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Anal & Rectal Pain It’s not just Hemorrhoids Greta Bernier, MD Colon & Rectal Surgeon
Anal & Rectal PainIt’s not just Hemorrhoids
Greta Bernier, MDColon & Rectal Surgeon
Anal & Rectal PainIt’s not just Hemorrhoids
No financial disclosures.
I have hemorrhoids… …I can’t stand it anymore…They are getting worse…They hurt…I need surgery…My doctor said I should see a specialist
Tell me about it… …What is your pain like?…Where is it?…When does it happen?…Do you have bleeding?…Do you feel external tissue?…Straining or difficulty with evacuation?
So… is it a hemorrhoid?
Dentate Line
Anoderm
Mucosa
Dentate Line
(Mucosa)
(Anoderm)
1. External Thrombosed Hemorrhoids
• Symptoms o Intense, acute onset, sharp pain, worsens in first ~48 ho Constant, unrelenting, difficulty sitting, pain with walkingo New external swelling or masso Possible bleeding, often with relief afterward
• Examo Blueberry, swollen, firm to rubbery, tender, ulcerated
• Treatmento Sitz Baths, stool softeners, fiber supplement, pain
medicationso Clot evacuation – OR or clinic, within 72 hours
1. External Thrombosed Hemorrhoids
2. Fissure
• Symptoms• Razor blade, glass shard pain, bright red blood. • Occurs with BMs. • Pain may last few minutes or several hours.
• Exam• Distal aspect of fissure noted with effacement of anal orifice• Very tender, difficulty with relaxation• Defer rectal exam• Typically anterior or posterior midline
2. Fissure
• Treatment• Sitz Baths, stool softeners, fiber supplement• Avoid pain medications, concern for constipation• Topical Nifedipine, Diltiazem, Nitroglycerin +/‐ lidocaine• Surgical Management: Botox injection, sphincterotomy
2. Fissure
3. Abscess & Fistula
Dentate Line
• Symptoms• Pain, swelling, cellulitis, fever• Difficulty with urination, rectal bleeding
• Exam• Erythema, induration, cellulitis, fluctuance• Intersphincteric abscess: Inability to tolerate rectal exam
without external skin findings
• Treatment• Clinic or operative incision & drainage• Antibiotics• No packing, Sitz baths
3. Abscess & Fistula
3. Abscess & Fistula
Dentate Line
From the perspective of a colorectal surgeon…
4. Pelvic Floor Disorders / Dysfunction
From the perspective of a colorectal surgeon…
• Levator syndrome / spasm• Pain from spasm• Sharp to achy• Frequently after bowel movements• May worsen with laying supine• May last for hours
4. Pelvic Floor Disorders / Dysfunction
• Proctalgia Fugax• Sudden rectal pain• Wakes from sleeping• Rectal spasm
From the perspective of a colorectal surgeon…
4. Pelvic Floor Disorders / Dysfunction
• Coccodynia• Tailbone pain• Worse with movement or manipulation• May worsen with bowel movements• 1/3 of patients do not report preceding
trauma
• Outlet dysfunction constipation• Paradoxical puborectalis contraction• Pushing against a closed door• Incomplete evacuation• Pressure, aching
From the perspective of a colorectal surgeon…
• Levator syndrome / spasm
4. Pelvic Floor Disorders / Dysfunction
• Proctalgia Fugax
• Coccodynia
• Outlet dysfunction constipation
• Pudendal neuralgia
• Rectocele, Prolapse
Levator Syndrome / Proctalgia Fugax / Outlet Dysfunction
• Exam• No fissure or other anatomic abnormality on examination• Pain with palpation of puborectalis, lateral levators
• Treatment• Bowel movement regulation: Fiber, water, dietary changes• Pelvic floor physical therapy with biofeedback• Medicated suppositories (i.e. diazepam, Flexeril)• Injection of anti‐inflammatory agent, local anesthetic,
Botox (off label)
4. Pelvic Floor Dysfunction
• Gonorrhea, Chlamydia, Herpes, syphilis, HPV, HIV…
• Symptoms / Exam• Variable ‐ Pain, purulent drainage, bleeding, ulceration,
warts
• Treatment – dependent on pathogen
5. Sexually Transmitted Disease / Fungal Infection
Important to remember these in the differential diagnosis
• Overly aggressive perianal hygiene
• Chronic use of steroids, witch hazel or other topicals
• Any of the prior diagnoses
• Primary skin condition: psoriasis, warts
6. Perianal skin irritation / maceration
• Exam:• Butterfly distribution• Papules• Rash• Flat or raised• Dry or wet
• Treatment:• LESS IS MORE!!!• Stop topical medications• Barrier creams• Perianal hygiene
6. Perianal skin irritation / maceration
Please don’t forget…
Colorectal Cancer
Anal Cancer
• 11% of colon cancer diagnoses are patients <50 years old
• 18% of rectal cancer diagnoses are patients <50 years old
Young Onset Colorectal Cancer
• 11% of colon cancer diagnoses are patients <50 years old
• 18% of rectal cancer diagnoses are patients <50 years old
Young Onset Colorectal Cancer
International Agency for Research on Cancer – 2015World Health Organization
‐Eating 50g of processed red meat per day increases risk of colorectal cancer by 18%
‐ Classified red meat as probable carcinogen‐ Equivalent of 4 strips of bacon or 1 hot dog‐ Increase lifetime risk from 5% to 6% in avgerage risk person
• 11% of colon cancer diagnoses are patients <50 years old
• 18% of rectal cancer diagnoses are patients <50 years old
Young Onset Colorectal Cancer
American Cancer Society – May 30, 2018‐Recommended colon cancer screening at age 45
‐ “Simulation modeling of CRC incidence demonstrated favorable benefit‐to‐burden balance of screening at age 45”
‐ Current risk for CRC in those ages 45‐49 is nearly identical to the 50‐54 age group when age 50 was first recommended
‐ 51% increase in CRC in <50 age group since 1994‐ 2x risk if born in 1990 than those born in 1950
• 11% of colon cancer diagnoses are patients <50 years old
• 18% of rectal cancer diagnoses are patients <50 years old
Young Onset Colorectal Cancer
When a patient isn’t improving or symptoms don’t add up… consider cancer
Rectal exam or Refer
• Less common overall than colorectal cancer• 1‐2% of all GI cancers• Incidence increasing
• HPV associated
• Bleeding, pain, swollen perianal tissue
Anal Cancer
When a patient isn’t improving or symptoms don’t add up… consider cancer
Rectal exam or Refer
1. Thrombosed External Hemorrhoid
2. Anal Fissure
3. Anal Abscess and Fistula
4. Pelvic Floor Disorders: Levator Syndrome / Proctalgia Fugax / Coccygodynia / Pudendal Neuralgia
5. STDs / Fungal Infection
6. Perianal skin irritation / Skin Disorders
7. Malignancy
Anal & Rectal Pain
