Mistakes in managing perianal disease and how to avoid them

December 22, 2016 By: Phil Tozer and John T Jenkins

Image credit line: © Can Stock Photo Inc./alila

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Mistakes in managing perianal disease and how to avoid them

Perianal disease is very common and can impair quality of life significantly. It is crucial to identify the serious causes of these symptoms, but also to reduce the burden of the less dangerous conditions that nevertheless can be debilitating and interfere with an individual’s work and life. 

Perianal disease takes many forms, is very common and can impair quality of life significantly. The symptoms of perianal disease, including pain, bleeding, discharge and pruritus, are common to several conditions that are sometimes difficult to disentangle.


It is crucial to identify the serious causes of perianal symptoms, but also to reduce the burden of the less dangerous conditions that nevertheless can be debilitating and interfere with an individual’s work, social or intimate life. Below we discuss some of the frequent and important mistakes made in the management of perianal disease based, where possible, on evidence, and where not, on clinical experience.

 

 

 

 

 

 

 

Mistake 1 | Assuming bleeding is due to the (incidental) perianal disease, rather than the ‘occult’ cancer

Rectal bleeding is a frequent symptom and conditions such as haemorrhoids are a common finding at anorectal examination.1 However, the presence of haemorrhoids, for example, does not mean that the 65-year-old man who is presenting with rectal bleeding does not also harbour a left-sided cancer that is the cause of this symptom. If haemorrhoids are a common finding, their presence should not reassure a doctor that a more sinister diagnosis is absent and instead such a diagnosis should be sought and excluded.

Mistake 2 | Failing to address the underlying constipation/straining in haemorrhoids/fissure

Anal fissure is believed to be caused by trauma to the anal mucosa, often by the passage of a hard stool, which fails to heal in some patients and so becomes a chronic fissure. Treatment of the fissure is aimed at reversing the conditions that allow its persistence and chronicity, for example, through relaxation of the internal anal sphincter.2 However, the primary insult, if repeated, may lead to the development of a further chronic fissure, particularly when a temporary chemical sphincterotomy (produced by administration of topical nitrates, calcium channel blockers, or injection of botulinum toxin) is used to facilitate healing.
The same can be said of haemorrhoids, particularly when they are treated with non-excisional techniques. The high pressure in the anal canal that is associated with straining to pass a hard stool is thought to promote formation of haemorrhoids. Indeed half of haemorrhoids may regress in the presence of laxation and avoidance of straining alone.3

Interventions such as haemorrhoidal banding or botulinum toxin injection for anal fissure may induce regression or healing, but they do not prevent the next episode of constipation or the recurrence of symptoms that follows. A failure to address the underlying cause—achieved by advising the patient to obtain a soft stool by increasing dietary fibre and fluid or by using laxatives, and to avoid straining—will lead to recurrence and loss of the benefits of the treatment employed.

Mistake 3 | Assuming pruritus ani is idiopathic and untreatable

Pruritus ani is a difficult symptom for patients and clinicians and can lead to severe impairment of quality of life for some patients. The cause of a patient’s pruritis is often obscure and symptomatic treatment may be offered, which may not wholly resolve the symptoms. The various causes of pruritus should be considered and treated.4

Frequent causes include mucus leakage onto the perineum and a high-fibre diet. Mucus leakage may occur for several reasons. An internal sphincter defect, a fistula or fissure can create a channel or gutter permitting mucus leakage. Haemorrhoids prolapsing through the anal canal expose their mucus-producing surface to the perianal skin. These conditions are curable and their diagnosis should be sought and eradicated in the presence of pruritus. A high-fibre diet will also lead to a degree of anal seepage in some patients and it may, therefore, be necessary for patients to reduce their fibre intake.

Alternative diagnoses include dermatological disorders. Indeed, the presence of apparent skin changes (other than the dampness or maceration seen with seepage and scratching) should prompt referral for assessment by a dermatologist.

In the absence of a treatable underlying cause, symptomatic management is a reasonable approach.

Mistake 4 | Missing the opportunity to identify Crohn’s disease in the presence of perianal disease, particularly where it is recurrent

It is known that a significant proportion of patients with Crohn’s disease may present with perianal disease before any luminal diagnosis is made.5 Analysis of English national data suggests that 3% of patients presenting with a perianal abscess will be diagnosed with Crohn’s disease a median of 14 months later.6 Simply undertaking rigid sigmoidocopy as part of examination under anaesthesia (EUA) at the time of abscess drainage may reveal proctitis at this early stage, lowering the threshold at which a diagnosis of Crohn’s disease is considered.

Troublesome anal skin tags, multiple fissures that may be deep and appear away from the classic 6 and 12 o’clock (lithotomy) positions and the more obvious ulceration and stricturing, may be due to underlying Crohn’s disease. The presence of these features should, therefore, prompt a high index of suspicion.

Taking biopsies to look for the presence of granulomata, a careful personal and family history of IBD symptoms, and assessing luminal inflammation (with faecal calprotectin levels or colonoscopy) may provide a golden opportunity to diagnose Crohn’s early and hence initiate treatment earlier in a patient’s disease course.

Mistkae 5 | Incorrectly assessing anal fistulae

Anal fistulae should be assessed systematically in the outpatient clinic or in the operating theatre to help the clinician determine the course of the track through the muscles of the anal sphincter.7 When feeling for the internal opening, it is common to feel too far cranially in the anal canal when it is usually located more caudally.

When probing the track, resistance may be found at the level of the external sphincter, where the track may narrow in an ‘hourglass’ configuration. A smaller probe (such as a lachrymal probe) can be used to pass this area, but no fistula probe should ever be pushed and it should be remembered that narrower probes are sharper. In addition, at the sphincter and in the intersphincteric space it is often important to pull the probe caudally to find the innermost part of the track as it changes direction a little more towards the verge in the intersphincteric space.

A failure to appreciate these subtleties may lead to injudicious probing and produce iatrogenic injury. When in difficulty, the surgeon should stop and reassess another day, delineate the track with MRI or refer the patient to a specialist unit.

Mistake 6 | Incorrectly assessing the patient’s objectives of anal fistula treatment

Broadly speaking, patients must choose between a high rate of cure of the anal fistula, which can be achieved by laying open, and a greater risk of failure but with preservation of continence, which is offered by the sphincter-preserving procedures such as the anal fistula plug, LIFT procedure or advancement flap. The patient must understand what the risk of continence impairment really means. For the majority, continence impairment is no more than a modest reduction in their ability to control flatus and occasional ‘skid marks’ in their underwear.8 The word ‘incontinence’ is therefore unhelpful and probably best avoided.

Patients at different points in their journey may take differing views on this choice, with some wishing to avoid even the most minor inadvertent passage of flatus but others willing to accept this and marking of the underwear in order to be rid of a recurrent and troublesome fistula. Other patients still may simply wish to avoid recurrent abscess formation and further operations in equal measure and in these patients a permanent loose seton can be a good solution.

A failure to centre this decision around the patient’s goal and their willingness to accept risk in order to achieve it, may mean failing to improve the patient’s quality of life despite a ‘successful’ outcome in the eyes of the surgeon.

The presence of underlying Crohn’s disease will also affect the patient’s goals as recurrence is common and symptom control is often the the main objective.  Additionally, the risk of loose stool in the future due to flares of luminal disease or bowel resection, prompts a more conservative approach with regard to lay open.

Mistake 7 | Haemorrhoidectomy in middle-aged women with borderline continence

In a normal patient, the resting anal tone is produced by the internal anal sphincter (55%), the external sphincter (30%) and by the anal cushions (15%).9 Impairment of either sphincter through surgery, obstetric trauma or atrophy associated with aging, may increase the relative importance of the anal cushions as part of the continence mechanism. A reduction in the volume of the anal cushions has been shown in women who have passive faecal incontinence.10 Mucosal sensation is also thought to contribute to continence and is disrupted following excisional surgery.

Given this, haemorrhoidectomy in middle-aged women with borderline continence may have a greater impact on continence than expected, despite preservation of the sphincter and in contrast to other patient groups. Assessment of continence, prior surgery, obstetric history and a high index of suspicion will allow the surgeon to identify those for whom excisional haemorrhoidectomy may carry this increased risk.

Mistake 8 | Failure to address the importance of anal intercourse, trauma and STIs in perianal disease

Anal intraepithelial neoplasia and anal squamous cell carcinoma are associated with the human papilloma viruses (and in particular HPV 16 and 18), which are sexually transmitted. In addition, sexually transmitted infections (STIs) can cause bleeding, pruritus and discomfort.

Also, treatments such as stapled haemorrhoidectomy and abdominoperineal excision of the rectum prevent anal intercourse or may lead to injury. Anal intercourse is common11 and a failure to consider these factors in the aetiology of disease or when considering treatment options, may lead to missed diagnoses, treatment failure or dissatisfaction with outcomes following surgery.

Mistake 9 | Mistaking rectal prolapse for prolapsing haemorrhoids

Rectal prolapse is an important diagnosis and can lead to incontinence, discomfort, bleeding, reduced mobility and social isolation. Many patients may not recognise the prolapse for what it is, instead assuming they have haemorrhoids that prolapse out of the anal canal.

When considering a patient with perianal ‘lumps’ that come down during defecation, incontinence or bleeding, particularly if they are an elderly woman, the clinician should ask the patient to strain on the commode and try to produce a prolapse that the surgeon can then observe and assess.

Failure to do this will mean a missed diagnosis, recurrent failure to treat the ‘haemorrhoids’ that will not respond to conservative measures or banding and will produce persistent symptoms. As the patient may not realise they have a prolapse, the clinician must actively seek this diagnosis in appropriate patients.

Article information

© UEG 2016 Tozer and Jenkins.

Cite this article as: Tozer P and Jenkins JT. Mistakes in managing perianal disease and how to avoid them. UEG Education 2016: 16; 43–45.
Phil Tozer and John T Jenkins are at St. Mark’s Hospital, London, UK.
Correspondence to: philtozer@nhs.net
Published online: December 21, 2016
Conflicts of interest: The authors declare there are no conflicts of interest.
Image credit line: © Can Stock Photo Inc./alila
A pdf of this article can be found in the UEG Education Library.

About the authors

Phil Tozer is a Resident Surgical Officer and researcher with the Fistula Research Unit (FRU) at St. Mark’s Hospital, London, UK. His particular research and clinical interests include complex proctology, inflammatory bowel disease and pelvic floor disease.

John T Jenkins
is a Consultant Surgeon at St. Mark’s Hospital, London, UK, and is Colorectal & Anal Cancer Lead at London Northwest Hospitals NHS Trust and Honorary Senior Lecturer ar Imperial College, London. He is on the UEG Scientific and Postgraduate Training Programme Committees. His interests relate to minimally invasive colorectal surgery, advanced and recurrent colorectal and anal cancer and surgical education.

 

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