After you complete the diagnosis, it’s time to move to the next stage: treatment. In this short video, Dr. Abhitabh Patil will review some of the most common diagnoses in reference to the anorectal area and teach you the associated treatment options.
Watch this short video to learn:
Most commonly encountered anorectal diagnoses
Specifics on pain management
Different therapy and treatment options
Referral options for your patients who need additional support
Treatment Options for Anorectal Disorders
Dr. Abhitabh Patil: “In this section, we'll discuss management of various disorders that were presented. First, let's talk about anal fissures. This is most often in the anterior or posterior midline. In fact, 80% of patients or greater, have an anal fissure in the posterior or anterior midline. If it's found in the lateral positions, this should prompt an evaluation for other diseases, such as Crohn's disease. This is usually found by a rectal exam, by eliciting tenderness during the rectal exam, especially when palpating the posterior or anterior midline. You might even see a sentinel pile on visual inspection. Treatment for anal fissure includes soluble fiber of up to 30 grams per day in divided doses, sitz baths, 15 minutes at a time, up to three times a day, including or without Epsom salts, topical agents, such as Rectiv, which is nitroglycerin 0.4%, used twice daily for about two weeks. Or a compounded form of nitroglycerin 0.125%, used twice a day, compounded for two weeks. Or nifedipine or diltiazem, in ointment form for two weeks, applied locally, or lidocaine 1-2%, twice a day, especially if patients are complaining of acute severe pain. This is used for pain relief or topical analgesia. Seven days is my maximum for using this. You can also use hydrocortisone suppositories or Preparation H twice a day, for acute pain, but no more than seven days.
The next most commonly encountered condition is a thrombosed external hemorrhoid. If you're lucky and the patient comes in within the first 72 hours, you can perform a local bedside thrombectomy by performing a superficial incision and extracting the thrombus, and then packing the wound. If it's more than 72 hours since the onset, then management is usually conservative, including fiber, sitz baths and pain control.
Anorectal carcinoma is sometimes confused as hemorrhoidal complaints by patients. If this is encountered, patients will need a referral to a colorectal surgeon and an oncologist. Rectal prolapse can also be seen. And if this is found on rectal examination, then a referral to a colorectal surgeon is appropriate for rectopexy. Very mild cases can be treated with hemorrhoidal banding, as this will tack down the rectum and prevent it from prolapsing. Pruritus Ani, which is an itching condition, usually centers around skin hygiene. These patients often wipe excessively or apply alcohol-based wipes to their anus. This further complicates the problem because it dries out the skin and prompts more itching. So we tell patients to avoid hot baths, avoid excessive wiping, avoid alcohol-based products, such as baby wipes, avoid soaps, alcohols or anything else that's going to worsen the drying of the skin, because this leads to a worsening of the itch-scratch cycle. Sometimes we'll ask them to apply agents that will actually moisturize the skin such as petroleum jelly, or even Vicks, which has capsaicin in it, and can actually provide topical relief. Capsaicin cream, low doses, and apply topically can also be helpful.
Sometimes dermatitis is encountered. This can be of a variety of causes. If it's fungal, sometimes topical Lotrimazole can be used, which is athlete's foot cream. Eczema can also be a cause. In which case, topical hydrocortisone cream can be used. If this appears to be a psoriasis or psoriasiform, then a dermatology referral is needed. And if you're just not sure, referring them to a dermatologist can be helpful.
Internal hemorrhoids are usually treated with hemorrhoidal banding or laser therapy. Keep in mind, there are three major hemorrhoids, the right anterior, right posterior, and left lateral. I usually band one of these at a time. This reduces the risk of bleeding and other complications. This procedure is simple, quick, effective, and safe. The disadvantage of performing this one at a time is multiple visits, but patients often tolerate this well. Laser therapy can also be performed. It's safe, however, it is slightly more time consuming and it’s modestly complex. Advantage is that you can treat multiple hemorrhoids at once, so sometimes this is appropriate for patients.
Probably one of the more serious conditions is a perirectal abscess. Patients usually will present with severe localized tenderness and a fluctuant mass on digital rectal examination. Prompt referral to colorectal surgeons for incision and drainage is appropriate. Antibiotics may also be helpful. Describing the location for a colorectal surgeons is also very helpful.
Sometimes these abscesses as seen, in this diagram with the blue circles, can be ischiorectal. That is between the ischium bone and the rectum. They could be inter-sphincteric, that is between the internal anal sphincter and the external anal sphincter, they can be perianal, just around the anal skin, or they can be supralevator, or that is above the external anal sphincter, but external to the internal anal sphincter.
Anal rectal ultrasound can also be used for the evaluation of patients, especially for those with incontinence. On the top left, you see normal endoscopic ultrasound appearance of the internal anal sphincter muscle. This is the thick black ring around the probe. They should measure at least five millimeters. On the right, at the top, you can see an internal anal sphincter muscle, the black ring, which is very thin. This is usually a sign of atrophy. At the bottom, you can see that the black ring is disrupted. This is a patient who has an obstetric trauma, and this can also be a cause of fecal incontinence. The surgical approach to fecal incontinence usually includes anterior sphincteroplasty, it may, in severe cases, involve a colostomy. There's improved continence in 85% of patients with sphincter defects. The failure rate of a sphincteroplasty is about 50% after three to five years.
Colostomy is only performed again in most severe cases. InterStim is another technology that's been used to treat fecal incontinence. Initially, a temporary pacer is placed as a trial. If the patient has a response, then a permanent placer can be used in its place. Solesta is an injection of a local agent that is used to induce a local reaction and cause bulking of the internal anal sphincter. This has been shown to improve incontinence symptoms in some patients.
Probably the most effective therapy for fecal incontinence is biofeedback therapy. Treatment revolves around strength training, coordination, and improving rectal sensation. Patients are asked to squeeze in response to reflex inhibition of internal anal sphincter, during rectal filling. Patients are able to visualize this on a monitor and monitor their own response. This has probably been shown to be the most effective therapy for patients with defecation disorders.
In summary, evaluation of anorectal disorders is very straightforward. An accurate diagnosis requires a systematic approach with history, physical examination, including a thorough rectal examination, and appropriate testing. Management is simple, but disease-specific, and patients will be grateful for your assistance. Thank you very much. This concludes my presentation on anorectal manometry. Again, I'd like to extend a thank you to Medspira for allowing me to discuss this with you. Thank you.”
View more informative videos like these on our Resources page.