Today's talk was given by chief medical resident Rebecca Glassman on anorectal malformations.
At times in clinic we can be presented with a patient complaining of rectal pain. As a clinician, you perform a rectal exam to
feel the prostate and rectal muscles when there's a suspected GI bleed, complaints
of prostate enlargement symptoms, concern about prostatitis, and also when patients have lower back pain to test for tone of cord compression.
Case Study:
A 34 y/o M with a history of painless bleeding from
hemorrhoids in the past presents with severe anal itching. You would
think hemorrhoids, incontinence, fungal infections.
This is Pruritus ani, the differential of which is very large. There are systemic illnesses (diabetes, thyroid disease), mechanical factors (chronic dirarrhea, anal fissure), dermatologic factors (psoriasis), skin sensitivity from food (tomatoes, beer, milk products), infections (scabies, syphilis), and medications (bacitracin).
Take Home Points:
Anorectal pain:
- The patient history tells you a lot about the condition.
- Among the possible variations of anorectal pain are fissures, constipation, hernia, internal hemorrhoids, prolapse, thrombosed external hemorrhoids, fistulas, and proctalgia fugax.
- It's important to stop the itch cycle by identifying the underlying cause and then soothing the area with the appropriate medication.
Anal fissure
- The stretching of the anal mucosa beyond capacity
- The internal sphincter muscle is exposed causing spasm
- Spams pulls apart the edge of fissure causing pain and impairing healing.
- Goals are to relax the interal sphincter, maintaining bowel movements, relief the pain.
- Medical therapy includes topical nitroglycerin, topical nifedipine (less side effects), injected botulinum toxin (decreases spasm), or surgical therapy (sphincterotomy).
- Management includes either stool softeners (Miralax) or contractile agents (senna).
Fissures are hard to treat to referring the pt to surgery is really helpful for if it comes to sphincterotomy. These patients are so miserable that if they don't respond to the topical treatment, you want them to have other options.
Hemorrhoids
- Thrombosed blood vessels
- The cushion composed of arterio-venous chall and connective tissue is swollen.
- Complications: thrombosis (acute pain with large mass) which need surgery to open up the hemorrhoids bringing instant relief. Other complications are bleeding, prolapse, pain, abscess, incontinence.
- Management: fiber supplementation, Preparation H suppositories, analgesic creams, sitz baths (soaking hemorrhoids in warm water) for soothing and decreasing irritation.
Anorectal abscess:
- Infection starts in crypts of Morgagni --> extends along anal gland.
- Over 50% of abscess will result in fistulas. The patients need to have abscess drain.
- Think about other potential underlying diseases such as Crohn's and diabetes.
Proctalgia fugax:
- Episodes can occur yearly or 4x/week. Associated with sweating, pallor, incredibly distressing to pts. Urgency to defecate but pass no stool.
- Treatment: warm water, ice, valium, deep breathing.
- A lot of patients have spontaneous onset.
