Ebook Anorectal surgery - Made easy: Part 2

(BQ) Part 2 book “Anorectal surgery” has contents: Biofeedback, functional anorectal disorders, anorectal malformations, fissure in ano, hemorrhoids, anorectal abscess, hidradenitis suppurativa, pilonidal sinus, rectal prolapse, feca incontinence,… and other contents.

chapter 11 Biofeedback

Dyssynergic defecation is one of the most common forms of functional constipation both in children and adults

It is defined as incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic floor muscles when straining to defecate

Up to one half of patients with constipation suffer from the entity known as dyssynergic defecation

This is an acquired behavioral problem and is caused by the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools

In the current scenario, it is possible to diagnose this problem through:

• History

• Prospective stool diaries

• Anorectal physiologic tests

Biofeedback also known as neuromuscular training is:

• The use of electronic or electromechanical equipment to measure

• Provide information about specific physiologic functions

• That can then be controlled in therapeutic directions

Neuromuscular training or biofeedback therapy is an based learning process that is based on ‘‘operant conditioning’’ techniques

The goal of neuromuscular training using biofeedback techniques

is to restore a normal pattern of defecation

A Standard Biofeedback Training Protocol

The mainstay of behavior therapy is to first explain the anorectal dysfunction and discuss its relevance with the patient before approaching the treatment

to relax the pelvic floor and anal muscles during straining.

This objective is first pursued with the help of visual feedback

on pelvic floor muscle contraction, accompanied by continuous encouragement from the therapist

When the patient has learned to relax the pelvic floor muscles during straining, the visual and auditory help are gradually withdrawn

Biofeedback is often recommended for children who have constipation and encopresis

• Training in the coordination of abdominal and pelvic floor musculature for elimination (For those who have pelvic floor dyssynergia or paradoxical contraction)

Pelvic floor dyssynergia is the abnormal closure of the anal canal during straining for defecation

During attempts to defecate, children who have dyssynergia squeeze the buttocks and hips but are unable to relax the external anal sphincter

The child squeezes the anal canal during defecation:

In patients with dyssynergic defecation, the goal of neuromuscular training is two fold:

• To correct the dyssynergia in coordination of the abdominal, rectal, and anal sphincter muscles to achieve a normal and complete evacuation

• To enhance rectal sensory perception in patients with impaired rectal sensation

In children, it is essential and prerequisite to decide which type of biofeedback be provided to a particular patient as the type

of biofeedback used is a function of the physiologic mechanisms hypothesized to underlie the child’s soiling

For example, training aimed at improving rectal sensation is indicated, if a child’s soiling is thought to be associated with poor sensation of the urge to stool

Sphincter strengthening through EMG biofeedback would be a better option, if soiling is associated with poor control caused by a weak external anal sphincter

Most available research apparently focuses on biofeedback treatment of constipation and encopresis associated with pelvic floor dyssynergia

Most children who have encopresis contract the external anal sphincter during defecation, thereby impairing their ability to empty the rectum completely and which in turn compounds ongoing impaction

To assess pelvic floor dyssynergia two electrodes are used:

1 Surface EMG electrodes to monitor abdominal muscles

2 An anal sensor (manometric sensor within anal canal or surface EMG electrodes just outside the anal opening)

Improve or correct dyssynergia: If there is dyssynergia between the

two muscle regions this training is used

Along with manometric—guided pelvic floor relaxation, this training consists of improving the abdominal push effort (diaphragmatic muscle training) lastly followed by simulated defecation training

Rectoanal coordination: The purpose of this training is to produce

a coordinated defecatory movement consisting of an adequate abdominal push effort which in turn is reflected by a rise in intrarectal pressure on the manometric tracing that is synchronized with relaxation of the pelvic floor and anal canal as depicted by a decrease in anal sphincter pressure

Ideally the subject should be seated on a commode with the

manometry probe in situ, to facilitate this training

Posture and sitting correction needs a special mention before any maneuver:

• As against the regular posture of keeping the legs together correct the same by keeping the legs apart

• Also correct the sitting angle at which the patient will attempt the defecation maneuver (i.e leaning forward)

Anorectal Surgery

236

At least 10 to 15 maneuvers are performed To provide the subject with a sensation of rectal fullness or desire to defecate, the balloon

in the rectum is distended with 60 ml of air

While observing the pressure changes in the rectum and anal canal on the display monitor the patient is encouraged to push and attempt defecation, as soon as the he/she experiences this desire to defecate

The breathing and postural techniques are corrected, once again The maneuvers are repeated approximately 5 to 10 times

Following instructions are passed to the patient during the attempted defecation, to titrate:

• To reduce the amplitude of electrical wave forms on the monitor

• To decrease the intensity of sound signals

Simulated defecation training: The patient is trained and taught to

expel artificial stool in the laboratory by using the correct technique Either a 50 ml water-filled balloon or an artificial stool is placed in the rectum to perform this maneuver

The patient is asked to sit on a commode and to attempt defecation, after the balloon is placed in the rectum in the left lateral position

During the attempt to pass the balloon assistance is provided to the patient and he/she is taught:

• To relax the pelvic floor muscles

• To correct the posture and breathing techniques

Biofeedback 237

Apply gentle traction to the balloon, if the patient is not able to expel the balloon, just to add to the patient’s efforts

Gradually and with repetition of the maneuver, the subject learns how to coordinate the defecation maneuver and to expel the balloon

Sensory training: The main goal of this training is:

• To improve the thresholds for rectal sensory perception

• To promote better awareness for the process of passing stool Intermittent inflation of the balloon in the rectum, is the primary maneuver

The primary objective is to teach the patient to perceive a particular volume of balloon distention but with the same intensity

as they had previously experienced with a larger volume of balloon distention

First and foremost the balloon is inflated progressively till the patient experiences an urge to defecate Note this threshold volume The balloon is reinflated to the same volume, after deflation and

to educate the subject and to trigger appropriate rectal sensations, the maneuver is repeated two or three times

The balloon volume is decreased in a stepwise manner by about 10% with each subsequent inflation, thereafter

During each distention, the patient is encouraged:

• To observe the monitor

• To note the pressure changes in the rectum

• Simultaneously pay close attention to the sensation they are experiencing in the rectum

• To use the visual cues for volumes that are either not readily perceived or only faintly perceived

In case if the patient fails to perceive:

Periodic reinforcements at 6 weeks, 3 months, 6 months, and 12 months after completion of neuromuscular training, may provide additional benefit.

These periodic reinforcements can improve the long-term outcome of these patients

Devices and techniques for biofeedback: Several devices and methods

are available, and newer techniques continue to evolve, the reason being neuromuscular training is an instrument-based learning technique

Some of the devices being commonly used include:

• Manometric-based biofeedback treatment with a solid-state manometry system

This visual display in turn provides visual feedback to the subject

To provide both visual and auditory feedback, surface EMG electrodes can be incorporated on the probe

The same probe can be used to provide sensory training All in all the system can serve as a comprehensive device for neuromuscular training

Instant feedback regarding the changes in electrical activity of the anal sphincter, can be generated from the pitch of the auditory signals.

Such feedback responses help the patient titrate the defecation effort and in turn can augment the learning process

Home training devices largely use an EMG home trainer or silicon probe device attached to a hand-held monitor with an illuminated liquid crystal display

The pressure or electrical activity of the patient’s sphincter responses can be displayed on a simple gauge, a strip chart recorder,

or a color liquid crystal display and these are used to provide visual feedback for the subject

Efficacy of Biofeedback Therapy

The symptomatic improvement rate ranges between 44 and 100%

in different uncontrolled clinical trials

The results show that biofeedback therapy is superior to controlled treatment approaches, such as:

Anorectal Surgery

240

A home-based, self-training program is essential, to treat the vast number of constipated patients in the community

Other Measures for Treating Dyssynergic Defecation

Injection of botulinum toxin into the anal sphincter has been tried with mixed results

Different surgical procedures like division of puborectalis muscle with varying degree of success have been described for managing dyssynergic defecation

Biofeedback training seems to be a good treatment for lower gastrointestinal disturbances, especially for pelvic floor dyssynergia The effects of such training may not be limited to the anorectum and might also be useful in other conditions in which pelvic floor dyssynergia plays a role

With biofeedback therapy the symptom improvement is caused

by a change in underlying pathophysiology, it is not only efficacious but also superior to other modalities

Use of home biofeedback programs along with development of user-friendly approaches to biofeedback therapy will significantly enhance the adoption of this treatment by gastroenterologists and colorectal surgeons

In children who have pelvic floor dyssynergia and are not showing a positive response to standard medical management, recommended biofeedback protocol is a brief training program of around two to four sessions

Biofeedback training to be more effective needs to be a complete comprehensive package of:

chapter 12

Functional Anorectal

Disorders

A functional anorectal disorder is defined as “a variable combination

of chronic or recurrent anorectal symptoms not explained by structural or biochemical abnormalities”, or in simple terms,

“Anorectal symptoms, the etiology of which is currently unknown or

is related to the abnormal functioning of normally innervated and structurally intact muscles, or is attributed to psychological causes” Chronic anal or perianal pain without evident cause produces maximum mixed reactions among family, friends and physicians as compared to other disorders

Usually the result of common and easily recognized disorders such as:

Men and women of all ages are affected by anorectal disorders Their management is not limited to the evaluation and treatment

of hemorrhoids

The spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer) disorders

Patients usually present with ‘‘constipation’’, but the clinical picture of these disorders includes:

A combination of the following work-up helps arrive at the diagnosis:

Functional Anorectal Disorders 243

• Though discomfort or pain is the predominant symptom; patients may also have dysfunctional voiding or defecation

• Associated findings frequently include impaired quality of life, anxiety, and depression

• Though it is presumed that visceral hypersensitivity and pelvic floor dysfunction may play a role, pathophysiology is not properly studied and poorly understood

• Because therapeutic approaches have not been rigorous, therapy is guided by clinical features

Levator Ani Syndrome

Irrespective of the fact that several syndromes have been described, the most common question in the mind of a colorectal surgeon is: What is the cause of this idiopathic perianal pain and how can it be relieved?

The first reference to anal pain appeared in 1859 when a syndrome called “Coccygodynia” was described

Ever since a number of different terms have been used, adding to confusion as to the definition of this syndrome

Coccygodynia is said to consist of a:

• Vague tenderness or ache in the region of the sacrum and coccyx

Anorectal Surgery

244

It was later suggested to the use of the term ‘levator syndrome’, and treatment in form of digital massage of the pelvic floor musculature was offered

Around one-fourth patients suffering from this symptom consult

a physician, yet it is presumed that the associated disability is significant

More than half of affected patients are aged 30 to 60 years and prevalence tends to decline after age 45

Pathophysiology

Though the exact etiology is unknown different studies have suggested Different hypothesis for the pathology of levator ani syndrome, some of which are as mentioned:

• That levator ani syndrome results from spastic or overly contracted pelvic floor muscles

• That levator ani syndrome is associated with psychological stress, tension, and anxiety

• It is unclear if the association between chronic pelvic pain and psychosocial distress on multiple domains (e.g depression and anxiety, somatization, and obsessive-compulsive behavior) reflects an underlying cause or an effect of pain

Functional Anorectal Disorders 245

• That levator ani syndrome may be due to visceral hyperalgesia

or increased pelvic floor muscle tension, supported by the fact that there is tenderness to palpation of pelvic floor muscles in chronic pelvic pain and levator ani syndrome

• That levator ani syndrome patients may have increased anal pressures or electromyogram activity Higher anal pressures may reflect increased external or internal anal sphincter tone

• Inability to relax pelvic floor muscles suggests pelvic floor dysfunction

Diagnostic Criteria

If the patient complains of atleast 12 weeks consecutively in previous

12 months for the following:

1 Chronic or recurrent rectal pain or aching and discomfort

2 Episodes last 20 minutes or longer

3 Other causes of rectal pain such as ischemia, inflammatory bowel disease cryptitis, intramuscular abscess, fissure hemorrhoids, prostatitis, and solitary rectal ulcer have been excluded, then the patient can be labeled as suffering from levator ani syndrome

Clinical Evaluation

The diagnosis of levator ani syndrome is based on symptoms alone.One important sign which can raise the diagnosis is:

• Posterior traction on the puborectalis revealing tight levator ani muscles and tenderness or pain

• Tenderness usually may be predominantly left-sided

• Massage of this muscle will generally elicit the characteristic discomfort

Depending on the above-mentioned sign and symptom complex the syndrome has been classified into two levels:

• A “highly likely” diagnosis of levator ani syndrome if symptom criteria are satisfied and these physical signs are present, or

• A “possible” diagnosis if the symptom criteria are met but the physical signs are absent

Anorectal Surgery

246

To exclude alternative diseases, clinical evaluation will usually include sigmoidoscopy and appropriate imaging studies such as defecography, ultrasound, or pelvic CT

In situations where it becomes essential to offer treatment

it would be wise to select a modality like biofeedback which has

no significant adverse effects and prevent further harm to the patient

Many patients fail to respond to treatment Yet surgery should be avoided

Proctalgia Fugax

Proctalgia fugax is an enigmatic disorder Proctalgia fugax is a condition characterized by recurring attacks of pain deeply inside the rectum

Functional Anorectal Disorders 247

Described in 1935, proctalgia fugax as against levator ani syn- drome, is a relatively well-defined syndrome of obscure causation Ever since it was named in 1935, in an article entitled “Proctalgia fugax: a little known form of pain in the rectum”—It has been a source of controversy

The majority of observations that were made then in 1935, in the article mentioned hold true today

Proctalgia fugax is described as sudden, severe, irregular attacks

of rectal pain lasting several seconds or minutes followed by complete resolution without any untoward effects

Proctalgia fugax has also been defined as recurring attacks of distressing rectal pain with no local positive findings in the rectum Attacks are infrequent, occurring less than five times a year in more than half of the patients

Pathophysiology

The etiology remains unknown, however most theories are focused

on spasm of the levator ani muscle and sigmoid colon, where as some studies suggest that smooth muscle spasm may be the cause

of proctalgia fugax

It has certain features which suggest that it is due to a sustained muscle spasm

Because of the short duration and sporadic, infrequent nature of this disorder, the identification of physiological mechanisms of this disorder is difficult

Many patients on psychological testing have been found to be perfectionistic, anxious, and/or hypochondriacal

It is commoner in men than women, though prevalence rates may vary in men and women

Beginning in early adult life and the symptoms cease spontaneously in late middle life

The ages of the patients varies between 18 and 65 years Estimated prevalence ranges from 8 to 18% However only 17 to 20% of those affected report the symptoms to their physicians

Yet a curiously large number of reports have concerned doctors

Attacks may occur on several consecutive nights, during periods

to account for it

In its most common form the disease starts with nocturnal attacks of pain Other ways of onset are less common and the patients ultimately develop the nocturnal attacks

Functional Anorectal Disorders 249

Particularly common at night it can occur at any time

It begins suddenly and progresses to a cramp-like pain which may be very severe, but which usually resolves after less than 30 minutes

The pain is felt at a constant site above the level of the external anal sphincter in the anal canal or rectum

A feature which suggests that it may be due to a cramp-like spasm

of the muscles of the pelvic floor is that the pain may sometimes

be relieved by flexing the extended legs as far as possible onto the abdominal wall, as when sitting on the floor

There is a high incidence of symptoms of irritable bowel syndrome in patients with proctalgia fugax However, the pain itself

is not accompanied by an acute bowel disturbance

Specific description of pain like “gnawing, aching, cramp-like, or stabbing” has been reported by some patients

But there are many more vivid accounts:

be necessary

Other endoscopic and imaging modalities are used to exclude other underlying disorders.

Treatment

The real difficulty in treating proctalgia lies in preventing attacks This is practically impossible and all efforts directed towards this end have failed so far

Treatment for most patients consists only of reassurance and explanation, because episodes of pain are very brief

Before referral most of the patients have been treated without success

Various treatments including tricyclic antidepressants, diazepines, phenothiazines, paracetamol, codeine, dihydro-codeine, and stronger narcotic analgesics are offered to patients

Others have recommended clonidine or amylnitrate

However, a small group of patients who have proctalgia fugax

on a frequent basis: Have shown improvement and reduction in the duration of episodes of proctalgia with inhalation of salbutamol (a beta adrenergic agonist)

Local measures such as local anesthetic creams, and surgical approaches such as maximal anal stretch procedures, removal of anal mucosal tags, hemorrhoidectomy or pelvic floor repair, were also unsuccessful

In most cases, in patients considered to be suffering from pain of psychogenic origin, if subjected to psychiatric evaluation,

no abnormality other than that attributed to the effect of chronic unrelieved pain is usually found

It is difficult to devise appropriate treatment because the exact pathophysiology is unknown

Functional Anorectal Disorders 251

Percutaneous vibration has been used without effect in some patients

Pudendal nerve block relieved the pain on the treated side for a few hours only and that too in small number of patients

Similarly, carbamazepine is also ineffective or only partially effective

Treatment thus remains unsatisfactory Massage of the pelvic floor musculature was uniformly ineffective

The patient should avoid the kind of food or drug that, in his experience, precipitates the pain

The belief that Proctalgia fugax is a visceral neurosis is supported

by the fact that a number of variety of the measures have been devised by the patient and have given good relief in good number

self-of patients

Though in any complaint which is naturally self-resolving and

of short duration, it is admitted that this is a common enough happening

Most patients learn from their own experience some maneuver which seems to help them relieve the symptoms

• Similarly the discharge of any particulate fecal material, even

in small amounts; may relieve pain in some patients

• It is likely that each effort only signals the relaxation of muscle spasm and the end of an attack

Anorectal Surgery

252

Fig 12.1: Genupectoral position

In some instances, the effort of ineffectual straining may only intensify and prolong the spasm because the patient can expel nothing at all from the rectum

Once the attack is impending, postural treatment is considered the most effective The genupectoral position can be adopted (Fig 12.1)

Or the patient is advised to lie down on the right side with the buttocks slightly elevated on a pillow, and this should be supplemented

by firm pressure on the anus using the left hand for that purpose This may help abort or greatly alleviate a severe attack

It can be relieved most effectively by the immediate taking of food or drink The mechanism presumed behind this is that the initiation of the gastrocolic reflex inhibits the painful muscle spasm Most of the other lines of treatment like the ones mentioned below are largely impracticable:

• The passing of a rectal catheter, or even

• The giving of a small enema, warm or cold, water or oil, or even air alone

It seems likely that any success in such maneuvers results from engaging the attention and by arousing interest, curiosity, or expectation

Functional Anorectal Disorders 253

Use of Clonidine for Proctalgia Fugax

Clonidine works by stimulation of alpha receptors which in turn:

• Produce relaxation of the rectal smooth muscle (effect on para sympathetic neurones)

• Relaxation of internal anal sphincter (effect on sympathetic neurones)

The antispastic effect of clonidine might possibly inhibit the spasm of levator ani and external anal sphincter

Apart from this, the central sedative and analgesic actions of clonidine also appear to be very useful in producing relief

Clonidine though needs more evaluation, appears to be effective

in treatment of proctalgia fugax

Perineal Descent Syndrome

Perineal descent was first described by Parks et al in 1966

It was assumed to be the final outcome of a cycle that included regularly straining with bowel movements which in turn caused the anterior rectal wall to balloon into the anal canal

The hypothetical sequence of events have been documented as follows:

• Patients usually have a complain of a feeling of inadequate evacuation of stool

Pathogenesis

Perineal descent syndrome has usually been attributed to:

• Pelvic floor weakness resulting from

– Abnormal defecation behaviors.

However, the claims that there is relation between increased perineal descent and pudendal neuropathy have been proved otherwise

With increasing number of vaginal deliveries, a prolonged terminal motor latency is seen yet no association between perineal descent and pudendal neuropathy has been demonstrated in these patients

Individuals with descending perineal syndrome present with:– Constipation in the early phase

Functional Anorectal Disorders 255

Pruritus Ani

Pruritus ani is defined as intense chronic itching affecting perianal skin Characterized by intense itching around the anus pruritus ani, is

a troublesome symptom that is associated with most forms of anal disease, but in some patients with this symptom no etiological anal disease may be found

As good number of patients suffer prolonged intractable symptoms and treatment is often unsuccessful It is a frustrating condition for both patients and clinicians

Actually the symptoms of itching or irritation of the perianal skin are usually a disorder of mixed etiology:

Even though the dermatological conditions are usually not restricted to the perianal area, the morphology of perianal skin lesions may be atypical for the disease elsewhere

Paradoxically in most patients the problem is due either:

Anorectal Surgery

256

As against the fact that nearly 100 different causes for pruritus ani have been reported, most patients with pruritus ani do not have

a discernible cause for their condition, pruritus ani is classified as idiopathic when no cause can be found

Though but not conclusively proved to be of relevance the following factors play an important role in the etiopathology of pruritus ani:

Hygiene: Perineal fecal contamination: Fecal contamination causing

pruritus ani is because of prolonged contact with a moist substance

or a hygiene issue

Small particles of feces accumulate on the perianal skin, in presence of any condition that hampers efficient wiping of the anus and these accumulated particles act as an irritant

Fecal contamination or soiling may be overt or occult The patients with occult soiling are unaware of the same yet the soiling

is good enough to initiate itch and scratching

Functional Anorectal Disorders 257

Clothing: Excessive sweating exacerbated by poorly fitting

undergarments and poor personal hygiene are also implicated

Quality of perianal skin: Perianal skin also reacts differently from

skin elsewhere, skin-patch testing using autologous feces have produced anal symptoms in up to one-third of patients with pruritus ani and around fifty percent plus of asymptomatic individuals, where as only four percent of cases have been reported to develop irritation with a fecal patch test on the arm

Occuring within six hours, the itching usually gets relieved by washing suggesting irritation as the cause rather than an allergy Any factor which increases occult or overt soiling augments exposure of the perianal skin to irritants and is a potential area of therapy

Quality of stool: Stool consistency and mucous seepage are

attributed as etiological factors

• Occult or overt soiling

The following two causes have been documented:

– Anal sphincter relaxation in reaction to rectal distension

– Coffee by lowering the anal resting pressures

Accidently during anorectal physiology testing exaggerated rectoanal inhibitory reflexes and incontinence are found in patients with pruritus ani

Patients with pruritus ani are less able to maintain absolute continence when dealing with:

• Candida albicans in diabetic individuals

Candida infection may occur via a colonized partner and

they too may need therapy

• Threadworms are known to infect multiple family members

• Perianal viral infections: There is no evidence for their causative role

in idiopathic pruritus ani, even though they commonly cause itch

• Sexually transmitted bacterial infections

• β-Hemolytic streptococci, Staphylococcus aureus and Coryne­

bacterium minutissimum infection can lead to itch that lasts long,

β-Hemolytic streptococci mostly occurs in children and presents

Functional Anorectal Disorders 259

– Sensitization by chemicals found in the following is the basic cause:

For this reason, patients should avoid contact with the irritant and soap

Foods

Some form of the following foods have been implicated in idiopathic pruritus ani, the supporting fact being relief in itch of pruritus ani after some days of avoidance of these foods, these foods have also been shown to have a quantity based effect as acceptable levels can

be calculated by gradual reintroduction:

– Anal trauma from recurrent wiping.

Colorectal and Anal Disease

Most coexisting anal conditions have been found to precipitate or exacerbate itch

More than half of the patients with pruritus ani have anorectal disease

The most common anorectal condition being hemorrhoids Functional bowel disorders may contribute and hemorrhoids may add to sphincter dysfunction and fecal seepage

Literature shows that around one quarter of patients with proctological disease and pruritus ani have by anal or colorectal cancer as the primary pathology

Treatment of all colorectal and anal conditions in these patients have shown some excellent results

Anal surgery contributed to the elimination of perianal fungal infection and together reduced pruritus

Dermatological Conditions and Neoplasia

• Psoriasis: In 5 to 55% of patients with pruritus ani, psoriasis has

been found

• Perianal plaques: Isolated perianal plaques may not be very

characteristic, the reason being they are altered by repeated scratching, but they can occur and have a sharp edge

Functional Anorectal Disorders 261

• Lichen sclerosus: Perianal skin is white, atrophic, and wrinkled in

lichen sclerosis and has typical biopsy features

• Paget’s disease: More than half of patients have associated itch.

• Bowen’s disease: Same as in paget’s disease, more than half

of patients have associated itch, the skin lesions in both these conditions have well-defined limits

• Other skin cancers present with pain and bleeding

Steroid-Induced and other Medications

Because potent topical steroids can cause: Thinned skin, acute dermatitis and contact dermatitis from sensitization, they are used sparingly

Addiction of topical steroids has been described in patient who use it frequently to control the rebound itch after cessation

Some medications ingested orally, such as:

Symptoms may be the sole focus of attention, and are usually worse at night

Because of excessive sweating the condition is worse during the summer

Functional Anorectal Disorders 263

Scratching the perineum, produces short lived relief and relieves the patient of the itch But continued scratching causes damaging excoriations, which may bleed

This vicious circle of itching and scratching is difficult to break and may induce a state of nervous exhaustion

Examination of the perineum discloses a wide range of appearances

Some patients with severe pruritus ani have:

Considered safe, devoid of side effects and not as a medicine a good number of over-the-counter topical therapies may have been the causative factor for the symptoms or altered skin morphology History of previous patch testing, illness, diarrhea and treatments such as antibiotics and steroids may guide to the diagnosis

Intermittent or seasonal itch is very typical of recurrent anorectal pathology, different clothes or laundry detergents

Examination

The patient should be examined for evidence of other dermatological disorders

Complete and general examination may reveal other sites of localized or generalized skin disease or infection

• Tinea, psoriasis or neoplasia have a distinct boundary

• Erythema is seen with chronic topical steroid use

• Bright erythema suggests yeast infection

• Hyperpigmentation is evidently present in any chronic inflammation, in these cases infection and chronic discharge should be looked for

• The labia or perineum are always involved in lichen sclerosus

• Herpes is associated with severe itch and multiple lesions

• Severe cases have the following characteristic symptoms:– The skin becomes lichenified

– Sexually transmitted infections

– Idiopathic inflammation is nonspecific visually and is identified by indistinct borders

• Chronic trauma results in lichen simplex chronicus

• Threadworms appear as thin white threads about 6 mm in length and may be seen around the anal orifice, they can also be identified in the effluent of a diagnostic saline enema

• A thorough anorectal examination is performed to identify potentially treatable causes of pruritus ani

Investigations

Because microbiological investigations are frequently incorrectly performed, false negatives occur, even though the concurrent rate

of infection is significant; this is the reason for treatment failure in these type of patients

Functional Anorectal Disorders 265

Special instructions for media and preservation of specimens:

• Fungal and bacterial specimens should be placed in bacterial transport medium and refrigerated

• Anaerobic samples can be stored at room temperature but need specific anaerobic medium

• Exudates from vesicles should be placed on a slide or viral culture medium, after vesicles have been unroofed

Apart from the affected skin, neighboring normal skin should be included in all biopsies

Skin-patch testing should be carried out, in all refractory and persistent cases

Management

Treat the Cause is the Thumb Rule

However, most patients will not have an identifiable lesion to treat, and many of the patients who undergo surgery for potentially implicated anorectal conditions continue to have symptoms

Patients tend to make repeated visits to outpatient clinics with little improvement, seeing a different doctor at each visit

Guidelines on how to minimize the symptoms need to be provide

to these patients with refractory disease

As a matter of fact strict adherence to such advice undoubtedly helps and the regimen may be relaxed as symptoms ease

Management has three components which function in parallel:

Functional Anorectal Disorders 267

• Certain foods

• Drinks

The perineum should be rinsed free of residue with a shower head,

if a shampoo or any other cleanser is used whilst in the bath

Patient should be provided with a list of foods that have been found to be associated with itching

An elimination diet may be attempted and symptom diary kept

Clothes should be washed in nonperfumed detergent

If itch worsens after the use of wet wipes, patients must be warned against their use and they must be stopped immediately in case of sensitization

General Control Measures

The perineum needs to be washed with a shower head without soap, and dried with a hair dryer

To assure that the anal canal is washed of retained feces Perineal cleansing should ideally be done in the squatting positions

Instead of soap aqueous cream or emollients should be used Barrier creams, such as zinc oxide or petroleum ointment can be applied after washing

Before underwear is worn The perineum should be absolutely dry and the underwear should be changed daily

Especially for nocturnal itch, acute itch is suggestive of fecal seepage and immediate cleansing is the most effective remedy

Patients should be given advice on how to cleanse when outside their homes

Small containers of oil-based preparations or aqueous cream tubes take up little space and the contents can be squeezed onto cotton wool to clean the perineum

In those who sweat excessively, cotton tissue can be placed perianally to absorb moisture

To reduce trauma from inadvertent nocturnal scratching, short finger nails have been advocated

Anorectal Surgery

268

Active Treatment

If threadworms are discovered:

• Patients and their families are treated with a course of mebendazole

• To prevent reinfection, strict measures of hygiene need to be adopted

Pediculosis pubis and scabies are treated with topical lindane or malathion

If the diagnosis is confirmed as fungal infection, treatment with a topical antifungal agent is given

All dermatophyte infections should be treated in all with a topical imidazole or terbinafine

Treat Candida infection with nystatin ointment.

Many may become obsessional about their bowel habit and perineum because they continue to suffer

The vicious circle of itching and scratching can be broken by local applications Calamine lotion and carbolic lotion are the most popular topical preparations used to soothe the perineum

Though some doctors advocate injecting alcohol or phenol into the perianal skin in order to destroy the subcutaneous nerves and ease the itching, the results, however, are almost invariably disappointing Dermatological conditions should be treated by an appropriate specialist as for example in chronic cases a skin condition such as psoriasis should not be missed and a dermatological opinion is valuable

β-Hemolytic streptococci, S aureus and C Minutissimum should

be eliminated with topical antibiotics such as fusidic acid or mupirocin, and oral antibiotics may be necessary especially if:

Functional Anorectal Disorders 269

Nocturnal scratching which is probably a marker of anal seepage can be reduced by systemic antihistamines and, the patient should

be advised to wash the area immediately and apply a barrier cream Topical antihistamines are not potent enough and sensitize the skin

The short, intense, burning sensation produced by topical capsaicin produces an inhibitory feedback which may eliminate to need to scratch

Anal tattooing should be considered:

– Not only to reduce the expectation of immediate cure

– But also to improve compliance with advice given

• Warn the patient that a precise cause for their condition may not

be found but that

• By paying attention to personal hygiene their symptoms can be minimized

Anorectal Surgery

270

Solitary Rectal Ulcer Syndrome

Solitary rectal ulcer syndrome (SRUS) and stercoral ulceration, are two conditions that are related to local tissue ischemia and often seen in the elderly population though it can affect all ages

Solitary rectal ulcer syndrome is the final clinical outcome of different pathologic settings associated with compromised perfusion

to the rectal mucosa

Solitary rectal ulcer syndrome, as the name implies, consists of several different clinical pathologic processes, which ultimately end in a mutual common pathway that is associated with reduced blood perfusion of the rectal mucosa, leading to local ischemia and ulceration

Solitary rectal ulcer syndrome is a benign uncommon disorder of evacuation frequently associated with rectal prolapse, but most of the times it is a disabling condition in which excessive straining at defecation results in focal mucosal changes with pain, bleeding, and mucous discharge

In the early nineteenth century, by the French anatomist J Cruvilhier, in his report on chronic rectal ulcer described the SRUS

In 1969, by Madigan and Morson, the distinctive histopathologic characteristics were defined

With a prevalence of less than 1 in 100,000 per year, SRUS is a rare syndrome

Functional Anorectal Disorders 271

Clinical Presentation

Solitary rectal ulcer syndrome (SRUS) diagnosis is delayed in many cases due to:

• Excessive straining during defecation

• A behavioral disorder

Although the gradual sequence of this pathology may originate for various reasons, SRUS has been related to several independent clinical settings:

• Occult or overt rectal prolapse with paradoxical contraction of the pelvic floor