Perianal Complaints Research Articles

A retrospective analysis of clinical characteristics and management of perianal streptococcal dermatitis in children and adults

Due to the paucity of recent literature on perianal streptococcal disease (PSD), we performed a comprehensive analysis of clinical characteristics of PSD and its management. We conducted a retrospective search in the laboratory information system of the Institute of Microbiology and Immunology, Ljubljana, Slovenia, between January 2006 and December 2016 and identified patients with suspected PSD. We reviewed patients' medical records and obtained data on patient age and sex, concomitant illnesses, duration of complaints, signs and symptoms of PSD, epidemiological history, date of diagnosis, microbiological characteristics of beta-hemolytic streptococcal isolates, additional laboratory findings, duration and type of systemic and/or topical therapy, and recurrence of PSD. We identified 64 pediatric and eight adult PSD cases in total. The most common signs and symptoms were perianal erythema (67/72; 93.1%), anal fissures (28/72; 38.8%), itching (22/72; 30.6%), and blood-streaked stools (19/72; 26.4%). The duration of symptoms varied from < 1 week to > 1 year, with 58.3% of patients experiencing symptoms between 1 week and 6 months. The majority of patients received systemic (63/72; 87.5%) and topical (56/72; 77.8%) treatment. Although the signs and symptoms of PSD are non-specific, clinicians should be highly suspicious of the disease in adults and especially in preschool children with perianal complaints. Despite being a common disease, there is still considerable delay in correct diagnosis and treatment, prolonging the discomfort of PSD patients.

Hemorrhoids and related complications in primigravid pregnancy

PurposeTo identify the effect of pregnancy on the development of external hemorrhoids and constipation. Subjects and methodsThis pilot study involved 61 primigravid women without a history of perianal diseases. Each patient was examined and filled a questionnaire between the 11th and 14th gestational week prior to prenatal screening tests. Patients were re-examined and questioned in relation to perianal symptoms and hemorrhoidal changes again in the 24th and 37th gestational weeks. ResultsA total of 5, 8, and 11 women had symptomatic external hemorrhoids with or without perianal complications in the 11–14th, 24th, and 37th gestational weeks, respectively. Meanwhile, 27, 25, and 29 women complained about constipation in the 11–14th, 24th, and 37th gestational weeks, respectively. Only 4 (6.6%) patients experienced painful hemorrhoids. The overall morbidity rate was 18% (11 cases). We found a statistically significant relationship between external hemorrhoids/perianal complications and gestation-induced constipation through logistic regression analysis (p<0.001). ConclusionVarious risk factors and biological explanations exist for the high frequency of hemorrhoids during pregnancy. Because participants were primigravid women without a history of perianal complaints, findings suggest a direct effect of pregnancy itself on the development of external hemorrhoids/perianal symptoms.

Angiogenesis inhibitors and symptomatic anal ulcers in metastatic colorectal cancer patients

Background: Angiogenesis inhibitors are a standard first-line treatment for metastatic colorectal cancer. Anal canal pain is a common adverse event, but its cause has never been described. The aim of the study was to evaluate the association between the use of angiogenesis inhibitors and symptomatic anal ulcer development.Methods: This retrospective cohort study included all 601 consecutive metastatic colorectal cancer patients undergoing first line treatment from January 2010 to June 2016 at the Veneto Institute of Oncology. Details about patient characteristics, treatment and proctology reports were retrieved and compared. Vascularization of the anal canal was evaluated with contrast MRI.Results: Fifty out of 601 patients reported perianal complaints during treatment and underwent proctologic evaluation. Among those, 16 were found to have an anal ulcer. Symptomatic anal ulcers occurred only in patients receiving bevacizumab (4.2% vs. 0% with other regimens, p = .009). The peak incidence was 4–8 weeks after treatment start. Vascularization of anal canal was significantly lower in patients treated with bevacizumab (p = .03). Hypertension and hemorrhoids were associated with a lower risk of anal ulcer occurrence (p = .009 and p = .036). Pain intensity was severe. All attempts at symptomatic treatment only led to transient benefit. The absence of symptomatic ulcers was protective against earlier permanent discontinuation of treatment (HR = .22, 95%CI: 0.04–0.62).Conclusions: The development of symptomatic anal ulcers in patients receiving angiogenesis inhibitor is a common adverse event which can compromise the continuation of cancer therapy. We recommend an early proctologic evaluation in case of anal symptoms with the aim to prevent and timely manage such complication.

Perianal Dermatitis.

Perianal complaints are often consulted in dermatology clinics, and in many cases, a conclusive diagnosis is not easily made. The aim of this study was to study and identify the epidemiological, clinical, and contact allergy features of patients with perianal dermatitis who attended at a contact dermatitis unit in a tertiary hospital in Spain. Adult patients with long-lasting (>4 weeks) perianal dermatitis were recruited during the past 10 years for investigation and follow-up. Every patient underwent a diagnostic workup consisting of dermatological exploration and patch tests with the standard and specific series, as well as the patients' own products. General surgical exploration was also performed in some patients. One hundred twenty-four patients were included. The MOAHLFA index was as follows: 43.5, 0, 4.8, 11.3, 1.6, 8.1, and 75. The main final diagnoses were allergic contact dermatitis (32.3%), psoriasis (24.2%), irritant contact dermatitis (17.7%), and lichen simplex (neurodermatitis) (10%). Eighty-one patients (66.1%) showed 1 or more positive reactions, and in 52 patients (43%), positive reactions relevant to the present disease were found. Contact allergy in patients with long-lasting perianal complaints is frequent. It is mandatory for these patients to be referred to a dermatologist for an adequate evaluation and patch testing. Methylchloroisothiazolinone/methylisothiazolinone seems as the most common allergen implicated in perianal contact dermatitis.

Angiogenesis inhibitor bevacizumab and symptomatic anal ulcers in metastatic colorectal cancer patients: A single center experience.

e15042 Background: Chemotherapy (CT) associated with angiogenesis inhibitor bevacizumab (bev) is a standard first line treatment in metastatic colorectal cancer (mCRC). Among adverse events related to bev, anal canal ulcers have never been extensively described. The aim of our study was to evaluate symptomatic anal ulcers development and its impact on clinical practice and proctologic management. Methods: We retrospectively reviewed clinical records of 601 consecutive mCRC patients (pts) undergoing first line CT from January 2010 to December 2015 at our Institute. Pts’ characteristics, treatments and proctology reports were analyzed. Anal pain was graded in a semi-quantitative scale. Vascularization of the anal canal was compared with contrast MRI in 5 pts treated with bev and 5 healthy controls. Non parametric statistics was performed. Results: Fifty out of 601 pts reported perianal complaints during treatment and underwent proctologic evaluation. Among those, 16 were found to have an anal ulcer. Symptomatic anal ulcers occurred only in pts receiving CT plus bev (16 out of 384, 4.2%) while none was observed in 217 pts treated with other regimens (p = 0.009). The peak incidence was 4-8 weeks after treatment start. Vascularization of anal canal was significantly lower in pts treated with bev (p = 0.03). Hypertension and hemorrhoids were associated with a lower risk of anal ulcer occurrence (p = 0.009 and p = 0.036) while a previous neoadjuvant pelvic CT-RT was not associated with a higher risk. Pain intensity was severe. All attempts at symptomatic treatment with topical and sistemic drugs only led to transient benefit. Pts with symptomatic anal ulcers suspended their first line therapy significantly earlier than other pts (HR = 0.30, 95%CI 0.07-0.80). Conclusions: Symptomatic anal ulcer in mCRC pts treated with CT plus bev is a common adverse event in our series. It can compromise oncologic treatment and pts’ quality of life. We recommend an early proctologic evaluation in case of anal symptoms with the aim to prevent and timely manage such complication in pts treated with bev. A more extensive analysis is ongoing considering subsequent treatment lines and other angiogenesis inhibitors.

Anorectal complications and function in patients suffering from inflammatory bowel disease: a series of patients with long-term follow-up.

The aim of this study is to describe the long-term course of anorectal complains and function in a single centre cohort patients suffering from inflammatory bowel disease (IBD) with perianal lesions. Between 1993 and 2000, 56 IBD patients (43 Crohn's disease and 13 ulcerative colitis) with perianal complaints underwent anorectal function evaluation (AFE) (baseline). For follow-up, they were approached between 2010 and 2012 by sending questionnaires including Inflammatory Bowel Disease Quality of Life Questionnaire (IBDQ), Perianal Disease Activity Index (PDAI), faecal incontinence scale (Vaizey) and an invitation for AFE. At follow-up, 46 patients (82 %) were available, 9 (16 %) were lost and 1 (2 %) had died. Thirty patients returned the questionnaires of which 17 also underwent AFE. The remaining 16 patients were interviewed by phone and were only willing to mention their anorectal complaints. Median follow-up was 14 year. In 25 of the 46 patients (54 %), perianal complaints persisted faecal incontinence (n = 7); soiling (n = 13) and active fistula (n = 5). Eighteen (39 %) patients had an active fistula at baseline and three persisted at follow-up. Two developed a new fistula. Mean IBDQ, Vaizey and PDAI were 178 (SD 29), 7 (SD 5) and 4.2 (SD 3.0), respectively. In 17 patients, who underwent AFE, anal endosonography showed healing in nine of the ten fistulas. Anal pressures as well as rectal capacity remained unaltered in the individual patient, but showed a large range within the group. After 14 years, 54 % of the IBD patients with perianal lesions still have mild complaints. The quality of life remained moderate over a long period, which is concerning.

Contemporary management of perianal conditions in febrile neutropenic patients

IntroductionThe aim of this study was to examine the type and frequency of perianal conditions in a contemporary series of febrile neutropenic patients and to examine the risk factors, management options and outcome of septic perianal conditions. MethodsMedical records of all adult febrile neutropenic patients (933 patients) who were admitted during the period from January, 2009 to December 2011 were retrospectively review. All patients with perianal complaints or conditions were included. The clinical features, management and outcome of septic conditions were recorded. ResultsOf all the reviewed charts, 101 (10.8%) had perianal complaints or conditions. Most of them were non septic (74.3%), like piles and fissures, and were treated conservatively. In 26 patients the diagnosis was a septic condition: abscess (12 patients), fistula (4), inflammation (9) and necrotizing fasciitis (1). Septic conditions were more commonly found in males younger than 40 years. Surgery was done in 13 patients to drain a collection and in 2 patients to debride necrotic tissue. Most patients who had no collection had conservative management. There was 1 fatality only (3.8%) in those 26 patients. ConclusionMost of the perianal conditions in febrile neutropenic patients are non septic and are managed conservatively. Septic perianal conditions are not associated with a poor prognosis as in the past. Surgical drainage should be reserved to conditions where there is a collection; otherwise patients should be managed conservatively but with close monitoring.

The Evaluation and Treatment of Hemorrhoids: A Guide for the Gastroenterologist

A references to symptomatic hemorrhoidal disease date back thousands of years and can be found in the ible as well as early Egyptian, Babylonian, and Greek scripts.1–3 The first known mention of this condition is from an Egyptian papyrus in 1700 BC, which advises . . . “Thou shouldest give an ointment of acacia leaves, ground and titurated together . . . and place in the anus, that he recovers immediately.”4 Indeed, there are few diseases more recounted in human history than hemorrhoids. The word hemorrhoid is derived from the Greek, with haima meaning blood and rhoos meaning flowing. Another common word for hemorrhoids used in the vernacular is “pile,” which comes from the Latin pila, meaning a ball. As aptly noted by Senagore, “although few people have died of hemorrhoidal disease, many patients who have undergone certain hemorrhoid therapies wish they had,” and this entity is one of the few diseases with its own patron saint (St Fiachre, the patron saint of gardeners and hemorrhoid sufferers).1 Symptomatic hemorrhoids are common, and those with hemorrhoids along with other anorectal diseases frequently present to the gastroenterologist with lower gastrointestinal (GI) bleeding and perianal complaints for evaluation and treatment. These patients and their referring physicians have an expectation that the gastroenterologist who examines this area should be able to provide comprehensive care of any nonsurgical anorectal ailments that are present. However, in large part because of the fact that formal training in anorectal pathology is not included in the combined Gastroenterology Core Curriculum, the care of these problems is often deferred to surgical specialties.5,6 There now seems to be an increasing recognition of this gap in the training of gastroenterology fellows, because an increasing number of GI programs are beginning to include nonsurgical anorectal care into their curricula. Some have called for the formal inclusion of anorectal entities into GI fellowship training.5 It is the intent of this article to serve as a general introduction of the nonsurgical care of hemorrhoids to gastroenterologists, helping them provide a more complete continuum of care to their patients.

Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation

Introduction and hypothesisMany women with chronic constipation are referred for anorectal function tests (AFT) when they fail initial conservative treatment with lifestyle advice and laxatives. Our goal was to prospectively investigate the diagnostic potential of AFT in women with constipation in order to identify treatable conditions.MethodsBetween May 2003 and June 2011, all women with constipation referred to our tertiary referral center completed a questionnaire regarding their perianal complaints and underwent physical examination and were evaluated according to our AFT protocol, including anorectal manometry (ARM) and anal endosonography.ResultsOne hundred and thirteen women were referred and classified as having idiopathic constipation (n = 100), neurological disorder (n = 8), or others (n = 5). Of the 100 women with idiopathic constipation, clinical examination identified 25 (25 %) with hypertonia of the pelvic floor (dyssynergic pelvic floor) and 15 (15 %) with a rectocele. In 37/100 women also complaining of impaired evacuation, the yield of rectocele was 15 (41 %) and of hypertonia 5 (14 %). Women with hypertonia were younger (40 vs. 51 years; P = 0.002) and had no rectoceles identified (P = 0.02), and fewer women could relax during straining on ARM (56 % vs. 92 %; P < 0.001) compared with women without pelvic hypertonia. Other ARM measurements showed no differences between women with evacuation disorders, rectoceles, or hypertonia. Anal endosonography showed no internal sphincter hypertrophia.ConclusionPotentially treatable conditions, such as rectocele and pelvic floor hypertonia, are found on clinical examination in 40 % of women with idiopathic constipation. Impaired evacuation is associated with the presence of a rectocele. AFT contributes little and should be reserved for selected cases.

Safety, Feasibility, and Usefulness of Rectal Endoscopic Ultrasonography for Pediatric Anal and Perianal Complaints

Safety, Feasibility, and Usefulness of Rectal Endoscopic Ultrasonography for Pediatric Anal and Perianal Complaints

Safety, Feasibility and Usefulness of Rectal Endoscopic Ultrasonography (EUS) for Pediatric Anal and Perianal Complaints

Safety, Feasibility and Usefulness of Rectal Endoscopic Ultrasonography (EUS) for Pediatric Anal and Perianal Complaints

Rectal Endoscopic Ultrasound in the Management of Rectal and Perianal Complaints of Crohn's Disease Patients

Background: Rectal and perianal complaints are frequent among Crohn's disease (CD) pts. Rectal endoscopic ultrasound (EUS) is useful in assessing rectal and perianal disease. However, it appears to be underutilized in CD pts. Furthermore, it has been suggested that it should be combined with another method of assessment (exam under anesthesia; EUA) for better results. We report our experience in utilizing EUS as the initial study to assess and manage perianal and rectal complaints among pts with Crohn's disease. Methods: CD pts who underwent rectal EUS were included. Complaints / indications included pain, urgency, fecal incontinence, discharge and suspected fistula, abnormal digital rectal exam, follow up of a previous exam or combination of the above. Management was based solely on EUS findings. Results: Between January 2006 and November 2006 31 CD pts (20 F and 11 M) underwent 36 EUS exam. Indications were: suspected fistula and / or abscess (20), follow up of fistula post treatment (5), rectal pain (7), fecal incontinence and / or urgency in absence of mucosal disease (4). Among pts with suspected fistula and / or abscess, 5 had one fistula and 4 had multiple fistulas (2 rectovaginal and the rest perianal and perirectal), 4 had associated abscesses / septic process and 7 had no fistula or abscess. Treatment based on findings included addition of immunomodulators and / or infliximab in 7, referral for EUA and draining +/- seton placement in addition to medical therapy in 4, observation and reassurance in 11. None required additional assessment beyond what was determined on EUS findings. Among the 5 pts who had repeated EUS for f/u of Rx, 3 had resolution of fistula tract, 1 had a new abscess and 1 had persistent symptomatic fistula (findings were confirmed by EUA). Among pts with persistent rectal pain despite therapy for presumed causes (2 with rectal stricture, 3 with internal hemorrhoids and 2 with suspected fissures) EUS identified a fistula and / or a septic process in 4 pts (1 in pt with stricture, 2 in pts with hemorrhoids and 1 in pt with presumed fissure). Among pts with fecal incontinence and / or urgency in absence of mucosal disease 1 was found to have a complex perirectal fistula and 1 had significant sphincter disruption. Interestingly, mild external sphincter disruption in this cohort was reported in 11 pts (35%). Conclusion: EUS should be considered in all Crohn's disease patients with rectal and perianal complaints. It is complementary to mucosal examination in those patients and can lead to significant changes in the management plan. Furthermore, EUS may be used alone to guide and follow up medical and surgical therapy.

Ätiologische Faktoren der perianalen Dermatitis: Prospektive Studie mit 126 Patienten

Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area. Studies on the epidemiology of causative factors are rare. Over a 4-year period we prospectively studied 126 patients with a presumptive diagnosis of anal eczema. The diagnostic algorithm comprised medical history, inspection, microbiology, laboratory chemistry, patch tests, proctoscopy, and biopsy if appropriate. The age range was 7-82 years and the majority of patients were male (57.1%). Periods of anal symptomatology ranged from 6 days to 120 months and most of the patients (51.6%) had complaints for more than 12 months. The clinical diagnosis in 68 patients (54%) was: intertrigo/candidiasis (42.9%), atopic dermatitis (6.3%), pruritus ani (5.6%), psoriasis (3.2%), skin atrophy from steroid use (2.4%), lichen sclerosus et atrophicus (n = 2), herpes simplex (n = 1), and condylomata acuminata (n = 1). Contact eczema was suspected in 58 patients (46%), but 25 of these (43.1%) showed no contact sensitization. The majority of patients with symptoms of anal eczema suffer from intertrigo/candidiasis, and relevant, causative contact sensitization may be found in only some of them. Patch-testing is a valuable investigative tool only when the patients' own products are included in the test series. Most patients suffer from their perianal complaints for more than 12 months, therefore diligent evaluation is warranted.

Anorectal Crohn's Disease

Anorectal disease affects many patients with Crohn's disease. Clinical manifestations vary from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. Surgical management needs to be conservative and must focus on draining septic sites, preserving sphincter function, and palliating symptoms. Medical management has had some success in improving symptoms, but as yet, it has not been able to ameliorate most perianal complaints quickly and enduringly. Many new and exciting treatment modalities are being investigated with the hope that more effective approaches to these complex and difficult problems can be realized.