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A colon and rectal surgeon is a physician who has completed a general surgery residency program (usually 5 to 6 years of training after medical school) and then goes on for further, more intensive training in diseases of the colon and rectum. This additional training is one to two years. Colon and rectal surgeons have special interests in diseases of the colon and rectum and have special training in techniques to treat these diseases.
Hemorrhoids are masses of blood vessels that occur at the anal verge. All individuals have three hemorrhoids. Each hemorrhoid has an external component (covered by skin) and an internal component (covered by rectal mucosa). External hemorrhoids cause problems if a painful blood clot develops. This is known as a thrombosed hemorrhoid. Internal hemorrhoids cause problems if they enlarge and bleed or protrude through the anus.
Hemorrhoids usually do not cause severe pain unless a blood clot (or thrombosis) is present. Other causes of rectal pain include anal fissure and anorectal abscess. Pruritus (itching) is more likely a skin problem or a hygienic problem rather than due to hemorrhoids.
Hemorrhoids and other anorectal conditions can be diagnosed by a fairly simple and relatively painless examination in the office. Hemorrhoids may be treated by: (1) Medical measures such as fiber, tub soaks, and hydrocortisone topically (2) Rubber band ligation or (3) Surgical hemorrhoidectomy.
Rubber band ligation is performed in the office. A rubber band can be placed on an internal hemorrhoid when bleeding or prolapse occurs. An internal hemorrhoid is not covered with tissue containing nerves and can be banded without much discomfort. Although not as extensive as surgical hemorrhoidectomy, rubber band ligation can provide significant improvement in patients’ symptoms when patients are properly selected. Usually two or three sessions are required to band three major hemorrhoidal groups. Complications such as bleeding and infection are rare.
Surgical hemorrhoidectomy is not done as often today as in the past. However, a small percentage of patients with large, prolapsing hemorrhoids may require surgery. Surgery is performed in the hospital under local, regional (spinal), or general anesthesia. Patients may go home after surgery or may stay in the hospital one or two days depending upon the extent of the surgery. Post-operative pain, which can be severe, varies from individual to individual and is treated with mild narcotics. Patients are away from work for one to two weeks. The most common complication is post-operative bleeding and this occurs in less than 5% of patients.
A surgical hemorrhoidectomy performed by a fully trained surgeon should be associated with few complications and should give good long-term results.
Polyps refer to benign growths in the colon and rectum. They are found using endoscopic examinations (sigmoidoscopy or colonoscopy) or radiologically using a barium enema. Most polyps can be safely removed through the endoscope. and sent to the pathologist for microscopic examination.
The most common type of polyp is the hyperplastic polyp. This polyp is benign and probably has no precancerous tendency. Some reports have suggested that people with hyperplastic polyps are at a higher risk for developing adenomatous polyps or cancer, but this question has not been resolved to date.
A second very common type of polyp is the adenomatous polyp. Adenomatous polyps are thought to be precancerous lesions; they have the potential to become a cancer. Approximately 10% of the population over the age of fifty will have an adenomatous polyp.
Two other types of polyps are the juvenile polyp, usually seen in children, and inflammatory polyps. These polyps have no cancerous potential.
Therefore, the polyp of concern is the adenomatous polyp. When polyps are found, they should be removed endoscopically and sent for pathological evaluation. If the polyp is adenomatous the entire large intestine should be checked. About 15% of patients will have more than one adenomatous polyp. Removal of all adenomatous polyps reduces the risk of colon and rectal cancer. After removal of the polyp, individuals should have follow-up examinations every one to three years indefinitely.
Polyps may be pedunculated (on a stalk) or may be sessile (flat). Most pedunculated polyps and small sessile polyps can be removed through the colonoscopy. Larger polyps, especially when sessile, occasionally require surgical excision.
Polyps may be asymptomatic. and diagnosed on screening examinations (see “Screening for Colon and Rectal Cancer”) or they may cause symptoms such as bleeding, rectal discharge, or occasionally the polyp will prolapse through the anus.
Endoscopic removal of benign polyps and polyps containing an early cancer is adequate therapy. When polyps are determined to contain invasive cancer (into the wall of the colon), surgical resection is required to assure adequacy of removal of all cancer cells.
Colonoscopy refers to the examination of the large intestine with a flexible endoscope. It is done in a hospital or an outpatient endoscopic facility. Patients may be discharged one to two hours after the procedure and may return to work the following day. The procedure is done with the help of intravenous sedation or conscious sedation. General anesthesia is rarely required.
A twenty-four (24) hour preparation of the colon is required to allow good visualization of the colon and to ensure safety of the procedure.
Indications for colonoscopy include: (1). Evaluation of symptoms such as rectal bleeding and change in bowel habit. Rectal bleeding may include the passage of gross blood per rectum, the finding of blood on chemical testing of the stool (hemoccult), or the finding of iron deficiency anemia; (2). The evaluation of abnormalities found on barium enema examinations; (3). Removal of polyps; (4). Search for additional polyps or cancer when polyps are found on proctoscopic or sigmoidoscopic examination in the office or on barium enema; (5). Follow-up or surveillance of patients at increased risk for colon cancer. These include patients with a history of polyps or cancer, patients with a family history of colon cancer and patients with ulcerative colitis.
Complications of colonoscopy can occur. Bleeding may occur after removal of polyps. Perforation of the colon may occur with passing of the scope in difficult cases and may occur after removal of polyps. Both of these complications are infrequent, but may require surgery to correct.
March is colon and rectal cancer screening month.
March has been chosen to recognize the importance of screening for colon and rectal cancer. We have summarized the important information concerning screening for colon and rectal cancer and have listed several helpful websites to help answer your questions concerning colon and rectal cancer.
There are approximately 133,000 new cases of colorectal cancer per year in the United States and approximately 54,000 deaths per year. The lifetime probability of an individual developing colorectal cancer is 5–6%. Aggressive screening for colorectal cancer could decrease both the numbers of new cases and the numbers of deaths per year.
The American Society of Colon and Rectal Surgeons guidelines separate individuals into low or average risk (65–75% of people), moderate or increased risk (20–30%), and high-risk (6–8%) groups.
|Risk||Procedure||Onset (Age, yr)||Frequency|
|I. Low or Average – 65 to 75%||Digital Rectal Exam and one of the following:||50||Yearly|
|A. Asymptomatic – no risk factors||Fecal occult blood testing and flexible sigmoidoscopy||50||FOBT yearly Flex-sig every 5 years|
|B. Colorectal cancer in none first degree relatives||Total colon exam – colonoscopy or double contrast barium enema and proctosigmoidoscopy||50||Every 5 to 10 years|
|II. Moderate Risk 20 to 30%|
|A. Colorectal cancer in 1st degree relative, age 55 or younger, or two or more 1st degree relatives of any ages||Colonoscopy||40 or 10 yrs. before the youngest case in the family, whichever is earlier||Every 5 years|
|B. Colorecal cancer in a 1st degree relative over the age of 55||Colonoscopy||50, or 10 yrs before the age of the case, whichever is earlier||Every 5 to 10 years|
|C. Personal history of large (>1 cm) or multiple colorectal polyps of any size||Colonoscopy||One year after polypectomy||If recurrent polyps -1 year,;If normal-5 years|
|D. Personal history of colorectal malignancy- surveillance after resection for curative intent||Colonoscopy||1 year after resection||If normal-3 years
If still normal-5 years
If abnormal-as above
|III. High Risk (6 to 8 percent of people)|
|A. Family history of hereditary adenomatous polyposis||Flexible Sigmoidoscopy; consider genetic counseling; consider genetic testing||12 to 14
|Every 1 – 2 years|
|B. Family history of hereditary nonpolyposis colon cancer||Colonoscopy; consider genetic counseling; consider genetic testing||21 to 40
|Every 2 years
| C. Inflammatory bowel disease
1. Left-side colitis
|Every 1 to 2 years
Every 1 to 2 years
FOBT = fecal occult blood testing; Flex-sig = flexible sigmoidoscopy
LOW RISK INDIVIDUALS are those that are asymptomatic, with no family history of colorectal cancer in a first-degree relative, and with no other risk factors. Screening should begin at age 50. Digital rectal exam and fecal occult blood testing (FOBT) should be performed annually. If the FOBT is negative, flexible sigmoidoscopy is performed every 5 years. If the FOBT is positive, examination of the entire colon by colonoscopy is carried out.
If at the time of flexible sigmoidoscopy, a polyp is identified, it should be biopsied. If the pathological diagnosis is a hyperplastic polyp, no further studies are necessary. If the diagnosis is an adenomatous polyp, then colonoscopy should be carried out.
Colonoscopy allows visual examination of the entire colon, detection and removal of most polyps, and biopsy of cancers. Colonoscopy can be recommended as screening of average risk individuals. The interval selected is every 10 years because there is only a slight risk of developing advanced adenomas during surveillance after an initial examination with negative results.
MODERATE RISK INDIVIDUALS are those with one or more first-degree relatives (sibling, parent, or child) with colorectal cancer and those with a personal history of adenomatous polyps or colorectal cancer.
CANCER IN A FAMILY MEMBER. If an individual has 2 or more close relatives or 1 close relative under the age of 55 with colorectal cancer, screening should begin at age 40 or 10 years before the age of the youngest affected family member. Screening should be colonoscopy.
If an individual has 1 close relative with colorectal cancer over the age of 55, the risk is not as great and screening should begin at age 50 or 10 years before the age of the affected family member.
POLYP (ADENOMA) SURVEILLANCE. Following colonoscopy, if a large polyp (>1 cm.) is removed or if multiple polyps are removed, colonoscopy is repeated in 1 year. If only a small polyp (<1cm.) is removed, colonoscopy is repeated in 3 years. Once a normal (negative) colonoscopy has been performed, colonoscopy is carried out every 5 years. The finding of an adenoma at any subsequent examination may prompt yearly colonoscopies until the colon is again clear of polyps.
CANCER SURVEILLANCE. When facing surgery for a malignant tumor, the patient should have colonoscopy prior to surgery. Colonoscopy should be repeated 1 year after surgery. If colonoscopy is not feasible prior to surgery, it should be carried out 3-6 months later. If the follow-up examination is normal, it is repeated in 3 years, and if still normal, then every 5 years.
(Patients with prior uterine, ovarian, or breast cancer and those with a history of pelvic radiation are at increased risk for colorectal cancer and should be offered colonoscopic examinations.)
HIGH RISK INDIVIDUALS include those with hereditary or genetic predisposition for the development of colorectal cancer and those patients with inflammatory bowl disease.
Patients with FAMILIAL ADENOMATOUS POLYPOSIS (FAP) develop hundreds of adenomatous polyps and eventually develop cancer if the colon is not removed. An affected parent transmits the disease to ½ of his offspring. If an individual has a family history of FAP, screening begins at puberty (12-14) and should be performed annually. Sigmoidoscopy is adequate screening for the development of these polyps in FAP. The duration of the screening is not clear, but is usually carried out to age 40. If a patient with FAP has had a subtotal colectomy, the rectum remains intact and that patient should have sigmoidoscopy every 6-12 months.
If a patient has a family history of HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (HNPCC), colonoscopy begins at age 20 or 10 years prior to the age of the youngest family member with colorectal cancer. Colonoscopy is required for screening because cancers in this condition tend to occur in the right colon. Colonoscopy is performed every 2 years until age 40 and then yearly.
The availability of genetic testing may change the recommendations for screening of patients with a family history of FAP and HNPCC.
The presence of INFLAMMATORY BOWEL DISEASE, either chronic ulcerative colitis (CUC) or Crohn’s disease (CD) significantly increases the risk of colorectal cancer. In CUC, the risk of cancer increases with the duration of the disease and with the extent of the disease. When a patient has CUC involving the entire colon, screening (colonoscopy) should begin after 8 years of the disease and should be done every 1-2 years. When CUC is limited to the left colon, screening should begin after 15 years and should be done every 1-2 years.
In patients with long-standing Crohn’s disease, there is an increased risk of colorectal cancer, but not as high as in CUC. Screening should begin after 15 years and should be carried out every 1-2 years.
Simmang CL, Senatore P, Lowry A. et al. Practice Parameters for Detection of Colorectal Neoplasms. Diseases of the Colon & Rectum 1999; 42: 1123-1129.
These websites contain helpful information concerning colon and rectal cancer and screening recommendations.
www.gastro.org/public/cc_screening.html – Colon and rectal cancer screening guidelines from the American Gastroenterological Association.
www.fascrs.org – American Society of Colon and Rectal Surgeons – See Practice Parameters for colon and rectal cancer screening.
www.coloncancerprevention.org – a web-site created by Dr. Ernestine Hambrick devoted to preventing colorectal cancer through public awareness and screening.
www.LSACCA.org – a web site describing one person’s battle with colon cancer which also has very good information concerning the signs, symptoms, diagnosis and prevention of colorectal cancer.
It is estimated that 6% of all colorectal cancer occur in patients with inherited genetic abnormalities. The two most common of these are familial adenomatous polyposis (FAP), or a variant known as Gardner’s Syndrome, and hereditary non-polyposis colon cancer (HNPCC).
FAP comprises about 1% of all cases of colorectal cancer. This condition is inherited as an autosomal dominant genetic abnormality, meaning that about one-half of the kindred (off-spring) will develop the disease. In patients with FAP, polyps develop throughout the colon (average age of onset: 15-22) and if the colon is not removed cancer eventually develops (average age of onset: 39.)
At the present time, if a patient is known to have FAP, their off-spring should be checked yearly with sigmoidoscopy beginning at age 12. Since polyps occur throughout the colon, examination of the rectum and lower colon by sigmoidoscopy is adequate screening. If adenomatous polyps develop, surgery is indicated to prevent the development of colon cancer. Screening should begin at an early age because cancer may develop in the third decade of life.
The diagnosis of HNPCC is based on the so-called Amsterdam criteria, which are very strict, requiring (1) three or more relatives with colorectal cancer, one of whom must be a first degree relative (sibling, parent or child) of the other two; (2) involvement of two generations; and (3) one individual less than 50 years of age.
When these criteria are met, HNPCC is diagnosed. It is then recommended that all family members have total colonoscopy beginning at age 20 and repeated every two years until age 40 and then repeated yearly. If colorectal cancer occurs, the individual should have subtotal colectomy. In a subgroup of patients with HNPCC, there is an increased risk of other cancers, especially uterine and ovarian. Therefore, hysterectomy and removal of the ovaries is recommended in women beyond the child bearing age at the time of colectomy.
In some centers that treat numbers of patients with hereditary colon cancer, the patients are entered into a registry to identify all individuals who might be affected and who should be surveyed. These registries and subsequent surveillance of at risk individuals save lives by prevention and early detection of hereditary colon cancer.
Colorectal cancer is the second most common internal malignancy in men and women, with lung cancer being the number one. Men and women are about equally affected by colorectal cancer. Colorectal cancer is the third leading cause of cancer death in men, behind lung and prostate cancer and the third leading cause in women, behind lung and breast cancer.
Colorectal cancer occurs at any age. However, it is uncommon before the age of 40 (less than 5% of patients). The death rate (the number of deaths per 100,000 people per year) from colorectal cancer has been dropping in both men and women for several decades. There are a number of likely reasons for this. One is that colorectal polyps are now being found more often by screening and removed before they can develop into cancers or are being found earlier when the disease is easier to treat. In addition, treatment for colorectal cancer has improved over the last few decades. As a result, there are now more than 1 million survivors of colorectal cancer in the United States.
The cause of colorectal cancer is not known. Genetics play a role as individuals with a family history of colorectal cancer, especially a parent or sibling, are at increased risk. Dietary factors may be contributory and most physicians recommend a low-fat, high fiber diet.
The most frequent symptoms of colorectal cancer are rectal bleeding and a change in bowel habit. Rectal bleeding may be due to other causes such as hemorrhoids, but in general, this symptom requires investigation. When considering colorectal cancer, abdominal pain and weight loss are later symptoms of more advanced disease. Of course, abdominal pain and weight loss may be seen in other disease entities as well.
Colorectal cancer is diagnosed by digital rectal examination, sigmoidoscopy, barium enema (x-ray), or fiberoptic colonoscopy. Following diagnosis, the primary treatment is surgical excision. When the cancer is confined to the colon or rectum, surgery can be curative. Cancers are staged by surgical and pathological findings. Cancers confined to the wall of the colon are most likely to be cured. Cancers which spread to the lymph nodes or to other organs are most likely to recur after treatment. Early diagnosis is the key to curing colon and rectal cancer.
Chemotherapy is frequently given following surgery for colon cancer. It has recently been shown that surgery plus chemotherapy gives better results than surgery alone in some stages of colon cancer.
Radiation therapy is occasionally used in conjunction with surgery for rectal cancers, again in an effort to improve survival.
A frequently asked question by patients who are diagnosed with colorectal cancer is, “Will I need a colostomy?”. A permanent colostomy is required when the rectum must be removed in order to extirpate the cancer. Removal of the rectum is required in only 5% of all patients with colorectal cancer.
The death rate (the number of deaths for 100,00 people per year) from colorectal cancer has been dropping in both men and women for several decades. There are a number of likely reasons for this. One is that colorectal polyps are now being found more often by screening and removed before they can develope into cancers or are being found earlier when the disease is easier to treat. In addition, treatment for colorectal has improved over the last few decades. As a result, there are now more than 1 million survivors of colorectal cancer in the United States.
Chronic ulcerative colitis (CUC) refers to an inflammatory condition of the colon or large intestine. The cause of this inflammation is unknown. Patients who have CUC may have symptoms of abdominal pain, diarrhea, frequent urge to defecate (tenesmus), or rectal bleeding. These symptoms may range from mild to life threatening.
Chronic ulcerative colitis is different from a condition known as Crohn’s disease (CD). CUC is limited to the large intestine and can be cured by surgery. Crohn’s disease, on the other hand, can occur anywhere in the gastrointestinal tract and may recur following surgical removal.
The indications for surgery in CUC fall into two general categories: (1). When complications from disease occur, surgery is required. Complications include massive hemorrhage, perforation of the colon with peritonitis, the development of cancer, and toxic megacolon. This last condition refers to massive distention of the colon occurring in a very sick individual with severe CUC. (2). The second indication for surgery in CUC is a failure of medical management. Patients may be treated medically with anti-inflammatory drugs including steroids and never become free of symptoms. After a period of time the patient and his or her doctor may come to the decision that surgery is required. Other patients frequently develop more serious symptoms (abdominal pain, diarrhea, bleeding, weight loss, and fever) requiring hospitalization. When medical treatment is unsuccessful, surgery is required.
Until recently, the standard operation for CUC was procotocolectomy with Brooke ileostomy. Proctocolectomy means removal of the entire colon and rectum. This effectively cures CUC but the patient is left with a permanent stoma or ileostomy. The end of the small intestine is brought through the right lower quadrant of the abdominal wall as a Brooke ileostomy. The ostomy cannot be controlled by any means and discharges small amounts of intestinal contents several (3 to 4) times a day. The patient must wear an appliance or pouch and must empty it as necessary. However, this operation restores the patient’s health and the patient has a normal life expectancy. In our experience, patients would not normally desire to have an ileostomy, but almost all patients think that the ostomy is a relatively small sacrifice after being very sick with chronic ulcerative colitis. The formation of ostomy societies and the specialization of enterostomal therapy nurses has greatly helped patients and their families adjust to the use of an ostomy.
Another surgical option developed in the early 1980’s is the proctocolectomy with an ileoanal J-pouch anastomosis. This procedure uses a portion of the small intestine to create a pouch that acts as an internal reservoir. The pouch is connected to a remnant of the rectum. A temporary ileostomy is required but this can usually be taken down in 6 to 8 weeks after surgery. Taking down the ileostomy requires another operation.
Patients with pouch procedures go on to live full, productive lives. They can expect, however, to have 6 to 8 bowel movements a day and usually need to take constipating agents to help control bowel movement. In spite of this, most patients are happy with this operative choice. For more information, see Pouch-O-Gram on the Net.
Diverticulosis refers to the formation of diverticula or “pockets” in the colon wall. Diverticula are herniations of the lining of the colon through an area weakened by the penetration of a blood vessel. Diverticula may occur anywhere in the colon but are most commonly found in the lower portion of the left colon in an area called the sigmoid colon. The incidence of diverticulosis increases with age. It affects fifty percent (50%) of Americans by age 55 and almost all by age 80.
Diverticulosis is usually asymptomatic. However, it can cause massive gastrointestinal bleeding. Fortunately, this is an unusual consequence of diverticulosis.
Diverticulitis refers to infection associated with diverticulosis. Diverticulitis causes pain in the left lower abdomen, tenderness on examination of the area, fever, and an elevation of the white blood cell count.
Diverticulosis, the mere presence of diverticula, may be diagnosed by sigmoidoscopy, colonoscopy, or barium enema. It is theorized that the development of diverticula may be encouraged by a diet low in fiber. Therefore, treatment includes the use of a fiber supplement (psyllium, bran, and/or foods high in fiber) and the avoidance of popcorn, peanuts, and seed containing foods.
Diverticulitis is a clinical diagnosis. Sometimes x-rays such as a CT scan or a water soluble enema (dye study) are helpful. Diverticulosis can be confused with other colon problems, especially irritable bowel syndrome which is also very common in the United States. Diverticulitis, being an infection, requires treatment with antibiotics; irritable bowel syndrome is usually due to stress. Following resolution of diverticulitis, the large intestine should be studied by either sigmoidoscopy and barium enema or colonoscopy.
Surgery is required when complications of diverticulitis occur. These include perforation of the colon, intra-abdominal abscess, or stricture formation with obstruction of the colon. Another complication of diverticulitis requiring surgery is the development of fistulas to other organs, especially the bladder (colovesical fistula) or the vagina (colovaginal fistula).
Surgery is also required for repeat attacks of diverticulitis that resolve with antibiotic therapy. This is necessary to prevent the development of the complications described above. The development of a complication is associated with urgent surgery, the possibility of a temporary colostomy, and a higher complication and mortality rate.
Finally, surgery may be required in diverticulosis when massive bleeding or recurrent bleeding requiring transfusion occurs.
An anal fissure is a linear crack or tear of the lining of the anal canal. With time, this tear may become a chronic ulcer. The most common cause of an anal fissure is the passage of a hard stool or constipation. Other causes include chronic diarrhea, hypertrophy of the anal sphincter muscle, and infection. Anal stenosis (narrowing) may follow the removal of excessive amounts of tissue during anorectal surgery, especially hemorrhoidectomy. Anal stenosis may lead to the development of a fissure.
An anal fissure may be diagnosed by history alone, severe pain at the time of a bowel movement. The fissure can be visualized by gentle examination of the patient. “Scopes” are not usually required. The primary treatment of an anal fissure is the avoidance of constipation with the use of fiber (psyllium, bran, diet). Warm soaks, a cleaning agent such as Balneol, and topical ointments may be useful. Nitroglycerin ointment has been used experimentally. When fissures do not heal (about 50%), surgery is required. Surgery may be performed in the office or in an outpatient surgery facility. Several surgical procedures are available, but the most common procedure in the United States involves incision of a portion of the internal anal sphincter. Lateral internal sphincterotomy (the most common operation) when properly applied, results in a cure in almost all cases and has few complications.
Ninety-five percent of anal ulcers conform to the above description. Less than 5% of ulcers are due to other causes such as Crohn’s disease, tuberculosis, HIV infection, anal cancer and other causes.
An anorectal (perirectal) abscess and an anorectal fistula have a common origin. The abscess is an acute problem and the fistula is a subsequent chronic problem. A fistula is an abnormal communication between the anal canal and the perianal skin.
In 90% of cases of perirectal abscess, the source of the abscess is an infection occurring in glands which empty into the anal canal. Usually, no specific cause of this infection can be found and it is termed a cryptoglandular Infection. A cryptoglandular infection may occasionally be seen in association with a diarrheal illness, anal fissure, tuberculosis, Crohn’s disease, and AIDS.
Non-cryptoglandular infection (less than 10%) occurs secondary to trauma, a foreign body or cancer of the rectum. Rarely an intraabdominal source of infection may result in a perirectal abscess.
A patient with a perirectal abscess presents to the surgeon with persistent rectal pain (unlike anal fissure in which the pain occurs following defecation), perirectal swelling, possible fever and drainage if the abscess has ruptured. An abscess may be diagnosed by inspection of the tissue around the rectum or by digital palpation. Occasionally endoscopic examination is required if not too painful. In a small number of patients with severe pain, examination under anesthesia is required for diagnosis. Treatment is rendered at that time.
The treatment of a perirectal abscess is adequate surgical drainage. There is no role for antibiotics as primary treatment; they may be used in conjunction with surgical drainage in some cases. Small abscesses can be drained in the office with the use of local anesthestics. At least one-half of abscesses require drainage under anesthesia, either general anesthesia or spinal anesthesia.
Following rupture of an abscess or following surgical drainage, a fistula may (but not necessarily) develop. Signs of a fistula include persistent drainage and recurrent abscess formation. The presence of a symptomatic fistula is an indication for surgery. Fistulas rarely heal and are associated with recurrent abscesses. Rarely, a long standing fistula may be the site of development of a cancer. Surgical treatment of a fistula usually means complete incision of the fistula (fistulotomy).
The goal of treatment of a fistula is complete eradication of the fistula and maintenance of fecal continence. Fistulas can be simple problems with the diagnosis obvious and treatment straight forward. In a small percentage of cases, the fistula may be difficult to identify and eradicate. Multiple operations may thus follow.
If at the time of drainage of a perirectal abscess a fistula is identified, surgical treatment of the fistula may be carried out. If a definite fistula cannot be identified, the best treatment may be simply to drain the abscess and caution the patient that he may need further surgery should a fistula develop.
A fistula usually involves some portion of the anal sphincter muscle and correction of the fistula requires division of a portion of the muscle. The most significant complication of surgery for a fistula is fecal incontinence. If this occurs, the sphincter muscle can be subsequently repaired.
The treatment for a fistula associated with other conditions is treatment of the primary condition.
Some infections and abscesses may occur near the rectum, but do not originate in the rectum. A Bartholin’s abscess originates in the vagina. Infections may involve the perianal skin or its appendages. These include infected pilonidal cysts, hidradenitis originating in sweat glands, and infected sebaceous cysts.
Infection of the perirectal tissues may also originate from infections of the urinary system. The treatment of these infections is treatment of the underlying source.
Gordon, P.H. Anorectal Abscess and Fistula-in-ano. In Gordon, P.H. and Nivatvongs, S. Principles and Practice of Surgery for the Colon, Rectum, and Anus. St. Louis: Quality Medical Publishing, Inc., 1992, pp. 221-265.
Pruritus ani refers to a sensation of discomfort in the perianal area. It may be perceived as itching or as burning. Men are more often affected than women by a ratio of 4 to 1. The majority of cases are idiopathic – there is no apparent cause. The remainder may be due to local anorectal abnormalities (prolapsing hemorrhoid, anal fistula, etc.) or systemic diseases such as diabetes mellitus. Symptoms are frequently worse at night. Poor anal hygiene may cause pruritus ani or may make it worse. Stress and anxiety may exacerbate pruritus ani.
Anorectal examination should be carried out to identify any obvious cause. The patient should be asked about any other skin condition or skin rash. In early cases of idiopathic pruritus ani, the skin may appear erythematous and excoriated. Ulcerations may be present with “weeping”. In later stages the skin may appear pale and lichenified (thickened with exaggeration of radiating perianal folds). Ulceration may also occur. In women, pelvic examination should be done. A vaginal infection or discharge may be responsible for symptoms of pruritus.
Anal manometry – measurement of the anal sphincter pressures – in patients with idiopathic pruritus ani has shown transient decreases in the internal anal sphincter pressure. This suggests that fecal leakage may be causative. Coffee consumption has been shown to decrease the internal anal sphincter pressure.
TREATMENT The perianal skin should be cleaned several times per day and especially following bowel movements. Balneol is a cleansing agent that is frequently recommended. Medicated soaps should be avoided. The skin should be dried with the use of a hair dryer. Hydrocortisone, 2.5%, may be applied and act as a skin barrier as well as decrease inflammation. (Prolonged use of steroid creams may cause atrophy of the skin with symptoms similar to pruritus ani and should be avoided.) A cotton pad may be tucked into the area and changed frequently, thus keeping the skin dry.
With improvement the steroid cream should be replaced with cornstarch or talc to keep the skin dry.
If symptoms are worse after a bowel movement or if there is identifiable fecal leakage on the perianal skin, a small tap water enema following a bowel movement may be helpful.
Dietary substances may be causative in pruritus ani and the following should be deleted from the diet for two weeks – coffee (both regular and decaffeinated), tea, colas, alcohol (especially beer), chocolate, nuts, citrus fruit, dairy products (milk, cheese, ice cream), and tomatoes. If improvement is noted, these items are returned to the diet one at a time.
An antihistamine (Benadryl, 25mg, four times daily) may be helpful. Estrogen has been useful in postmenopausal women. Cultures of the perianal area may diagnose secondary bacterial infections or yeast infections. These can be treated with topical antibiotics or fungicides. The treatment of the possible anorectal lesion causing pruritus is treatment of the lesion – rubber band ligation of a prolapsing hemorrhoid for example.
Patient’s taking antibiotics may develop pruritus – possibly because of an allergic reaction or due to a change in the bacterial flora of the bowel or vagina. Severe jaundice, diabetes – due to its association with candida infections – and radiation injury to the perianal skin may be associated with symptoms of pruritus.
Patients may require dermatological consultation, when skin rashes or other skin problems are present and in refractory cases.
Gordon PH, Nivatvongs S. Principles and Practices of Surgery for the Colon, Rectum, and Anus, Second Edition. St Louis: Quality Medical Publishing, 1999.