the Gram-negative,
facultative anaerobic bacillus Haemophilus ducreyi .
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