EXPERT ANALYSIS FROM THE ANNUAL INTERNAL MEDICINE PROGRAM
ESTES PARK, COLO. (FRONTLINE MEDICAL NEWS) – As a colorectal surgeon, Michelle Cowan, MD, sees a steady parade of primary care referrals for surgical evaluation of hemorrhoids.
The thing is, most of the time, the referred patients don’t have hemorrhoids. They have one of the other common anorectal disorders, including anal fissure, anoperineal abscess, fistula-in-ano, or an anorectal sexually transmitted infection, according to Dr. Cowan.
At a conference on internal medicine sponsored by the University of Colorado, the surgeon explained how to tell these common disorders apart, which ones can be treated appropriately in a primary care office, and who needs referral for surgery.
The diagnostic challenge stems from the fact that most common anorectal diseases – whether benign or malignant – present with the same constellation of symptoms: pain, bleeding, itching or burning, swelling, and leakage.
The quality and intensity of the pain “down under” provides a useful clue in differentiating the disorders.
“Hemorrhoids rarely cause legit pain,” said Dr. Cowan , who practices at the University of Colorado at Denver, Aurora. “Excruciating pain, where the patient will only sit on one side, that’s typically an abscess, a fissure, or an STI.”
The exceptions in the hemorrhoid realm are external thrombosed hemorrhoids, which are exceedingly painful but also readily identifiable, and incarcerated hemorrhoids, which are quite rare.
The pain associated with an anal fissure is distinct from that of an abscess or thrombosed hemorrhoid – it’s a throbbing pain lasting minutes to hours per episode.
“These are the people who won’t sit down in your office,” Dr. Cowan said.
Anal fissure is a common condition in young and middle-aged adults, and especially in peripartum women. The pathophysiology involves microtrauma, typically either because of passing rock-hard stools, diarrhea, or the rigors of childbirth, any of which can cause a break in the anal mucosa. That break causes the internal sphincter muscle to go into spasm, temporarily choking off the blood supply to the area of the fissure. Those wounds won’t heal on their own. Close to 90% of the fissures are located in the posterior midline; if the fissure is ectopic, it’s time to consider Crohn’s disease, HIV infection, tuberculosis, cancer, and other possibilities.
The patient with an anoperineal abscess presents with extreme pain, a sensation of fullness in the anus and rectum, erythema, fullness of the perineum, drainage, and sometimes fever.
“This is legit pain, like with a fissure or thrombosed hemorrhoids,” she explained. “Patients with any of these conditions can tell you exactly when they went from feeling normal to when the pain started.”
The abscess is caused by an infected anal gland. The location is most commonly perianal or ischioanal. If that’s not the suppuration site, the abscess is intersphincteric or supralevator, in which case a confirmatory CT scan is called for before proceeding with treatment.
Regardless of the suspected cause of a patient’s anorectal symptoms, any GI bleeding needs to be taken seriously. Young adults are the only segment of the population in whom the incidence of colorectal cancer is going up. In response, the American Society for Gastrointestinal Endoscopy and other groups now recommend colonoscopy for all patients older than age 40 years with GI bleeding, even if their family histories for colorectal cancer are negative and they lack other high-risk factors. For those younger than age 40 years, flexible sigmoidoscopy is recommended, even if it’s obvious that the patient has external thrombosed hemorrhoids that are bleeding.
“I tell people that I will not do hemorrhoid surgery until they have the scope,” Dr. Cowan said.
Office-based treatment of common anorectal disorders
Nonoperative treatment of anal fissures and internal hemorrhoids is all about encouraging patient adherence.
“Patient expectations are often overlooked,” according to the surgeon. “It’s rare that these patients actually need to go to surgery, but they oftentimes don’t do what we tell them to do, which is why they end up in my office.”
With anal fissure, the goal is to relax the spastic sphincter muscle, allowing the fissure to heal. That can be accomplished medically or surgically.
Medically, treatment consists of increased water intake, incorporation of more fiber in the diet, undertaking warm sitz baths a couple times a day, and application of a pea-sized amount of topical 2% diltiazem three times daily on the outside of the anus for 6-8 weeks.
“Compliance is huge. This whole thing is about consistency. Oftentimes, the reason treatment fails is people can’t do this. They feel good after about a week, so they stop before the fissure is completely healed,” she said.
The topical diltiazem must be prepared at a compounding pharmacy. It’s usually covered by insurance. Even if it’s not, an 8-week prescription costs only about $25. The drug is effective in up to 95% of patients who follow the instructions.
Topical 0.2% nitroglycerin, an alternative treatment, is less attractive because 30% of patients experience often-disabling headaches as a side effect. Topical diltiazem has a much better side effect profile, Dr. Cowan noted. If a patient shows a partial response to 6-8 weeks of topical diltiazem, it’s worth prescribing a second round. If the fissure still hasn’t healed after that, it’s time for referral to a surgeon. The options are onabotulinumtoxinA (Botox) and lateral internal sphincterotomy.
Botox is effective in 60%-80% of patients, she explained, providing temporary benefit lasting up to 3 months with a much lower risk of incontinence than with lateral internal sphincterotomy. Open and closed sphincterotomy techniques yield a similar success rate, with healing in 93% of cases.
For internal hemorrhoids, stool softeners, 25-30 g of fiber supplements per day, warm sitz baths, avoiding straining during defecation, and not loitering on the toilet are key elements in achieving symptomatic control nonoperatively.
Patients who don’t have a bathtub in which to take sitz baths can accomplish the same thing using an easily removable, commercially available device that fits over a toilet bowl.
Disposable baby wipes for adults have become the No. 1 cause of anal itching and are to be shunned by patients with internal hemorrhoids or other anorectal disorders.
“Patients often engage in excessive wiping because of the poor consistency of their bowel movements,” Dr. Cowan explained. “If they’re pasty and not coming out in one fell swoop, it leads to residue that patients appropriately feel they need to wipe multiple times to keep clean. The majority of these dipe wipes for adults are alcohol based, and even though on your exam you may see nothing, the dipe wipes cause microexcoriations of the skin. The patient itches and doesn’t know why.”
Primary care physicians can readily learn to do mucosal banding for grade II and III prolapsing hemorrhoids in the office, she noted. However, banding should never be attempted on external thrombosed hemorrhoids, though.
Surgical excisional hemorrhoidectomy is a lasting solution for such hemorrhoids, but patients need to understand that even though it’s only a 10- to 15-minute procedure performed in an outpatient setting, it’s excruciatingly painful for a week – and that’s not the end of the story.
“I tell patients to take a week off work,” the surgeon said. “And don’t sit on a donut; it pulls on the suture line. Pillows are okay. But it takes 6-8 weeks to heal, so even though they’re only in excruciating pain for about a week, they have to poop past the suture line, so they’ve got to avoid rock-hard stools.”
With an anoperineal abscess, first-line treatment is incision of the abscess as close as possible to the anus, followed by placement of a drain to be left in place for 7-10 days. Prophylactic antibiotics are reserved for immunosuppressed patients.
Patients need to understand up front that, 30%-50% of the time, a fistula can develop after drainage of an abscess. Indeed, abscessed anoperineal fistula is one of the most common conditions Dr. Cowan sees in the emergency department and clinic. The telltale symptoms are recurrent abscess and/or persistent drainage. Those patients need referral to a colorectal surgeon.
“Fistula-in-ano is a frustrating disease for the patient and the surgeon. As surgeons, we like to fix – and there’s really no good option,” according to Dr. Cowan.
Among the surgical treatment options are debridement followed by fibrin glue injection, an anal fistula plug, an endorectal flap closure, and ligation of the intersphincteric fistula tract, or LIFT, procedure.
Dr. Cowan reported serving as a consultant to Applied Medical.