Anorectal Disorders

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[edit] Anorectal Disorders

David McAneny

Anorectal disorders are common and often readily managed in a primary care setting. Nevertheless, some physicians regard the anorectal canal with trepidation. This may be the result of medical education and a reluctance to examine this part of the body, as evidenced by the written response “deferred” on this portion of many physical examinations. This chapter clarifies anatomy and evaluation of the anorectum to help physicians more confidently diagnose and treat anorectal disorders.

[edit] ANATOMY

The anatomy of the anorectal canal is somewhat confusing because of the various descriptions and terms applied to this region. The levator ani and coccygeus muscles form the floor of the pelvis. The puborectalis muscle is a component of the levator and contributes to the anorectal sling that maintains rectal continence (Fig. 112-1). During a digital examination the anorectal sling is especially appreciated along the lateral walls of the anorectal canal, where the digit extends over the floor of the pelvis. This identifies the superior portion of the sphincter mechanism and is an important consideration in the management of rectal tumors.

Figure 112-1 Anorectal anatomy. (From Coates W: Disorders of the anorectum. In Rosen P et al:Emergency medicine: concepts and clinical practice, ed 4, St Louis, 1998, Mosby.)

Conceptually, the anus is comprised of two concentric muscular cylinders. The voluntary external sphincter and puborectalis form the outer muscle layer and are confluent with the levator ani. The inner cylinder is a continuation of the mucosa, submucosa, and circular and longitudinal muscle layers of the distal gut. The latter muscle bundle is the involuntary component of the sphincter mechanism. Everting the buttocks, the examiner can palpate the intersphincteric groove between these two cylinders.

The anal verge refers to the junction between pigmented cutaneous tissue and the sensate stratified squamous lining distal to the dentate (or pectinate) line. This area is of ectodermal origin, drains into the systemic veins and inguinal nodes, and harbors the external hemorrhoids. On the other hand, the mucosa of the true anal canal extends from the dentate line to the anorectal sling. This portion of the anus contains the endodermal, simple columnar mucosa that drains into the portal vein and the pelvic and lumbar nodes. Internal hemorrhoids arise at this level and are relatively insensate. Glands are concentrated at the dentate line and are the source of anal suppurative diseases.

[edit] PATIENT EVALUATION

[edit] History

Both the lay public and physicians use “hemorrhoid” to describe a myriad of anorectal complaints, just as “stomach” is applied to the abdomen. Patients should be queried about what hemorrhoid means to them. The history should ascertain whether the patient has felt and reduced any protrusions, whether symptoms occur during or after defecation or at night, bleeding frequency and volume, if mucus is expressed with stools or between bowel movements, and whether anal or pelvic pain is associated with passage of stool. If the anal area is pruritic, the patient may frequently rub or scratchthe surrounding area to obtain relief. Previous anorectal conditions and treatments, local operations, and obstetric trauma are critical. Determining the patient's daily diet is helpful, including the amounts of high-fiber foods and nondiuretic fluids. Bowel habits must be established, particularly the frequency, bulk, and firmness. Precise definitions of constipation or diarrhea should be elicited, and continence of solid stool, liquid feces, and flatus is relevant.

Patients should be questioned about nonprescription creams, ointments, and suppositories and whether any objects have been inserted into the rectum. A history of anoreceptive sex and sexually transmitted diseases can be elicited. Additional aspects include systemic illnesses, medications, a family history of gastrointestinal pathology (e.g., inflammatory bowel disease or tumors), and constitutional symptoms (e.g., fever, weight loss). Genitourinary symptoms are also associated with anorectal disorders.

[edit] Physical Examination

In conjunction with a thorough history, a proper examination should provide the diagnosis of most anorectal conditions. Besides the patient's general health, the physician should first assess the abdomen, genitalia, surrounding skin, and regional lymph nodes. This also creates a level of trust and comfort before probing the anorectum.

Patients may be examined in the prone or lateral decubitus positions. Although the latter is usually preferable for an examination, the jackknife prone position is valuable for rigid sigmoidoscopy. The left-side-down lateral decubitus position best serves the right-handed examiner. Certain conditions (e.g., rectal prolapse) warrant special positions and activities, such as performing Valsalva's maneuver while standing or squatting. The patient in the lateral decubitus position should move the buttocks to the examiner's side of the table and draw the knees to the chest. The examiner should first inspect the perianal region and evaluate the local skin for excoriations, external fistula orifices, protruding or thrombosed hemorrhoids, signs of infection, and skin lesions (e.g., tumors, condylomata, hidradenitis suppurativa). Pilonidal disease is located farther superiorly in the gluteal cleft and is often misinterpreted by patients as an anal problem. The buttocks are carefully retracted, everting the anus, and fissures are observed. When patients have severe anal pain, the examination may be limited to inspection alone. When reassured that a digital examination or an endoscopic procedure is not planned, patients often relax enough to permit identification of an anal fissure. An examination under anesthesia is an option for patients with severe discomfort or great anxiety.

The gloved digit should be well lubricated in preparation for a gentle insertion into the anorectal canal. The prostate gland or cervix is palpated through the anterior rectal wall, and tenderness can be elicited. A boggy, tender fullness in the intersphincteric, ischiorectal, or supralevator spaces typically connotes an abscess. Masses are sought, with particular attention to the relationship to the anorectal sling. The examiner should discern a tumor's morphology, extent of penetration into the rectal wall, and any suggestion of fixation to the surrounding pelvic tissues. Sphincter tone is noted and stool examined as to characteristics and presence of occult blood. The rectum also provides a “window” for the recognition of extrarectal pelvic pathology, such as tumors and abscesses.

[edit] Endoscopic Techniques

Primary care physicians should perform anoscopy with ease. When an endoscopic evaluation of the anorectum is anticipated, a mechanical preparation (e.g., Fleet's enema) is advised. Disposable anoscopes are readily available and permit visualization of the anal canal, including mucosal lesions, the dentate line, fissures, hemorrhoids, and purulence. Tumors, proctocolitis, ulcers, and extrinsic compression are apparent with a sigmoidoscope. The rigid sigmoidoscope should be another familiar instrument in the primary care setting. Air is insufflated through the sigmoidoscope to inflate and expose the rectal lumen and permit safe passage up to 20 cm from the anal verge. Suction equipment and cotton swabs might be necessary to eliminate residual stool. This device allows visualization of the entire rectum and a portion of the distal colon. The flexible sigmoidoscope can be passed as proximal as the hepatic flexure and is more comfortable than its rigid counterpart. Furthermore, the televised digital images enhance recognition of pathology. Biopsies and cultures can be obtained during sigmoidoscopy.

Anal manometry, defecography, electromyography, and endorectal ultrasonography are useful adjuncts in the evaluation of some anorectal disorders, although they are not usually available or indicated in primary care practice.

[edit] ANAL PAIN

Anal pain is usually diagnosed and treated with simple measures. The three most common causes are fissures, thrombosed external hemorrhoids, and abscesses (see later discussions). Each of these conditions is usually identified on careful inspection and palpation of the perianal tissues and does not require endoscopy or advanced diagnostic procedures. In fact, patients with severe anal pain typically do not tolerate digital examinations or anoscopy. Less frequent causes of anal pain include sexually transmitted infections (e.g., lymphogranuloma venereum, herpes simplex, condyloma acuminatum [see Chapter 29] ), tumors, proctitis, coccygodynia, and proctalgia fugax.

[edit] PRURITUS ANI

Pruritus ani is especially common among men and is caused by a variety of local and systemic disorders, although it is frequently a primary condition. Pruritus ani is a symptom, not necessarily a diagnosis, and an underlying source should be sought. A prospective study evaluated 109 patients with pruritus ani as the only presenting symptom.^[1] More than half the patients had an underlying benign anorectal condition, such as hemorrhoids, fissures, idiopathic or ulcerative proctitis, condylomata, fistulas, and abscesses. More importantly, 23% of the patients had occult neoplasms, including rectal cancer, epidermoid anal cancer, adenomatous polyps, colon cancer, and a premalignant anal lesion. Only one quarter were diagnosed with primary, or idiopathic, pruritus ani. Whereas most studies suggest that only 5% to 25% of patients with this symptom have an inciting source, selection criteria and referral practices could have biased this series. The report clearly affirms, however, that patients with pruritus ani should be thoroughly evaluated to diagnose underlying and correctable pathology. Appropriate studies include a careful inspection, digital rectal examination, anoscopy, rigid sigmoidoscopy, and perhaps colonoscopy.

The most common precipitants of secondary pruritus ani are the benign and malignant conditions already cited. Othercauses include Crohn's disease, hidradenitis, pilonidal disease, uncommon tumors (e.g., melanoma, Bowen's disease, Paget's disease), rectal prolapse, dermatologic conditions (e.g., psoriasis, lichen sclerosus, various dermatitides), infections (fungal, parasitic, bacterial), sexually transmitted diseases (e.g., gonococcus, herpes, syphilis), systemic diseases (e.g., jaundice, lupus, diabetes), and psychologic disorders. These problems are identified with proper evaluation.

Primary pruritus ani is a cyclic, self-propagating phenomenon. An itching or burning sensation prompts the patient to scratch or rub the perianal area. The resultant abrasion of the tissues causes further itching and thus more scratching and local trauma. The leakage of anal mucus or stool permits fecal bacterial neuraminidases to irritate any excoriations of the thin and well-innervated perianal skin, resulting in pruritus. If the initial evaluation fails to reveal a precipitant, efforts should focus on local hygiene and bowel habits. Patients are specifically advised not to scratch the itchy area. The anus must be kept clean and dry and should be gently blotted with nonscented toilet paper after bowel movements rather than vigorously rubbed. Patients should cleanse especially after activities that promote heavy sweating. Powders, creams, and soaps are avoided, and white cotton underwear is encouraged. A bowel regimen is prescribed to provide stool bulk, promote complete fecal evacuation, and diminish perianal soiling (Box 112-1). Diet is modified to contain fiber foods and to exclude spices, tomatoes, coffee and tea, carbonated beverages, cheese, nuts, citrus, and chocolate. A particularly effective maneuver is the application of a wisp (not a ball) of cotton to the perianal area. The cotton wisp absorbs anal mucus discharge and is exchanged after bowel movements and baths. A short course of a topical steroid (1% hydrocortisone cream) is occasionally administered to disrupt the itch-scratch cycle.

[edit] ANAL BLEEDING

Although lower gastrointestinal (GI) tract bleeding is distressing to patients, it is usually from a benign cause and not a harbinger of malignancy. Bright-red blood coating the stool or on the toilet paper generally implies an anorectal source, whereas darker hemorrhage indicates a more proximal lesion. Drops of blood associated with pain on defecation suggest a fissure. A thrombosed external hemorrhoid often presents with the passage of some blood from an acutely painful perianal lump. Bloody diarrhea occurs with proctocolitis, including infectious, ischemic, and inflammatory variants. The major sources of significant lower GI bleeding are diverticular disease and vascular ectasias, primarily involving the colon. Anorectal lesions rarely cause massive hemorrhage.

In the evaluation of lower GI bleeding, a thorough examination with anoscopy and sigmoidoscopy is valuable, especially if the characteristics of the bleeding and local symptoms suggest an anorectal source (see Chapter 109 ). The physician should exercise caution about casually ascribing hemorrhage to hemorrhoids, particularly in light of their prevalence. If hemorrhoids appear quiescent or if bleeding persists, neoplasms and other colorectal pathology must be considered and identified.

[edit] HEMORRHOIDS

Even when another clinician has assigned a patient a diagnosis of hemorrhoids, the physician should still obtain a precise description of what this term means to the patient. Hemorrhoids affect most people over age 50. Three dominant groups of vascular cushions normally reside in the left lateral, right anterolateral, and right posterolateral portions of the anal submucosa. These cushions may become engorged with blood during defecation to protect the anal canal. With age and various stresses, the buttressing muscularis submucosa deteriorates, resulting in venous distention. The cushions are then disposed to thrombosis and ulceration. The upright position and a low-fiber, constipating Western diet promote straining with defecation, making the hemorrhoid cushions more prominent. The numerous theories of the pathogenesis of hemorrhoids suggest a multifactorial process.

External and internal hemorrhoids are differentiated by their location relative to the dentate line, although the external and internal components can also create a confluent complex. Hemorrhoids are graded by size. First-degree hemorrhoids protrude into the anal lumen but do not prolapse. Second-degree hemorrhoids prolapse through the anal canal but spontaneously return to their original position. Third-degree hemorrhoids also prolapse but require manual reduction. Fourth-degree hemorrhoids remain prolapsed and are not reducible. This grading system is valuable in the selection of therapy.

[edit] External Hemorrhoids

External hemorrhoids manifest with discharge, modest bleeding, and thrombosis. Mucous discharge occurs when the hemorrhoid no longer apposes the adjacent anal mucosa, which can also precipitate pruritus ani. Of greater concern, external hemorrhoids are prone to thrombosis, a particularly painful condition as a result of the sensate, overlying modified squamous epithelium. A thrombosis often develops after an episode of constipation.

External hemorrhoids generally respond to a bowel regimen that improves stool bulk and texture (see Box 112-1). Local anal hygiene measures are also instituted, including Sitz baths and the avoidance of prolonged sitting and straining to defecate. Explaining the rationale of this bowel regimen fosters compliance. Acutely thrombosed hemorrhoids can be excised under local anesthesia, if performed within 2 to 3 days after onset of symptoms.

[edit] Internal Hemorrhoids

Internal hemorrhoids are relatively insensate, so pain is not a common feature. Associated with bleeding and prolapse, internal hemorrhoids are identified by anoscopy and are elusive to detection by digital examination. Again, proper diet and bowel habits, along with local care, suffice for many first-degree and second-degree hemorrhoids. When these measures fail, more sophisticated options are available.

Less than 10% of patients with symptomatic hemorrhoids require surgery. First-, second-, and some third-degree internal hemorrhoids have been obliterated with cryotherapy, bipolar diathermy, laser, infrared photocoagulation, injection sclerotherapy, and rubber band ligation; none has proved to be clearly advantageous. A meta-analysis of five trials using infrared photocoagulation, sclerotherapy, and rubber band ligation found that ligation provides the most effective long-term outcome and is inexpensive^[2] (Fig. 112-2). Rubber band ligation causes more discomfort, however, and is associated with rare episodes of serious complications (e.g., tetanus, perineal soft tissue sepsis). Therefore infrared photocoagulation may be the best nonsurgical approach. Proper training and recognition of complications are essential for any treatment.

Figure 112-2 Rubber band ligation of hemorrhoids. A, Redundant mucosa grasped at base of hemorrhoid within lower rectum. B, Excess tissue drawn into ligator, if not painful for patient. C, Band attached; hemorrhoid ligated. D, Instrument fired.

Hemorrhoidectomy is reserved for third-degree and fourth-degree lesions, smaller hemorrhoids that do not respond to nonsurgical techniques, and complexes of internaland external components. Costly lasers have been employed for hemorrhoidectomy but have not demonstrated greater efficacy or less pain than standard surgery. Although outpatient procedures can be performed, the physician must be judicious about patient selection. An overnight observation or short hospital stay for intensive analgesia can be beneficial. Age, debilities, social situation, travel distance, and pain threshold are factors to consider.

[edit] ANAL SUPPURATIVE DISEASES

About 6 to 10 anal gland orifices reside along the dentate line. These glands extend through the submucosa, pierce the underlying muscularis, and often track to the intersphincteric groove. Fecal bacteria are exposed to these glands, and an acute perirectal abscess develops when the orifice is occluded. A fistula in ano represents the chronic version of this infection.

[edit] Abscess

An infected anal gland tracks along various planes and results in a focal abscess (Fig. 112-3). A submucosal tract leads to a perianal abscess. If the infected gland traverses the adjacent musculature, the abscess cavity can rest in the intersphincteric space or in the ischiorectal fossa. Conversely, a proximal dissection within the intersphincteric groove creates a supralevator abscess. Abscesses present with pain and possibly discharge. A digital examination can be superfluous and painful if fluctuance is readily apparent, as usually occurs with perianal and ischiorectal infections. Intersphincteric abscesses are less visible but cause much pain and throbbing with defecation because of their tight confines. A digital examination should identify this source. Supralevator abscesses are uncommon and may manifest as occult sepsis. Digital examination or cross-sectional imaging can be diagnostic.

Figure 112-3 Common sites of anorectal abscesses: perianal (a), anorectal (b), intersphincteric (c), and supralevator (d).

A pervasive misconception is that perirectal abscesses should be managed with antibiotics to “bring them to a head.” In the immunocompetent patient, pus is present within the indurated phlegmon, even when fluctuance is not yet evident. Therefore these abscesses warrant incision and drainage. Antibiotics are an adjunct among patients with cardiac valve considerations or with significant cellulitis. An exception is the human immunodeficiency virus (HIV) or otherwise immunocompromised host with marked granulocytopenia and perianal sepsis; this patient is best treated with antibiotics alone. This situation is a rare and challenging problem requiring teamwork among surgeons, hematologists, oncologists, and infectious disease experts.

Perianal and ischiorectal abscesses are evacuated by placing a curvilinear incision through the overlying skin. The incision should be parallel to the underlying musculature to minimize the likelihood of sphincter disruption. In addition, the incision should be as close as possible to the anal verge so that, if a fistula develops, its tract will be limited and a fistulotomy will disturb less tissue. The abscess cavity is thoroughly laid open, and loculations are digitally disrupted to release all the pus. The anorectal canal is also evaluated to exclude underlying disease, and the wound is packed open. Because one third to one half of patients with acute abscesses eventually develop fistulas, some surgeons advocate a search for the gland's internal orifice during the incision and drainage, and they perform an empiric fistulotomy. A prospective trial demonstrated that this approach resulted in a reduced risk of recurrent abscess and fistula compared with incision and drainage alone (3% vs. 41%).^[3] However, an immediate fistulotomy was also associated with an increased risk of impaired anal function. Most surgeons treat the active infection and deal with a fistula later, when the tissues are not acutely inflamed.

Intersphincteric and supralevator abscesses are special problems that demand surgical expertise.

[edit] Fistula

A fistula is defined as a communication between epithelialized viscera. A few patients with an acute anorectal abscess develop a fistula in ano. These fistulas extend from the anorectal mucosa to the skin, although the tracts can be circuitous and envelop the entire sphincter mechanism. The tract is a function of the plane of dissection of the original septic focus in conjunction with the site of drainage. Fistulas in ano have been classified as intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric^[4] (see Fig. 112-3).

Patients with anal fistulas describe sporadic discharge that is occasionally stained with blood. New abscesses periodically form and spontaneously drain. The examiner recognizes the characteristic external orifice with surrounding heaped-up granulation tissue, suggesting chronic inflammation. In accordance with the cryptoglandular genesis of anorectal sepsis, the internal orifice is located along the dentate line. The course of the tract is predicted by Goodsall's rule (Fig. 112-4). If an imaginary line bisects the anus in the coronal plane, external orifices anterior to the line communicate with the internal orifice via the most direct radial tract. On the other hand, posterior external orifices correspond to an internal orifice in the posterior midline.

Figure 112-4 Graphic representation of Goodsall's rule.

Once a fistula has formed, it does not spontaneously close because the sphincter mechanism acts as a distal obstruction to the flow of gas and liquid stool through the anorectal lumen. Therefore the tract must be laid open by an experienced surgeon. Although most fistulas are intersphincteric or low transsphincteric and traverse minimal musculature,the sphincter is at risk if the tract is not fully appreciated. Extrasphincteric and suprasphincteric fistulas are challenging and suggest inflammatory bowel disease.

[edit] Pilonidal Disease

Although pilonidal disease is not an anal suppurative problem, the sacrococcygeal pilonidal sinus resides in the superior pole of the gluteal cleft, and infections are often confused with perirectal sepsis. Congenital theories for the etiology of pilonidal disease were once favored, but now this is believed to be an acquired condition. Pilonidal disease begins with hair follicles burrowing into the underlying subcutaneous fat. Other hairs and debris are propelled into this sinus over time, creating a foreign body reaction and a soft tissue infection.

Long-term hygiene is emphasized, with initially weekly shavings to prevent additional hairs from being drawn into the pilonidal cavity.^[5] Once the inciting foreign bodies have been eradicated, the inflammation should subside and the sinus will obliterate. An acute pilonidal abscess is incised and drained, preferably with a lateral vertical incision parallel to the midline cleft. Hairs are removed to the extent possible during the original drainage and in subsequent visits while the wound heals. Extensive and recurrent pilonidal disease may demand more aggressive surgical debridement and wound closure. However, it is critical to confine the dissection to the chronic fibrous tracts that contain the foreign debris and to spare the normal surrounding subcutaneous fat.

[edit] ANAL FISSURE

An anal fissure results from a disruption of the mucosal integrity of the anal canal. This usually follows a traumatic hard stool, although instrumentation or other local insults can also be the cause. Acute fissures are common and ordinarily heal spontaneously in a few days. The intense pain of a fissure engenders a reluctance to defecate, however, compounding the constipation and the aggravating effects of subsequent bowel movements. This cycle can produce a chronic fissure (Fig. 112-5). Anal manometry has demonstrated that some patients have a propensity to develop fissures as a result of increased anal sphincter resting pressures. Local ischemia is likely responsible as well.^[6]

Figure 112-5 Chronic anal fissure. Note sentinel pile, indurated ulcer, and hypertrophied papilla.

Anal fissures present with dramatic pain that is exacerbated by defecation. Bleeding and pruritus may also occur. Inspection and light palpation suffice to diagnose most fissures, although an examination under anesthesia may be necessary when pain is severe. A sentinel skin tag at the external portion of the fissure implies chronicity, as does a hypertrophied papilla at the proximal pole. Fissures are predominantly located in the posterior midline, but about 10% of fissures in women are in the anterior midline. Lateral or multiple fissures should arouse suspicions of underlying conditions, such as Crohn's disease, tuberculosis, HIV, chronic ulcerative colitis, leukemia, and sexually transmitted diseases (e.g., lymphogranuloma venereum).

The institution of a bowel regimen to create soft, bulky, atraumatic stools disrupts the provocative cycle and allows the fissure to heal in about half of patients (see Box 112-1). Surgery is necessary for chronic or refractory acute fissures to provide a wider aperture for stool to pass and to interrupt the internal sphincter spasm. Anal dilation accomplishes these goals, although the extent of sphincter disruption is unpredictable, causing undesirable rates of recurrence and of anal incontinence. Lateral internal sphincterotomy involves a more precise division of the distal portion of the internal sphincter muscle; success rates are greater than 90%, and incontinence is uncommon. The anorectum is also evaluated during surgery to identify underlying causes, such as inflammatory bowel disease.

[edit] PERIANAL CROHN'S DISEASE

Crohn's disease often involves the anus, and surgeons must be particularly circumspect about performing anal procedures on these patients, limiting the surgery to the minimal traumanecessary to relieve symptoms. When possible, it is prudent to defer surgery until the active Crohn's disease has subsided with medical management. Perianal Crohn's disease is associated with edematous discolored skin tags that can be mistaken for hemorrhoids, which are uncommon among Crohn's patients. When they do occur, hemorrhoids are best managed nonsurgically because of wound healing concerns and because proctectomy has been necessary for postoperative complications. However, surgery can be safely performed on select patients with quiescent Crohn's disease and symptomatic hemorrhoids that have failed to respond to nonsurgical measures.^[7]

Anal suppurative disease is common among patients with Crohn's disease. This diagnosis should be strongly suspected in those with multiple, recurrent, or complex anal abscesses or fistulas. Suppurative disease often heals spontaneously or with local supportive care and medical management. The most common procedure for septic complications is a simple incision and drainage. A limited fistulotomy can often be done safely without disturbing anorectal function once the acute inflammation has resolved. Although a proctectomy may eventually be necessary for some patients with perianal Crohn's disease, it is generally conducted for the complications of the disease rather than for nonhealing surgical wounds.^[8][7]

Most anal fissures associated with Crohn's disease are painless. However, a judicious internal sphincterotomy is successful in the minority of patients who require surgery.^[8]

[edit] HUMAN IMMUNODEFICIENCY VIRUS

Up to one third of homosexual men with HIV experience anorectal problems. In fact, these conditions constitute the most common indications for surgery in this population. Condylomata may be the most common anal disorder among HIV-positive patients (see Chapter 29 ), although suppurative diseases, fissures, ulcers, hemorrhoids, and various malignancies occur as well. Interestingly, anal fissures are typically situated in the posterior midline, as they are in the general population. Anal ulcers are a peculiar phenomenon and are likely associated with chronic fissures. These patients present challenging clinical dilemmas because of their immunocompromised states and impaired wound healing.

A series of 1502 patients with HIV, predominantly homosexual men, revealed that 101 of them had undergone 161 anorectal procedures.^[9] Pain was the most common symptom, followed by purulent discharge and bleeding. The indications for surgery, in decreasing order, were anorectal sepsis, fissures, condylomata, tumors, and hemorrhoids. Bacterial and viral cultures revealed fecal organisms, staphylococci, herpes simplex, cytomegalovirus, human papillomavirus, Neisseria gonorrhoeae, and cryptosporidia. Malignancies were identified in one quarter of the patients who underwent biopsies (10% of overall series). Lesions were often occult and included Kaposi's sarcoma, non-Hodgkin's lymphoma, anaplastic lymphoma, leukemia, and squamous cell carcinoma. Because only 40% of anorectal surgical wounds had healed by 3 months, a multivariate logistic analysis was done to identify critical factors.^[9] Independent predictors of poor healing included a CD4 count less than 50 cells/μl and surgery within the first year of the diagnosis of acquired immunodeficiency syndrome (AIDS). Conversely, the Centers for Disease Control and Prevention stages of HIV and AIDS were not significant determinants of wound healing. Chronic fissures were the least likely lesions to heal (16% at 3 months).

The ideal treatments for the numerous anorectal conditions of HIV patients have not been clearly established. The physician must cautiously select appropriate candidates for surgery, although cultures and biopsies should be liberally performed (see Chapter 32 ).

[edit] ANAL TUMORS

Anal tumors are relatively uncommon, accounting for only 4% of anorectal malignancies (see Chapter 105 ). Although these tumors occur infrequently, the primary care physician plays an important role in detection because the lesions typically present with bleeding, pain, pruritus, or a mass. Appropriate evaluation of these symptoms should result in the recognition of tumors. Squamous cell carcinomas constitute about two thirds of malignancies of the anal canal and anal margin. Other cell types include cloacogenic, mucoepidermoid, small cell, adenocarcinoma, basal cell, Bowen's disease (squamous cell carcinoma in situ), Paget's disease (adenocarcinoma in situ), melanoma, lymphoma, and leukemia. Over the last two decades the philosophy of care for anal epidermoid tumors has dramatically shifted from radical, ablative surgery to combined regimens of radiation and chemotherapy. This has resulted in improved local control and survival as well as sphincter preservation.

[edit] REFERENCES