Anal pain is a common reason for consultation. The patient does not know, usually precisely describe its symptoms and the most common self-diagnosis is that of “hemorrhoids” that often proves to correspond to something quite different: a crack, a fistula, dermatitis.
A survey among liberals gastroenterologists recently about the prevalence of proctology pathology gave the results shown in Box 1.
Box 1. Prevalence of proctology pathology gastroenterology practice
Number of patients: 2671
Rectal bleeding: 50.01%
Anal pain: 45,41%
Swelling: 23.2%
Prolapse: 17.4%
Itching: 17.71%
Transit disorders: 16.3%
Oozing fecal: 13%
Continence disorders: 3%
As can be seen anorectal pain is the second reason for consultation after rectal bleeding.
DIAGNOSIS:
A precise and directive interview can often suggest the diagnosis, confirmed by the fact proctology exam genupectorale position.
Anorectal pain may correspond to an organic disease generally easy to demonstrate by clinical examination or be of functional origin. This last hypothesis, though common, is to evoke that after removal of the previous etiologies.
Various neighborhood or neurological pathologies may also have a pained expression anorectal. Their diagnosis requires in this case a complementary balance sheet, proctology exam, the first to realize, usually being normal.
Examination:
The examination focuses on finding answers to the following questions:
– Are permanent pain in the day, at night or punctuated by stool?
– There are false desires, a sensation of incomplete evacuation, anal itching, urinary disorders associated?
– Does the patient has an analgesic position?
Reviews:
The inspection of the patient genupectorale position allows to examine the appearance of the integument of the anal margin, seeking erythema, lesions eczématisées, abscess fistulized or not an irregular formation, tumor.
Do not hesitate to ask the patient to make a thrust force, to discover a perineal descent, a non-permanent hemorrhoid prolapse or rectal prolapse (which is better externalized in a squatting position).
DRE:
DRE is interested in all sides of the anal canal and rectum including the posterior surface at the sacral concavity.
The anal contraction effort during the DRE can appreciate the tone of the perineum, the anal sphincter and the puborectalis. The thrust force (easier in the left lateral decubitus) can appreciate the existence of a prior rectocele.We can help with this maneuver a touch bidigital, vaginal and rectal.
Anoscopy:
Anoscopy ends the proctology examination.
Simple gesture that can be performed by any physician consultation, to discover the state of internal hemorrhoids, the appearance of the dentate line and the condition of the lining of the lower rectum.
ETIOLOGY:
Hemorrhoids:
External hemorrhoidal thrombosis:
Diagnosis:
The external hemorrhoidal thrombosis is the most common etiology, reflected in a sometimes very painful anal swelling, sudden onset. On examination, there is an outer border more or less edematous swelling of varied size sometimes revealing a bluish clot under the skin taut.
Treatment:
Treatment is simple, based on analgesics and especially non-steroidal anti-inflammatory respecting their cons-indications and precautions. Efficiency is often rapid at the same time on pain and edema. After 48 hours of evolution and if the hemorrhoid is not too edematous due to nonsteroidal anti-inflammatory drugs (NSAIDs), an incision or excision can often shorten evolution.
In the absence of incision swelling becomes painless but often starts many weeks to disappear, leaving a sawgrass.
Internal hemorrhoidal thrombosis:
Diagnosis:
The internal hemorrhoidal thrombosis is rare, visible rectal examination, but sometimes responsible for a thrombosed hemorrhoid prolapse which is often a hyperalgic emergency. This is externalized internal haemorrhoid packages often irreducible blackish, purplish, oozing. The pain does not rule in a complete examination.
Treatment:
Treatment with incision is against-indicated because of the risk of arterial bleeding. NSAIDs are effective if they are not against-indicated (eg pregnancy or postpartum). Sometimes the intensity of symptoms may require emergency hemorrhoidectomy. The strangled rectal prolapse is rare, because most often occurs in a context of hypotonic perineum. With no possible reinstatement, surgical treatment is urgent because of the risk of necrosis.
Anal fissure:
This is one of the most common diseases of the anal canal, often called hemorrhoid patient who can not describe his symptoms.
Diagnosis:
Pain, main symptom, can be extremely intense and the diagnosis is often made from the interrogation: the issuance of stools determines the wake of pain, followed by a break of a few minutes and then reappear, sometimes for extended periods. When pain becomes permanent, suspect or superinfection intersphincteric abscess. Clinical examination allows the diagnosis in the form of an epithelial ulceration mostly at the posterior pole of the anal canal.Spasm of the sphincter of the fact of pain can make it difficult this visualization. In a side location of the crack, and in the absence of contracture, one must evoke other diseases manifest themselves in a misleading way (venereal disease, cancer, Crohn’s disease). The crack is often covered, when old, a sentinel sawgrass.
Treatment:
When the crack is recent and superficial, treatment is based on topical local analgesia, associated with transit regulators to soften the stool thus allowing healing of the fissure. The likelihood of scarring is even lower than the crack is old, more or less deep surinfectée.
The treatment is surgical: fissurectomy with or without a side léïomyotomie.
It has been recently proposed nitrates ointment, which are effective due to their relaxing action on the sphincter. This ointment is not always well tolerated (headache).
Botulinum toxin has also been tested, but its effective limit price indications.
Anorectal abscesses:
They are less frequent than hemorrhoidal disease and anal fissure but can sometimes identify an intense anal pain syndrome requiring emergency care.
Anal fistula:
Diagnosis:
Anal fistula is the usual cause. The abscess is most often manifested by sudden onset of pain, sometimes pulsatile permanent, without insomniantes pace compared to the stool. Fever is often present and the clinical examination observes an erythematous swelling often poorly limited hot, sometimes tense, sometimes centered purulent hole if the abscess is fistulized. This determines fistula usually improved pain syndrome. The starting point of this abscess is a crypt at the dentate line of the anal canal. The fistula tract may be supra-sphincter, trans-sphincter or sub-sphincter. The distinction between the different clinical forms is done only during the intervention.
Treatment:
In emergency, treat pain with an incision that allows the evacuation of power and therefore could immediate relief.
Secondarily, it is imperative to perform a surgical fistula without which recurrence is the rule.
In all cases the collected abscess must be evacuated: the antibiotic treatment prior formal indication (valve disease, immunosuppression) should be avoided to prevent an evolution low noise infection that may later lead to a more complex fi stule .
NSAIDs are strictly against-indicated since they can promote a formidable pelvic floor gangrene because of its rapid expansion. It occurs more often in diabetic patients, ethyl or immunocompromised (HIV).
According to the anatomical type of fistula surgery in more time may be required with elastic bands in traction to respect the anatomical integrity of the anal sphincter.
The diagnosis of anorectal abscess is more difficult when there is an intramural abscess rectum.
In this case the pain is often associated with intense fever but inspection of the anal margin and DRE are not very contributory. When the diagnosis is suspected, an examination under general anesthesia allows most often confirm the diagnosis and implement the treatment.
Pilonidal cyst infected:
Anal pain can be related to a pilonidal cyst infection or a Verneuil’s disease. More trivially, a simple boil or infected sebaceous cyst, frequent at this level, can determine a similar symptomatology.
Anorectites:
Among the many etiologies must retain the sexually transmitted diseases that must be systematically raised especially when recognized anal intercourse.
Among venereal etiologies, the two most common are gonococcal proctitis manifested by pain, tenesmus and glairosanglantes losses. Diagnosis is based on the discovery of the germ on direct examination and culture.
The primary herpes infection is frequently hyperalgic, as ulcers associated with severe burns at the anal margin. It can manifest as an authentic proctitis also very painful.
The working diagnosis must lead to a search for the virus directly to the lesions. Serology is of no interest. Antiviral treatment is most effective when it is given quickly.
Proctitis chlamydial (Nicolas Favre disease) rarer, but recent resurgence, gives a similar picture, often less painful.
The isolation of the germ by local sampling allows the antibiotics (tetracyclines, quinolones, 3 weeks). In the same context can be isolated gonococcus. Ulcerative proctitis in the context of ulcerative colitis and Crohn’s disease is rarely found by anorectal pain.
An anal fistula may instead reveal a Crohn’s disease.
Rectal ulcers or strictures were described after abuse of suppositories for pain relief or anti-inflammatory (suppositories containing codeine, acetylsalicylic acid, acetaminophen). Think about it during the interrogation.
Tumors of the anal canal:
They are rarely very painful, often not symptomatic.
The most frequent diagnosis was squamous cell carcinoma that may develop at the anal margin usually easy to recognize but sometimes over internal development taking in this case a pseudofissuraire pace. Diagnosis is based on biopsy course. In its unevolved form, radiotherapy alone allows a cure in most cases without resorting to amputation abdominopéritonéale proposed before.
This cancer, favored by some papillomavirus (also responsible for cancers of the cervix) saw their frequency increase especially in the gay and immunocompromised population.
Other rarer tumors can occur such as melanoma, lymphoma (in case of HIV infection). Paget’s disease, also observed in the breast and armpit, may be localized at the anal margin and must find an underlying adenocarcinoma.
Bowen’s disease is characterized by painful ulcers at the anal margin. It is favored by HPV and can progress to squamous cell carcinoma authentic. A low rectal cancer can of course be found in the same way and that’s histology that differentiates the type of cancer.
Functional anorectal pains:
The functional anorectal pains designate all responsible anorectal disorders pain not related to organic disease previously considered and which are in principle detectable by a full clinical examination. This is a frequent reason for consultation, and a search for underlying organic nature must be the constant concern of the clinician before formally establish the diagnosis. The main elements which have to consider this diagnosis are females, atypical and polymorphic nature of pain, their increase in certain positions, their chronic nature (over three months), a psychological context including association with other disorders functional (IBS, dyspepsia) and poverty of the clinical examination which contrasts with the richness of semiological descriptions.
The three main anorectal pains are described fleeting proctalgia, levator syndrome and coccydynia.
Proctalgia fleeting:
Diagnosis:
The fleeting proctalgia is more commonly seen in women and a still debated mechanism. The diagnosis is easy in principle solely on the criteria of the questioning, the pain being characteristic. It typically occurs abruptly, usually at night sometimes favored by exemption or sex.
This is a deep pain, rectal, without radiation, sometimes very intense, paroxysmal outset and whose duration varies from a few seconds to several minutes, never more than half an hour. There are few signs associated. The frequency of attacks is highly variable and clinical examination, apart from pain was normal.
Treatment:
Treatment is difficult because the pain, by definition, is very short. Besides the usual measures (implementation of a suppository, sitz bath), inhalation of salbutamol was described as effective. The simple act of reassurance about the benign nature of symptoms is often the best treatment.
Levator syndrome:
Diagnosis:
Syndrome levator ani frequently occurring especially in women between 30 and 60 years. This is a permanent contraction of the pelvic floor muscles especially the levator ani. It is favored by multiple pregnancies, pelvic surgical history or prolonged sitting. Psychogenic involvement is often noted. This is less of a pain than a pelvic heaviness radiating to the gluteal fold, the sacrum or to the thighs. It is sometimes relieved by certain positions including standing or supine and usually disappear overnight. False cravings are sometimes associated. On examination, we discover the puborectalis muscle contracture, unilateral or bilateral.
Treatment:
Treatment with painkillers and muscle relaxant are rather disappointing. There is no surgical treatment.
Coccydynia:
Diagnosis:
Fairly close to the previous syndrome, it would be related to pathology of the joint sacrococcygeal sometimes favored by obstructed labor, a history of violent fall on the coccyx and horseback riding.
The pain is localized to the tailbone and can be caused during its mobilization during the DRE, the finger being positioned hook backwards.
Treatment:
There are no surgical treatment, and some offer infiltration of the sacrococcygeal joint, often ineffective.
Other anorectal pains:
Static pelvic floor disorders:
The static pelvic floor disorders so frequent in multiparous women can perform complex gravity tables and pelvic pain favored by a descending perineum, rectal prolapse, enterocele, cystocele or a uterine prolapse.
Neuralgia:
* Diagnosis:
Neuralgia also pose a difficult diagnostic problem and are linked to a neurological pain whose etiology varies depending on the level of involvement. We should mention the chronic compression of the pudendal nerve whose best known syndrome is the syndrome of the Alcock canal. In the latter case, the compression is in a duplication of the aponeurosis of the internal obturator muscle as a result of fibrosis, idiopathic most often.
Typically these are spontaneous pain develops gradually with net postural syndrome linked to nerve tensioning positions in some particular sitting. The symptoms are isolated without associated signs (no dysuria, no dyschezia or impotence, etc.). Neurological examination is normal. This is most often paresthesia, progressive installation of the anal area, vulvar and vaginal in women, quite characteristic for these disorders disappear when lying down and standing back while sitting. Biological and radiological examinations are normal. The diagnosis is made by electromyogram study with the latency of the pudendal nerve.
* Treatment:
Treatment is difficult, local infiltration with local anesthetics (Xylocaïne® 1% or corticosteroids) being qu’inconstamment effective. They are anyway performed in highly specialized areas. Surgical treatment only in case of failure of medical treatment is effective qu’inconstamment.
Other causes:
Chronic prostatitis, endometriosis may be the cause of anorectal pains.
Finally, it is frequently found in front of the original psychogenic pains whose terms are beyond the previous descriptions. They predominate in women especially after menopause.
They are often associated with old multiple functional disorders including digestive. The psychological context is often fragile and tempted all drugs are ineffective.
Before claiming the functionality, these pains frequently incite the realization of numerous additional tests which are listed in detail in box 2.
Box 2. Main additional tests to look for chronic anorectal neuralgia
Proctosigmoidoscopy
Anorectal endosonography
Radiographs of the pelvis, coccyx, sacrum, lumbar spine
Electrophysiological Assessment
Defecography
Colpocystogramme
Pelvic ultrasound
Pelvic CT
Pelvic MRI
Bone scan
CONCLUSION:
Anorectal pains are a frequent reason for consultation, often in emergency due to the intensity of pain syndrome that does not prejudge the severity of the diagnosis. The diagnosis is usually simple using the standard proctology exam that sometimes requires the use of anesthesia because of the pain.
Functional anorectal neuralgia is a diagnosis of exclusion, difficult to treat and whose formal diagnosis usually requires many investigation in a specialized.