Anorectal Care Introduction

 

Introduction

Every year, hundreds of thousands of individuals are diagnosed with colon or rectum cancer. Although anorectal symptoms and complaints are common and typically not a serious concern, all patients should be examined for signs of possible cancer. Common symptoms of anorectal disease include rectal pain, bleeding, anal itching, and rectal mass or lump.

hemorrhoidsPatients should be checked for anorectal disease as early as possible if symptoms arise. If caught in its early stages, the cancer will require less extensive treatment and stress to the patient. Patient assessments must include an anorectal exam, flexible sigmoidoscopy or colonoscopy. For colorectal cancer, patients 50 years of age or older in the general population and 40 years of age or older with risk factors or a family history of the disease should begin regular screenings.

Anorectal Anatomy

The anus is the outlet to the gastrointestinal tract, and the rectum is the lower 10 to 15 cm of the large intestine. The dentate line divides the outer skin from the mucosa. Four to eight anal glands drain into the crypts of Morgagni at the dentate line; most rectal abscesses and fistulae originate in these glands. The area of the rectum above the dentate line does not contain pain nerves, which allows for surgical procedures to be performed without anesthesia. However, the area below the dentate line is highly sensitive. Bowel movements are controlled by the muscles of both the involuntary internal sphincter and the voluntary external sphincter.

Vaginal Illustration

Anorectal Exam

anoscopeAnorectal assessments include inspection, palpation and anoscopic examination. The patient typically lies sideway on his or her left side, which is allows comfort for the patient as well as good visualization and access for the examiner.  The doctor often finds the external hemorrhoids, anal polyp, and anal fissure or fitstula by simple inpection.

The digital exam is to palpate any suspicious mass lesion in the anorectal canal.

Anoscopy is to confirm the diagnosis of hemorrhoids, anal fissure and other anorectal diseases.

Anorectal Symptoms

Anal Itching
anal itchingAnal itching is a common symptom, but initial relief of the itching does not necessarily mean the problem goes away. Continuous scratching or excessive cleaning of the anal area may further harm the sensitive tissues and worsen symptoms. In addition, the area can be highly sensitive to perfumes, soaps, fabrics, dietary intake and superficial trauma. When chronic itching occurs, the perianal area becomes white with fine fissures.

Treatments for anal itching include taking antihistamine as a sedative prior to sleeping to prevent the patient from unconsciously scratching, or using a topical corticosteroid to alleviate the itching. Underlying disorders such as hemorrhoids must be considered and treated when diagnosing and treating anal itching.

Anal pain
anal painAnal pain is a common sign of anorectal disease. Pain caused by an acute anal fissure may occur during intense, forced bowel movements that are often accompanied by rectal bleeding. Pain that begins gradually and becomes excruciating may indicate infection, and occurrence of fever and inability to urinate indicates need for emergency treatment. Immediate onsets of intense pain accompanied by a palpable mass are usually a result of an external thrombosed hemorrhoid, which may last a few days to a couple of weeks. Internal hemorrhoids, however, are not painful due to being located above the dentate line of the rectum. Similarly, rectal cancer typically does not cause pain unless the condition is advanced. The patients with chronic anal fissures usually have intermittent sharp rectal pain and bleeding with each bowel movement for a long time.

Proctalgia fugax is a more serious anal pain condition that involves short spasms of intense pain at night. This condition may occur once each year or up to three or four times each week. The pain is typically accompanied by sweating and an urge to pass stool. There is currently no treatment for proctalgia fugax, but placing oneself in hot water or applying ice may provide symptomatic relief.

Rectal Lump
anal lumpA rectal lump is a growth in the anal canal or rectal area. Rectal lumps vary in size and the degree to which they produce symptoms. Depending on the underlying cause, a rectal lump may or may not cause any pain. A palpable mass in the anal area may or may not indicate cancer or hemorrhoids. Lumps can be caused by a variety of conditions including anal warts, hemorrhoids, polyps, fissures, or cancer.

  • Hemorrhoids are probably the most common reason for having a rectal lump. It can be caused by internal hemorrhoids, but more commonly by external hemorrhoids. If a rectal lump is related to internal hemorrhoids, it usually gets bigger and more prolapsed right after the bowel movement; it could be spontaneously reduced in the early stage of internal hemorrhoids. But it could be non-reducible in the late stage of hemorrhoids.  It may be associated with other symptoms such as bleeding, itch or pain. The thrombosed external hemorrhoids are usually very painful if the varicose veins rupture and the blood clots develop.
  • Anal warts are caused by human papilloma virus (HPV). HPV infection is considered to be sexually transmitted diseases. Left untreated, anal warts can spread and increase the risk of cancer in the anorectal region.
  • Anal Fissure is a small cut or split in the anal lining often caused by a painful, hard bowel movement. Fissures are typically located anterior or posterior to the anus. Anal fissure is often associated with a lump called sentinel pile, accompanied by pain and bleeding.
  • Anal cancer occurs in the anal canal, it is account for 2% of cancer in the gastrointestinal tract. An external or internal mass may be palpable. Anal or rectal cancer generally does not produce any pain; Some lesions are so soft that they are missed on palpation. Anal cancer can take several forms including ulcers, polyps or verrucous growths.

Rectal bleeding
Rectal bleeding refers to the passage of red blood from the rectum and anus, often mixed with stool and/or blood clots. The severity of rectal bleeding varies widely. Most rectal bleeding is mild and intermittent, but it also may be moderate or severe.

Rectal bleeding can be caused by various conditions, but even the slightest amount of bleeding should be taken seriously. Common causes of bleeding are internal hemorrhoids, ruptured thrombosed external hemorrhoids, fissures, diverticulosis, colon cancer, colitis, polyps and angiodysplasias. Patients of older age or with significant family history of bowel disease or cancer should consider further examination. In addition, patients who were previously treated for rectal bleeding but continued to experience bleeding must be further examined.

The source of rectal bleeding is determined by history, physical examination and blood tests, assisted with anoscopy, sigmoidoscopy, colonoscopy, radionuclide scans, and angiograms.

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