Review of Anorectal Disease

Educational Objectives

The goal of this program is to improve the management of anorectal disease. After hearing and assimilating this program, the clinician will be better able to:

1. Compare pain in anal fistula with internal hemorrhoids grade 1.
2. Differentiate internal hemorrhoid prolapse from rectal full-thickness prolapse.
3. Manage hemorrhoids with medical and surgical treatment.

Summary

Introduction: hemorrhoids are fibrovascular cushions in the anus that help with continence and prevent accidents during sneezing or coughing; enlarged hemorrhoids can occur in the setting of other anorectal problems that may need to be prioritized; one should obtain a detailed history of the symptoms, eg, pain, bleeding, mass, bowel habits, and sexual history, and identify the patient’s major concern requiring treatment

Pain: external hemorrhoids (EHs) and thrombosed EH (TEHs) are painful; achy pressure discomfort occurs in symptomatic EHs (SEHs); anal fissures (AF) are severely painful; an abscess can have an indolent and quick onset and usually results in flaring and increasing discomfort until it starts draining; condylomas are not painful but are associated with itchy, burning, and mucous seepage type of discomfort; internal hemorrhoids (IHs) grade 1 do not cause pain; however, in grades 2 to 4, severe pain is often associated with IHs if they lead to a hemorrhoid crisis with necrosis and swelling

Bleeding: is not seen in TEHs; if they ulcerate and start draining, bleeding in the form of clots can be observed; no bleeding occurs in SEHs because of the skin encapsulation; blood streaks or drops of blood in the toilet bowl after defecation can occur in AFs; abscesses do not bleed unless they start to drain; mucopurulent and bloody drainage is seen in chronically inflamed fistulas; streaking is seen in condylomas if they get irritated; blood drops in the toilet bowl, blood on the toilet paper, or splattering can occur in IHs (larger volume bleeding may occur in grade 2-4 IHs)

Sensation: patients describe TEHs as a painful mass that feels like marble and SEHs as engorgement that comes and goes over time; abscesses are painful and hot (ischiorectal and perianal); patients can often feel anal verge condylomas and describe their growth; patients typically cannot feel IHs; however, they may be able to feel grade 2 through 4 IHs with prolapse

Onset: TEHs have an acute onset; SEHs are generally felt after bowel movements; AFs have an acute, abrupt onset that may become chronic over time; fistulas are intermittent, and symptoms tend to follow a cycle of swelling, drainage, and temporary relief; condylomas are chronic; IHs grade 1 and grade 2 through 4 are intermittent; acute onset and worsening pain may occur in grade 4 IHs

Inspection: before the examination, it is crucial to explain the procedure, positioning, and what to expect, ensuring patients are informed and comfortable; speaker’s method — the left lateral decubitus position is preferred by speaker; use gauze to spread the cheeks to examine externally; if AF is present, stop further examination and prioritize treatment because of potential severe pain on examination; if there are no signs of AFs, one can proceed with digital rectal examination (DRE)

Digital rectal examination: the right index finger is typically used for DRE; one should feel the tone of the internal sphincter muscle and feel back toward the coccyx to rule out retrorectal tumors; examine the area by palpating circumferentially in both clockwise and counterclockwise directions, and then assess the anal transition zone and canal during withdrawal

Anoscopy: choose a comfortable scope; a disposable scope with a light in it is a good option for bedside anoscopy during consultations; ensure adequate lubrication; for patients with past traumas, ensure comfort at each step; when assessing prolapse and its extent, have the patient sit on the toilet and strain; the first important part of the examination is excluding anal cancers, eg, squamous cell carcinomas

Internal hemorrhoids: the best method for differentiating IHs and EHs is to determine whether they are wet or dry; during anoscopy, IHs appear as hemorrhoid piles that are bulging and engorged; in IH prolapse, the mucosa, submucosa, and vascular tissue come down but are fixed up along the wall leading to radial folds; however, in rectal full-thickness prolapse, the entire rectal tissue comes down, leading to circumferential folds

Classification: IHs are graded on a scale from 1 to 4, which guides effective treatment; grade 4 is the hemorrhoid crisis (nonreducible prolapse; incarcerated, necrotic, painful IHs); grade 3 includes prolapse that can be manually reduced; grade 2 is prolapse with spontaneous reduction; grade 1 is painless bleeding (symptomatic IHs); other problems include seepage, moisture, and itchiness

Medical management: daily intake of 2 L of water and 30 g of fiber is recommended; in addition, supplements may be beneficial; polyethylene glycol 3350 (eg, Clearlax, GlycoLax, MiraLAX) and docusate (eg, Colace, Correctol, Docusoft) can be used for managing constipation; fiber supplements, ie, natural fiber, such as psyllium (eg, Citrucel, Metamucil, NOW Psyllium Husk) to synthetic fiber, help to manage diarrhea and constipation; starting low and gradually increasing fiber intake can help patients manage gas and bloating with fiber; synthetic fibers (eg, Benefiber, Citrucel, FiberCon) can be used for patients with irritable bowel syndrome; fiber gummies and psyllium wafers can be used; it is vital to educate patients on the dosing of fiber; patients should be educated on their toileting techniques, eg, proper positioning, proper timing, avoiding straining

Treatment of IHs: grade 1 — manage the concerning symptom; discuss the adverse effects and complications of the treatment with the patient; medical management and rubber band ligation (RBL; banding) can be performed; grade 2 — medical management, RBL, sclerotherapy, or transanal hemorrhoidal dearterialization can be performed; grade 3 — excisional hemorrhoidectomy (ExH) can be considered; grade 4 — ExH to remove the devitalized tissue should be performed to manage EHs and mixed hemorrhoids (IHs with EHs)

RBL: IHs can be managed with RBL; it is a quick procedure that can be performed in the clinic; it is indicated for patients with painless bleeding and can help with prolapse; patients need to work on their toileting techniques and stool consistency to obtain a durable result from RBL; it should not be performed for patients on blood thinners because of the increased risk for bleeding

ExH: there is immediate pain following the procedure and a 6-wk recovery period; risk vs benefit should be considered; topical creams provide symptomatic relief but may cause itching; ExH has the highest rate of pain and possibly risk for continence issues (5%-30%); it should be used thoughtfully in patients with prior trauma to the anus and radiation (may cause a nonhealing wound in the area)

Sclerotherapy: may be performed for patients on anticoagulation but may not be effective; a 10% solution of sodium tetradecyl sulfate (Sotradecol, Trombovar) injection is injected into the proximal aspect of the hemorrhoid head; it has a low rate of complications; RBL should be tried first before sclerotherapy

RBL vs ExH: ExH is superior (in terms of complete remission of symptoms) to RBL for grade 3 prolapsing manually reduced hemorrhoids (Shanmugam et al [2005]); there is no significant difference between the procedures for grade 2 IHs; however, ExH results in a higher rate of pain, a higher complication rate, and longer time off from work

Management of AFs: topical nitroglycerin (0.2%) and calcium channel blockers, eg, nifedipine cream can be used; nitroglycerin often causes systemic effects, eg, headaches; warm soaks can be used; AFs can be surgically managed with lateral internal sphincterotomy (95% effective); it has a 5% to 30% incontinence rate; onabotulinumtoxinA (Botox) injections are 60% to 90% effective but may cause transient incontinence

Condyloma: ask about the patient’s sexual history, HIV status, and prior Papanicolaou tests; anal verge condylomas can be treated with topical treatments, eg, podophyllin, imiquimod (for low-volume disease), fulguration, and excision; internal disease is treated with fulguration

Readings

Giuliani A, Romano L, Necozione S, et al. Excisional hemorrhoidectomy versus dearterialization with Mucopexy for the treatment of grade III hemorrhoidal disease: The EMODART3 Multicenter Study. Dis Colon Rectum. 2023;66(12):e1254-e1263. doi: 10.1097/DCR.0000000000002885 View Article; Jakubauskas M, Poskus T. Evaluation and management of hemorrhoids. Dis Colon Rectum. 2020;63(4):420-424. doi: 10.1097/DCR.0000000000001642 View Article; Kline RP. Operative management of internal hemorrhoids. JAAPA. 2015;28(2):27-31. doi:10.1097/01.JAA.0000459809.87889.85 View Article; Mott T, Latimer K, Edwards C. Hemorrhoids. Am Fam Physician. 2018;97(3):172-179 View Article; Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005;2005(3):CD005034. doi:10.1002/14651858.CD005034.pub2.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Evans was recorded at the 50th Annual Family Medicine Course, held June 4-7, 2024, in Burlington, VT, and presented by the University of Vermont Larner College of Medicine. For information on upcoming CME activities from this presenter, please visit med.uvm.edu/cmie/home. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

FP724201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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