Rectal and Anal Disorders: What to know, what to do

One of the most common complaints I see in the office is medical issues affecting the anus and rectum. This is a sensitive topic and probably not one that makes for great conversation around the water cooler / coffee shop/ office break room. 

Anal or rectal symptoms usually involve one or more of the following: pain, bleeding, or itching. 

Men and women can both present with these symptoms and at any age. I typically see a younger population in general so patients from the early 20s to 40s can have these issues.  

Below I break down some of the disorders I see based on symptoms. 

1.  Anal/rectal pain with bowel movements , often accompanied by bleeding upon defecation:

The most likely cause is usually an anal fissure. Anal fissures are tears of the mucosa (surface) lining the anal canal and anus (the opening of the anal canal). The pain associated with anal fissure can be excruciating. Patient's with severe pain may even avoid going to the bathroom, potentially worsening the condition as a result of formation of hards stool that become difficult to pass

Treatment of the fissure requires a prescription medication. A gastroenterologist is the best qualified to diagnose and treat an anal fissure.

Treatment is aimed at relaxing the external anal sphincter , improving blood flow to the area , treating any underlying constipation, and avoidance of straining. 

Treatment:

Lidocaine/Nifedepine cream 1.5%/0.3% . This cream applied twice daily to the anus will provide pain relief and relax the rectal sphincter muscles preventing muscle spasms that can exacerbate pain and cause further tearing. 

Sitz baths : A simple shallow warm water bath with or without epsom salts. Salts aren't really doing anything. Warm water can increase blood flow to the area and be soothing to the area.  Do this twice a day or more for 15 minutes.

Miralax 17 g daily: Adding an osmotic laxative should help soften/loosen stools preventing increased wall tension and straining

2. Painless rectal bleeding

Hemorrhoids are the most common cause of rectal bleeding when it occurs with defecation . However a visit to a gastroenterologist is always recommended to clarify the history, review colon cancer risk factors, and perform an in-office rectal exam/anoscopy. In certain situation a colonoscopy or flexible sigmoidoscopy is advisable. 

Hemorrhoids can be classified as internal or external.

External hemorrhoids are below the pectinate line and typically develop around the anus. The can be very painful when enlarged and thrombosed (clotted). The do not typically bleed unless the overlying mucosa is damaged or weakened. The pain of acute thrombosis may be so severe as to require urgent opening and drainage of the clot. This is performed by a colorectal surgeon. Not a gastroenterologist.  

Typically, external hemorrhoids will resolve through resorption of the blood clot and resolution of aggravating factors such as straining and hards stools.  

Treatments

Conservative (non-surgical) treatments involve Sitz baths, topical pain relievers, NSAIDs, in some situations topical steroids. Laxatives have the adjunct role of reducing pain from hard stools.

Internal hemorrhoids are above the pectinate line and are graded based on their size and whether or not they prolapse (protrude from the rectum out through the anus).  These typically bleed and are painless but can be painful the large and more swollen they are. 

Treatments:

Conservative treatment is similar for internal hemorrhoids as for external hemorrhoids.  I am not a fan of preparation H as the agents within them are usually not that effective for moderate to severe cases.

3. Rectal Pain, fever, drainage

Abscess, Fistula

This worries me for an abscess, a fistula, or both. This should prompt immediate evaluation by a physician as treatment requires incision and drainage and anti-biotic therapy.

STD with Herpes, Chlamydia, or Gonorrhea:

Men who have sex with men are at increased risk for STDS of the rectum. Unprotected receptive anal intercourse with a stranger is the most common risk factor I encounter. Patients report pain, bleeding, discharge, and tenesmus (rectal urgency).  Even patient's on PrEP are at risk. Some have a false sense of securityusing PrEP. PrEP , or Truvada therapy provides protection against HIV, not other STDS.

A diagnosis can be made based on a compatible clinical history and examination. A rectal swab should be obtained to confirm the disease. This require appropriate specimen collection kits available at a gastroenterologists office.  Empiric treatment is reasonable if suspicion is high. Treatment is  a single oral dose of Azithromycin and an intramuscular injection of Ceftriaxone.  However, if the swabs are negative an alternative pathology should be sought, such as proctitis.