Other Anorectal Conditions

This includes all forms of acute and chronic presentations including: abscess, sinuses and cysts and complex or recurrent disease.

Hidradenitis Suppurativa

Hidradenitis suppurativa is a disease of the skin containing apocrine glands, including the axillae, groin, and buttocks. Poral occlusion of the apocrine glands leads to bacterial infection and the formation of characteristic tender, erythematous, hard nodules that evolve into fluctuant interconnecting abscesses. Rupture of the abscess often leads to sinus tract formation, and multiple fistulous tracts, ulcers, fibrosis, and scarring are found in chronic disease.

The yeast Candida albicans can cause both candidal intertrigo found between the gluteal folds and also a perianal dermatitis. These conditions can often be precipitated by use of oral antibiotic agents, steroid use, and pregnancy. Intertrigo develops in moist environments, causing pruritic, red patches with a fringe of “collarette” scale. There can also be associated small white pustules located near the patches, as well as “satellite” erythematous macules. Perianal candidiasis presents with pruritis ani and a more localized erythema, around the anus.

Paget’s disease, most commonly associated with the nipple, can also be found at a number of extramammary sites, including the perianal region. Paget’s disease in the perianal region can also indicate the presence of an underlying malignancy such as a glandular adnexal carcinoma or a local internal carcinoma. The initial presentation is often a bland, persistent eczematous patch that can be intensely pruritic and/or painful. Often misdiagnosed early on, the true significance of this finding can be overlooked for years. Bleeding can be associated as a later manifestation. The presence of edema and a reddish discoloration can suggest lymphatic infiltration by the cancer. Diagnosis relies upon biopsy with histology showing hyperkeratosis, parakeratosis, acanthosis, and pale Paget’s cells in the rete ridges.

Treatment of perianal Paget’s includes surgical removal, and topical 5-fluorouracil has also been used preoperatively to help define tumor margins. Additionally, the evaluation for malignancy is of paramount importance.

Human papillomavirus-induced anal dysplasia is not uncommonly seen in the perianal area. Clinically, human papillomavirus-induced anal dysplasia and squamous cell carcinoma in situ (Bowen’s disease) of the perianal area can present with several different appearances, including: maceration of the perianal area; mimicry of a chronic eczematous process such as contact dermatitis; presentation as an erythematous and scaly patch or plaque resembling psoriasis; or as multiple hyperpigmented, flat-topped, coalescing papules with a cobblestone appearance, in a condition known as Bowenoid papulosis.

Treatment can be with topical 5-fluorouracil, topical imiquimod, liquid nitrogen cryotherapy, trichloroacetic acid applications surgical excision, or a combination of any of these modalities. After treatment, repeat biopsies are necessary to rule out persistent disease. It is also recommended that patients with perianal dysplasia and/or squamous cell carcinoma in situ be followed with an anal Pap smear and, if possible, with high-resolution anoscopy and biopsies of the transition zone.

Anal condyloma acuminatum is a human papillomavirus (HPV) that affects the mucosa and skin of the anorectum and genitalia. Anal condyloma acuminatum is the most commonly diagnosed sexually transmitted disease in the United States. To date, there are more than 100 HPV types, with HPV-6, HPV-10, and HPV-11 predominantly found in the anogenital region and causing approximately 90% of genital warts. Risk factors for anal condyloma acuminatum include multiple sex partners, early coital age, anal intercourse, and immunosuppression.

These may present as primary condition or as a secondary phenomena after the resolution of a thrombosed external hemorrhoid or after a fissure heals leaving a sentinel skin tag. Treatment is based on the symptoms that these lesions cause for the patient and may be as simple as observation or in some cases can be removed in the office or operating room.

Medications

Depending on the cause of fecal incontinence, options include:

• Anti-diarrheal drugs such as loperamide (Imodium A-D) and those containing diphenoxylate and atropine (Lomotil).
• Bulk laxatives such as methylcellulose (Citrucel) and psyllium (Metamucil), if chronic constipation is causing your incontinence.

Exercise and other therapies

If muscle damage is causing fecal incontinence, your doctor may recommend a program of exercise and other therapies to restore muscle strength. These treatments can improve anal sphincter control and the awareness of the urge to defecate.

Options include:

Kegel exercises
Kegel exercises strengthen the pelvic floor muscles. These muscles support the bladder and bowel and in women, the uterus. Strengthening these muscles may help reduce incontinence. To perform Kegel exercises, contract the muscles that you use to stop the flow of urine.

Hold the contraction for three seconds, then relax for three seconds. Repeat this pattern 10 times. As your muscles strengthen, hold the contraction longer. Gradually work your way up to three sets of 10 contractions every day.

Biofeedback.
Specially trained physical therapists teach simple exercises that can increase anal muscle strength. These exercises can help:

• Strengthen pelvic floor muscles.
• Sense when stool is ready to be released.
• Contracting the muscles if having a bowel movement at a certain time is inconvenient.
  Sometimes the training is done with the help of anal manometry and a rectal balloon.

Bowel training.

Your doctor may recommend making a conscious effort to have a bowel movement at a specific time of day: for example, after eating. Establishing when you need to use the toilet can help you gain greater control.

Bulking agents.

Injections of nonabsorbable bulking agents can thicken the walls of the anus. This helps prevent leakage.

Sacral nerve stimulation.

The sacral nerves run from your spinal cord to muscles in the pelvis. They regulate the sensation and strength of your rectal and anal sphincter muscles. Implanting a device that sends small electrical impulses to the nerves can strengthen muscles in the bowel.

Surgery
Treating fecal incontinence may require surgery to correct an underlying problem, such as rectal prolapse or sphincter damage caused by childbirth. The options include:

Sphincteroplasty.

This procedure repairs a damaged or weakened anal sphincter that occurred during childbirth. Doctors identify an injured area of muscle and free its edges from the surrounding tissue. They then bring the muscle edges back together and sew them in an overlapping fashion. This helps strengthen the muscle and tighten the sphincter. Sphincteroplasty may be an option for people trying to avoid colostomy.

Treating rectal prolapse, a rectocele or hemorrhoids. Surgical correction of these problems will likely reduce or eliminate fecal incontinence. The longer the prolapse goes untreated, the higher will be the risk of fecal incontinence not resolving after surgery.