Wendy C. Coates
A variety of anorectal conditions can prompt a visit to the emergency department (ED). These conditions may be isolated and temporary or may signal an underlying systemic disease. Great sensitivity is required in dealing with patients who have problems in this area, as they may be embarrassed to share details with the healthcare provider.
The rectum originates at the end of the sigmoid colon and stores stool until a convenient time for defecation. The anal canal is the terminal portion of the digestive system and is approximately 4 cm in length. At the dentate line of the anal canal, the epithelium changes from the columnar epithelium of the intestine to a modified squamous epithelium. Several glands reside in this area to provide lubrication for the easy passage of stool. Fecal continence is maintained by a cooperation of both voluntary and involuntary muscle sphincters.
CLINICAL PRESENTATION
Patients with anorectal conditions may present with a variety of symptoms, including pain, itching, swelling, bleeding, fever, mass, or discharge, depending upon the specific condition (Fig. 114.1). Many patients present with a chief complaint of “hemorrhoids” to represent any anorectal condition. Careful questioning can elucidate the actual diagnosis.
FIGURE 114.1 Anorectal complaints algorithm (Venn diagram).
Painful Swelling
Anorectal abscess is a common acute infection involving the anorectum. The etiology may be the entrapment of mucous and bacteria in the glands of the anal crypts. When deep abscesses rupture, a fistulous tract forms. A complex network of abscesses and fistulas may evolve if the acute condition goes untreated. Abscesses are named according to their location (Fig. 114.2).
FIGURE 114.2 Anorectal abscesses.
Symptoms and sequelae vary depending on the depth and natural ability of the abscess to drain. The clinical presentation depends on the depth and location of the abscess. Superficial ( perianal ) abscesses usually present as tender swellings near the anus. Foul-smelling pus may drain from spontaneously ruptured abscesses. Deep abscesses may cause pain within the rectal cavity or pelvis and progress to a systemic infection. Fistulous tracts may develop and may open directly into the anorectum or through the skin of the buttocks (1,2).
A pilonidal abscess (cyst) is a painful, indurated swelling that occurs in the presacral midline (3). Sinus tracts may develop and open into the surrounding skin of the buttocks. Afflicted patients may also demonstrate hair in the midline in other locations of their bodies, such as the eyebrows.
Hidradenitis suppurativa is caused by an infection to the apocrine glands and is related to poor hygiene or an underlying disease, such as diabetes mellitus or predisposition to the condition. Patients frequently have fever and leukocytosis and may have similar lesions in the axilla or sternum (4).
Painful Bleeding
Anal fissures produce sudden, sharp, tearing pain at the anal orifice during defecation. The patient generally reports seeing bright-red blood on the tissue. Most fissures occur in the midline. Ectatic fissures often suggest underlying disease. Fissures are the most common pediatric anorectal complaint. Hemorrhoids can present in a variety of ways, but the classic presentation is painful bright-red blood that coats the stool. A variety of factors predispose patients to develop hemorrhoids. Most often, the condition is self-limited and is caused by frequent diarrhea, prolonged sitting, low-fiber diet, and pregnancy and may be exacerbated by underlying medical conditions such as obesity, portal hypertension, or bleeding disorders. Patients may complain of anorectal swelling with moist discharge or intense unbearable pain and swelling (1,5,6).
Without Bleeding or Swelling
Some patients have rectal pain that does not have any of the pathophysiologic mechanisms described. Their pain may be of sudden or gradual onset and takes on different characteristics depending on the cause. Before making a diagnosis of the two common entities, levator syndrome or proctalgia fugax, it is important to exclude other causes of pain.
Painless Conditions
Patients with rectal prolapse ( procidentia) present with a large externally protruding mass. The presentation may be preceded by defecation, sneezing, or coughing. Most patients are in the extremes of age. A foul odor may be present (7).
Anal warts (condylomata acuminata ) may also present as a painless swelling at the anal opening. Patients generally report concurrent itching and often have had contact with another individual with a similar condition. Genital warts are caused by the human papilloma virus. A sexual history highlighting the role of the anus in intercourse is essential. Children with genital warts may have contracted them as a result of sexual assault or simply by the transmission of the virus on the hands of the person changing their diaper. Other causes of perianal itching ( pruritus ani) range from dietary habits (caffeine, citrus, and spicy foods) or drugs (steroids, tetracycline, and colchicine) to hygiene and underlying skin conditions (pinworms and psoriasis). Patients frequently complain of an insurmountable urge to scratch, and the symptoms typically are worse in the warm months. Underlying anorectal disease (fistula, fissures, proctitis, and prolapsed hemorrhoids) may present as pruritus ani.
Patients who have proctitis, an inflammatory condition of the rectum, may present with a sensation of internal fullness accompanied by a change in bowel habits such as constipation or diarrhea. This can be caused by infections, sexually transmitted diseases (STDs), antibiotics, radiation, or inflammatory bowel disease. Occasionally, proctitis may present with pain or discharge.
Foreign Bodies
Rectal foreign bodies are covered more specifically in Chapter 115.
DIFFERENTIAL DIAGNOSIS
Painful swellings of the anorectum include hemorrhoids, abscesses, pilonidal disease, and hidradenitis suppurativa (Fig. 114.1). The presence of pus or fever suggests an abscess. For many patients with abscesses and fistulas, their problem is recurrent. A specialized abscess that is lined with epithelium and is found in the presacral area is a pilonidal cyst. This condition occurs more frequently in young men and reflects a midline defect in which debris from hair follicles and glandular secretions collects and becomes indurated.
Patients who present with painful bleeding are likely to have hemorrhoids or an anal fissure. Fissures tend to present as sudden, sharp, and tearing pain with subsequent burning, whereas hemorrhoids generally have a more gradual onset and a more varied course. Hemorrhoids can mimic any anorectal condition. A thorough history and physical examination can confirm an ultimate diagnosis of hemorrhoids.
Rectal pain that occurs from a cause other than those already mentioned may be of neuromuscular etiology. Levator ani syndrome is distinguished by its gradual onset and persistence as a dull pain that is exacerbated by defecation. Patients with sudden, intense spasmodic pain in the rectal area may have proctalgia fugax. This condition is frequently associated with the “type A” personality but may occur in any patient. Its onset is often during intercourse, urination, defecation, or sleep (8,9).
Patients who present with rectal bleeding that is unaccompanied by pain may have internal or external hemorrhoids that are neither thrombosed nor lodged in the sphincter to produce pain. These patients typically have intermittent bright-red blood that coats the stool. Patients with bright-red blood mixed in with the stool should be evaluated for brisk upper or lower gastrointestinal (GI) bleeding. Patients whose source of bleeding is of uncertain etiology should be evaluated for rectal cancer or polyps.
Procidentia may be complete (all layers of the rectum protrude) or incomplete (mucosal layer only). It is important to distinguish this from prolapsed internal hemorrhoids and rectal masses. In young children, the diagnosis of cystic fibrosis is suspected (7).
Patients with pruritus ani should be examined closely and questioned about potential sources of their condition. Other diseases to consider in the differential diagnosis of condylomata acuminata are squamous cell carcinoma or secondary syphilis (condyloma latum), which is flatter.
Proctitis should be considered in patients who have undergone radiotherapy or recent antibiotic therapy, who utilize the rectum for sexual gratification, who have introduced foreign objects or lubricants into the rectum, or who have underlying inflammatory bowel disease.
ED EVALUATION
A thorough history and physical examination are important in distinguishing common anorectal complaints (see Fig. 114.1) (9). Local symptoms such as pain, bleeding, discharge, and itching are the foundation for the history. Questions about underlying GI conditions (e.g., Crohn disease, inflammatory bowel disease, and GI cancer); systemic illnesses (e.g., diabetes mellitus, AIDS, and cancer); and trauma provide clues about the etiology of the symptoms. Some individuals use the rectum during intercourse and others introduce foreign objects that they cannot retrieve.
The physical examination should begin with an observation of hygiene, structural integrity, and the presence of lesions, blood, or discharge. A digital rectal examination (DRE) can assess sphincter tone and can reveal masses in the anorectum or adjacent structures. Any stool remaining on the examiner’s glove can be used to check for occult blood. Finally, anoscopy can be performed to visualize lesions in the anal canal.
Abscesses are defined by their location. Perianal abscesses are adjacent to the anal outlet and are superficial in nature. Most patients are afebrile. Visual inspection of the perianal area may reveal pus or a fluctuant mass with or without surrounding erythema. Ischiorectal abscesses are exterior to the sphincter muscles and are located in the buttocks. Patients frequently cite severe buttock pain. Deeper ischiorectal abscesses may cause fever and leukocytosis. Intersphincteric abscesses form above the external sphincter and below the levator ani muscles. They may appear as a protrusion into the rectum and may be confused with inflamed hemorrhoids upon anoscopy. Supralevator abscesses are uncommon and are located deep to the levator ani muscles. There is an increased predominance in patients who are immunocompromised and in those with associated conditions (e.g., Crohn disease, pelvic inflammatory disease, or diverticulitis). Diagnosis relies on a high index of suspicion in patients with pelvic pain, fever, and leukocytosis. DRE may reveal a fistulous outflow track in the anal canal that may be palpable (1,2). If the extent of the abscess cannot be determined by physical exam, CT scan may be helpful.
Patients with a painful swelling in the presacral area with associated openings from sinus tracts have pilonidal disease. They are usually fluctuant and tender and may spontaneously begin to drain hairy pus. Extension of the disease to the entire presacrum is possible (3). Multiple infected openings that are not limited to the presacral area may indicate hidradenitis suppurativa. Local lymphadenopathy is a common finding, and many patients are febrile and have an elevated white blood cell count (4).
Anal fissures are suspected when there is a sudden pain near the anus and bright-red blood on the tissue. Most benign fissures are located in the anoderm at the posterior midline. Although women may have fissures in the anterior midline, fissures in other locations often herald a serious underlying disease (e.g., Crohn disease, leukemia, tuberculosis, or human immunodeficiency virus [HIV]). The acute appearance of the fissure is similar to that of a laceration of the anoderm. Chronic changes may occur if a fissure is left untreated and include the development of tissue edema, a sentinel pile (hypertrophic and edematous skin), and skin tags upon resolution (10).
Hemorrhoids may be classified as external or internal. External hemorrhoids are close to the anal orifice and are covered with anoderm. Careful inspection reveals a coloring of the epithelium that is similar to that of surrounding skin. Patients may have perianal skin tags that have resulted from prior episodes of external hemorrhoids. A hard, bluish mass in the location of an external hemorrhoid denotes a thrombosed external hemorrhoid (5,6).
Internal hemorrhoids originate superior to the dentate line and are supplied by the superior hemorrhoidal vessels. Their covering appears mucosal in nature and does not resemble surrounding skin at all. A classification system of four grades has been developed. Grade I internal hemorrhoids produce symptoms of fullness and pain with bleeding but do not exit the anus at any time. Grade II internal hemorrhoids prolapse during defecation but spontaneously retract when straining ceases. Grade III internal hemorrhoids prolapse during defecation and require manual replacement. Grade IV internal hemorrhoids prolapse at any time, cannot be reduced, and may thrombose or become gangrenous (5,6).
To delineate the cause of rectal pain that does not fit into one of the categories described previously, one must first rule out a serious underlying condition, including cauda equina syndrome, cancer, or endometriosis. The diagnosis of proctalgia fugax or levator ani syndrome is typically based on historical findings. If the patient tolerates a rectal examination, the levator ani muscles may be tender to palpation in levator ani syndrome (11).
Evaluation of patients with painless rectal bleeding includes DRE with subsequent hemoccult testing. If desired, anoscopy can be performed to visualize hemorrhoids or potential erosions in the mucosal wall. Procidentia is identified by noting concentric rings of mucosal tissue that may be ulcerated and is associated with a mucoid discharge or is stained with stool. If all layers are involved in the prolapse, they can be identified as well (12).
Anal warts appear as papilliform lesions that often coalesce at the anus and may extend to the anal canal. Direct irritation to the warts may induce minimal bleeding. A detailed sexual history may reveal that the patient is HIV-positive or has concurrent STDs. Evaluation of pruritus ani begins with a detailed history and physical examination.
Proctitis of infectious etiology is most often caused by organisms responsible for STDs in persons who have receptive anal intercourse. Common organisms are herpes simplex (HSV), gonorrhea, and chlamydia. Patients may present with diarrhea or constipation and may have a mucopurulent discharge from the rectum. Occasionally, they may have manifestations of systemic disease, including fever, chills, and leukocytosis. These patients may also have a component of allergic proctitis that results from the introduction of foreign substances into the rectum. For example, lubricants, erotic objects, and soaps may irritate the mucosa or produce small tears, leading to inflammatory changes. Patients with underlying inflammatory bowel disease may experience periodic inflammation of the rectum and have a mucoid discharge, constipation, or diarrhea, indicative of proctitis. Radiation proctitis occurs most often in cancer patients who have undergone focused irradiation to the pelvic and lower GI systems and may present with diarrhea, pain, tenesmus, fistula-in-ano, or rectal strictures (13).
KEY TESTING
• Digital rectal examination
• Anoscopy as needed
ED MANAGEMENT
General treatment of most anorectal conditions focuses on maintaining good hygiene and producing stool that is easy to pass. This can be accomplished by following the WASH regimen (Fig. 114.3).
FIGURE 114.3 The WASH regimen.
Perianal abscesses can usually be incised and drained in the ED with good local anesthesia. Exceptions include abscesses in children and in patients who are immunocompromised (14). Superficial ischiorectal abscesses may be incised and drained via a skin incision on the buttocks. However, deeper perirectal abscesses generally require drainage in the operating room (OR) under anesthesia. Antibiotics should be considered, especially if there is surrounding cellulitis, fever, or leukocytosis. Drainage of intersphincteric and supralevator abscesses takes place in the OR. If a fistula is palpated in the anorectum or along the surface of the buttocks, it should be left intact to prevent the inadvertent puncture and subsequent extension of the fistulous network. Definitive treatment is a fistulectomy in the OR, although fibrin glue has been tried successfully as a less-invasive management strategy (2,10). Patients with a fistula without evidence of an abscess may have Crohn disease, cancer, or tuberculosis. These patients should be referred appropriately when a fistula is detected.
The ED treatment of an isolated pilonidal cyst begins with its identification in the presacrum. Incision and drainage should be done vertically and lateral to the midline to prevent further scarring and inflammation. Antibiotics may be used as an adjunct to incision and drainage in patients who have accompanying cellulitis. Patients with extensive spread of pilonidal disease may be referred to surgery to consider wide excision (3).
Treatment of hidradenitis suppurativa begins with attention to improved hygiene. Incision and drainage of pustules may provide symptomatic relief, but a broad-spectrum antibiotic may be necessary to diminish the severity of the exacerbation of this condition (4).
Anal fissures should be treated acutely by following the WASH regimen so that the stool is easier to pass. Application of topical nitroglycerin ointment (0.4%) twice daily may alleviate symptoms. Short-term application of topical nifedipine gel (0.2%) with lidocaine (1.5%) alleviates symptoms and may promote healing. Finally, the injection of botulinum toxin (2.5 to 5.0 million units) into the muscular anal sphincter produces rapid relief from the fissure but may cause temporary fecal incontinence (10). ED management of external hemorrhoids is to follow the WASH regimen. Topical creams available over the counter may provide symptomatic relief but do not alter the course of the disease. Prolonged use of local anesthetic or steroid creams can lead to local skin irritation and breakdown. Thrombosed external hemorrhoids may be excised in the ED by anesthetizing the skin and completely removing the clot and its overlying tissue. The use of excision rather than incision and drainage prevents the formation of perianal skin tags. It is critical to distinguish between external and internal thrombosed hemorrhoids before attempting an excision (15).
Internal hemorrhoids should be managed with the WASH regimen. Warm water may produce enough anal dilation to reduce prolapsed internal hemorrhoids. Pain medications may be administered, but care should be taken to prevent constipation. Thrombosed fourth-degree internal hemorrhoids are generally managed operatively. Gangrenous hemorrhoids require prompt surgical treatment (6). If a benign source of rectal bleeding (e.g., internal hemorrhoid) cannot be identified, the patient should be referred to a specialist for endoscopic evaluation of the rectum and colon (9).
Treatment of levator ani syndrome focuses on the relaxation of the involved muscles using benzodiazepines, topical nitrates, or warm water baths (8). In addition to these regimens, patients who have proctalgia fugax have reported relief when applying upward pressure with their fist against the anus.
Procidentia can be managed in the ED or the OR by attempting reduction. Gauze moistened with saline can be applied to the protruding rectum, which can be reinserted through the anal verge. In most cases, sedation is required. If the reduction is successful, conservative management using the WASH regimen may prevent recurrence, especially in children (7). However, it is likely that a more permanent cure is surgical to strengthen the muscles that enabled the rectum to prolapse through the anus (12).
Once anal warts have been diagnosed, the cause should be identified. A full sexual history should be taken, and the patient should be referred for HIV testing. Children should be referred for testing for sexual abuse if there is not a credible source for inadvertent transmission of the virus during routine care. Treatment can be done as an outpatient with 0.5% podofilox gel for isolated condylomas. Diffuse disease requires frequent visits to the physician for application of podophyllin resin, excision, or other removal techniques.
Treatment of pruritus ani is directed at the particular cause, if possible. It may include advice on how to maintain proper hygiene or alter the diet to reduce intake of the offending food or beverage. If an anorectal problem is the cause, treating the underlying condition is likely to improve the symptoms. Medical conditions, both dermatologic and systemic, should be treated appropriately. For idiopathic pruritus ani, symptoms may be alleviated by a short course of topical 1% hydrocortisone ointment (16).
ED treatment of proctitis is aimed at relieving symptoms and is often simply supportive. Infectious proctitis should be treated with a regimen that covers organisms commonly associated with STDs. At the time of evaluation, the identity of the offending organism is usually unknown, and it is helpful to obtain cultures to direct future therapy. The suggested empiric antibiotic regimen is a single dose of ceftriaxone 125 mg intramuscularly, plus doxycycline 100 mg orally for 7 days. If ulcerative lesions are seen on anoscopy or in the perianal area, an infection with HSV is possible. In addition to the above regimen, treatment with acyclovir 800 mg orally for 7 to 10 days is indicated (17). These patients should be referred for HIV and syphilis testing.
Treatment for radiation proctitis is aimed at relieving symptoms. In addition to supportive therapy, patients can sometimes benefit from botulinum toxin injection, oral sucralfate, or hyperbaric oxygen therapy or may be referred to a proctologist for sclerosing therapy (18).
Some rectal foreign bodies may be removed with adequate sedation in the ED, as described in Chapter 115. Patients who have anorectal foreign bodies, trauma, or proctitis should be questioned about the possibility of sexual assault.
CRITICAL INTERVENTIONS
• Initiate antibiotics and surgical consultation for patients with a suspected deep perirectal abscess and systemic signs of infection.
• Stabilize patients with acute blood loss of anorectal origin.
• Search for signs of complications (hemorrhage and perforation) in patients with rectal foreign bodies. Consider sexual assault.
DISPOSITION
Most patients with limited anorectal complaints can be discharged safely from the ED and told to follow the WASH regimen (see Fig. 114.3). For abscesses that cannot be drained easily in the ED, operative management is indicated. Those who display signs of systemic infection, such as fever and leukocytosis, should receive prompt surgical intervention. Several surgical options are available for repair of hemorrhoids, and an appropriate referral should be made. Immediate surgical referral should be made for gangrenous fourth-degree internal hemorrhoids. For patients whose genital warts are widespread, referral for repetitive topical treatment or surgical management can be made. Patients with rectal foreign bodies can be discharged if the removal was routine and uncomplicated. Many require admission for surgical intervention.
Common Pitfalls
• Do not assume that a patient complaining of “hemorrhoids” actually has them. Consider underlying disease with an anorectal component that may be described as “hemorrhoids” by the patient.
• Mistaking a thrombosed internal hemorrhoid for an external one and excising it.
• Probing anorectal fistulas in the ED.
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