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Benign anal disorders can present with a broad variety of symptoms, ranging from itching to anal pain to profuse bleeding. With such a wide array of symptoms, many of which can portend more malignant disease, it is important for the practitioner to be familiar with the more common benign anal conditions so that the patient can be efficiently directed to receive appropriate care.[1] Such conditions include the following:
Images courtesy of David E Stein, MD.
Hemorrhoidal disease is the pathologic downward displacement of the anal cushions located most commonly in the left lateral, right anterior, and right posterior positions of the anal canal, above the dentate line. Dilation of the contained vessels is often noted, and this can lead to bleeding, thrombosis, or both. These complications generally develop when the supporting tissues of the anal canal deteriorate through excessive downward pressure.
External hemorrhoids originate below the dentate line, are covered with squamous epithelium, and are most often found as the external component of an internal hemorrhoid. Internal hemorrhoids originate above the dentate line and are covered with transitional epithelium. The most common manifestation of internal hemorrhoids is painless bleeding.
Image courtesy of David E Stein, MD.
Hemorrhoids are rarely painful unless they are thrombosed (shown). The acute thrombosis usually presents as a painful anal mass that has been present for less than 48 hours. In this case, incision and drainage with local anesthesia provides significant relief of pain. If the pain has already begun to lessen, expectant management with a high-fiber diet and the use of a sitz bath is appropriate.[2]
Image courtesy of Wikimedia Commons.
A 35-year-old accountant presents to your office with painless bleeding per rectum with bowel movements. She has occasionally noted tissue bulging out of the anus, but the bulge reduces spontaneously.
How would you grade this patient's internal hemorrhoids?
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Answer: B. Second degree.
Because the hemorrhoid prolapses during straining but reduces spontaneously, it is classified as second degree. First-degree hemorrhoids bleed but do not prolapse; third-degree hemorrhoids require manual reduction; and fourth-degree hemorrhoids cannot be manually reduced. Options for definitive treatment of hemorrhoids include the following:
All of these procedures can yield excellent results; the choice is made on the basis of the patient's and the surgeon's preferences.[2]
Image courtesy of David E Stein, MD.
Anal fissures result from increased resting anal pressure in the area of the anal canal with the poorest perfusion. The typical presentation is anal pain that is most severe after defecation. Primary anal fissures are almost always located in the posterior midline. In women, 10% of fissures may be in the anterior midline. If the fissure is away from the midline, other conditions (eg, HIV infection, anal cancer, tuberculosis, and hematologic malignancy) must be suspected. The diagnosis is often made on the basis of the history and gentle external examination; digital and anoscopic examinations generally are too painful to endure. A sentinel pile may be observed as a protruding tag at the distal end of the fissure, and the patient may confuse this tag with a painful hemorrhoid.[3]
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Treatment of anal fissures is aimed at reducing the pressure in the anal canal and thereby increasing blood flow so as to allow the area to heal. Medical therapy includes application of topical nitroglycerine (shown), calcium-channel blockers, or botulinum toxin type A injections, all of which relax smooth muscle. With these measures, about 50% of chronic fissures will heal. When surgical treatment is necessary, reduction of anal pressure is achieved by means of right lateral internal sphincterotomy, performed in an area where hemorrhoidal disease is least pronounced.[4]
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Anorectal abscesses are most commonly caused by blockage of the anal crypts, which leads to infection in the cryptoglandular tissue. When erythema, fluctuance, and tenderness are noted, the diagnosis of perianal abscess is obvious. The standard treatment is incision and drainage, a recommendation that has remained largely unchanged over time. If no outward signs of abscess are notable but fullness and exquisite tenderness are noted on digital rectal examination, intersphincteric abscesses are suspected.[5]
Image courtesy of David E Stein, MD.
A 28-year-old man with a past history significant for a previously drained perianal abscess presents to the emergency department (ED) with fever, tachycardia, and leukocytosis. He reports nonspecific abdominal pain that is worse with defecation, but he has no tenderness on abdominal examination. External anal examination shows no erythema or fluctuance, and the prior drainage site is well healed. Rectal examination elicits mild tenderness but otherwise yields normal results. Suspecting an anorectal abscess in a location that is difficult to establish by means of physical examination, you order computed tomography (CT) of the abdomen and pelvis.
Which of the following abscess types is suspected in this case?
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Answer: D. Supralevator abscess.
Supralevator abscesses are difficult to diagnose through physical examination. They should be suspected in any person showing signs of infection without an identifiable source and should be ruled out appropriately.
Anal fistulas result from anorectal abscesses that do not heal completely. A fistula is considered the progression of an abscess and occurs when the abscess (left) forms an inflammatory tract with an internal opening in the anal crypt and an external opening on the skin (right). Intersphincteric fistulas are the most common type; these arise from perianal abscesses. Transsphincteric fistula are the next most common type; these arise from intersphincteric abscesses in the ischioanal fossa.
Image courtesy of Wikimedia Commons.
A patient presents with a lesion in the right anterior quadrant of the perianal skin at the site of an abscess that drained spontaneously. She has noted persistent drainage from this area over the past 2 months. You plan to take the patient to the operating room (OR) for examination under anesthesia and possible seton placement.
Which of the following is the most likely location for the inner opening of the fistula?
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Answer: A. Right anterior quadrant of the anal canal.
Goodsall's rule predicts the location of the internal opening on the basis of the location of the external opening. An imaginary line is drawn transversely across the anus. An external opening anterior to this line will track toward the anus in a radial fashion; therefore, the inner opening in this patient is most likely to be found in the right anterior quadrant of the anal canal. If the external opening were posterior to the line, the fistula would likely track in a curvilinear fashion, and the location of the inner opening in the anal canal would be more difficult to predict.
Image by Sam Shlomo Spaeth, courtesy of Medscape.
Treatment of anal fistulas is evolving. Fistulotomy, which consists of unroofing the fistula track along its length over a probe, has long been considered the gold standard. However, there are a number of scenarios in which a higher risk of incontinence is associated with fistulotomy, including high transsphincteric fistulas, suprasphincteric fistulas, and anterior fistulas in women. In these cases, a seton may be placed within the fistula tract, either as a temporizing measure to control sepsis or for definitive therapy as it is tightened over the course of several weeks to cut slowly through the sphincter muscles.[6]
Image courtesy of David E Stein, MD.
In its earliest stage, pilonidal disease may present as cellulitis in the sacrococcygeal area, arising from the rupture of a hair follicle into the dermis. This progresses to a painful, fluctuant abscess. In the acute stage, treatment consists of local anesthesia and a longitudinal incision lateral to the midline over the abscess. The cavity is cleaned and lightly packed, and the patient is instructed to clean the wound daily. In the chronic stage, there is often a sinus that opens in the intergluteal fold and runs superior and posterior to the anus. Definitive treatment of chronic pilonidal disease consists of surgical excision of the sinus tract and local flap repair.[2]
Image courtesy of David E Stein, MD.
Answer: C. Fourth decade of life.
Predisposing factors for pilonidal disease include the following:
Pilonidal disease is part of the acne inverse tetrad, which includes hidradenitis suppurativa, acne conglobata, and dissecting scalp perifolliculitis.[2]
Image courtesy of David E Stein, MD.
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