External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment

BACKGROUND AND DESIGN

In a series of patients treated at a university department of dermatology, we assessed the clinicopathologic features of external anogenital lesions in organ transplant recipients. For 6 years, 1002 recipients with various dermatologic problems underwent assessment for the presence of proliferative external anogenital lesions; these lesions were examined histologically and virologically for the presence of human papillomaviruses (HPV).

RESULTS

Twenty-three patients (2.3%) presented with anogenital lesions, women being more often involved. Clinicopathologic examination revealed 18 anogenital warts, 3 cases of bowenoid papulosis, 1 giant condyloma, and 1 in situ carcinoma. Other viral coinfections were frequent. The lesions were extensive and refractory to treatment in 13 patients, but lesions in 7 were cured alter the immunosuppressive treatment was tapered of discontinued. Dysplastic changes were frequent on histologic examination. Twenty-one lesions contained HPV; 6 of 13 patients with HPV DNA in their lesions harbored oncogenic types that predominated in dysplastic lesions. In some patients, the same HPV types were detected within cutaneous and anogenital lesions, suggesting self-contamination.

CONCLUSIONS

External anogenital lesions are more rare than cutaneous lesions in organ transplant recipients. These lesions may represent a marker of immunosuppression, especially when they are extensive. Their clinical aspect is often misleading; furthermore, because of the presence of dysplastic histologic aspects and oncogenic HPV types, they could be susceptible to malignant transformation, necessitating regular surveillance.

Inflammatory cloacogenic polyp: an unrecognized cause of hematochezia and tenesmus in childhood

The rectal "inflammatory cloacogenic polyp" is a recognized pathologic entity in adulthood. We report three cases in children aged between 8 and 12 years. This disorder should be included in the differential diagnosis in patients with hematochezia and tenesmus. These polyps are usually located at the anorectal junction and so may be overlooked at colonoscopy unless an endoscopic retroflexion maneuver is performed.

Anal tenesmus caused by seminal vesicle cyst

Congenital cysts of the seminal vesicles with ipsilateral renal aplasia or dysplasia are rare but have been well described in the literature. We report the first case where anal tenesmus was the only presenting symptom. Another unique feature was the combination of this anomaly with a duplication of the inferior vena cava.

External anal sphincter dysfunction and postoperative bowel habits of patients with Hirschsprung's disease

An electromyogram (EMG) of the external and sphincter (EAS) was obtained both before and after surgery in five patients with Hirschsprung's disease and eight normal control patients. The EMG, evoked by the transrectal stimulation of the pudendal nerve, was recorded at both the sacral and anal regions to investigate the deep and superficial EAS, respectively. In eight control patients, the EMG at the sacral region consisted of a polyphasic wave with apparently two or three major peaks, and the simple monophasic wave with one or two peaks was found at the anal region. Its peak corresponded to the early peaks in the sacral region. The mean onset latency of the EMG in the sacral region was 2.8 ms. Four patients with Hirschsprung's disease also exhibited responses that were similar to the controls, and their postoperative bowel habits were satisfactory. However, the remaining one patient, who still required a daily enema after surgery, exhibited an apparently different response, which was monophasic at both the sacral and anal regions with a long onset latency of 5.0 ms before and after surgery. It is postulated that some cases with Hirschsprung's disease might be associated with an EAS dysfunction before surgery, which possibly led to the development of postoperative bowel dysmotility.

Prevalence of anal human papillomavirus infection and anal cytologic abnormalities in HIV-seropositive women

OBJECTIVE

To determine the prevalence of anal human papillomavirus (HPV) infections and anal cytologic abnormalities in HIV-seropositive and HIV-seronegative women.

DESIGN

This cross-sectional study of a cohort of women with known HIV serostatus involved a standardized interview and a gynecologic examination, including a cytologic evaluation of the cervix and anus. Anal swabs were tested for HPV DNA using the Hybrid Capture assay.

SETTING

Two HIV/AIDS clinics, a sexually transmitted disease clinic, a methadone clinic and women enrolled in a study of HIV heterosexual transmission in the greater New York City metropolitan area.

PATIENTS

One hundred and two HIV-seropositive and 96 HIV-seronegative women were selected from an ongoing study of the gynecologic manifestations of HIV infection.

MAIN OUTCOME MEASURES

Detection of anal HPV DNA and anal cytologic abnormalities.

RESULTS

Anal cytologic abnormalities were detected in 27 (26%) of the 102 HIV-seropositive women and in six (7%) of 96 HIV-seronegative women. Five (5%) of the anal smears from the HIV-seropositive women and one (1%) from the HIV-seronegative women had low-grade anal intra-epithelial neoplasia. The remainder of the anal cytologic abnormalities were classified as mild squamous cytologic atypia. HPV DNA was detected in 30 (29%) of 102 HIV-seropositive and two (2%) of 96 HIV-seronegative women. Of the 33 patients with anal cytologic abnormalities, 19 (58%) had anal HPV DNA detected as compared to 13 (8%) of 160 women without cytologic abnormalities (P < 0.001). In a multivariate logistic regression analysis, HIV-seropositivity was found to be an independent risk factor for both anal HPV infection and anal cytologic abnormalities and the strength of the association was greater in women with lower CD4+ T-lymphocyte counts.

CONCLUSION

The prevalence of both anal cytologic abnormalities and anal HPV infection are significantly increased in HIV-seropositive women.

Severe anal condylomata acuminata following high-dose chemotherapy and autologous hematopoietic stem cell transplantation: a case report

We report the case of a 37 years old male patient who developed severe anal condylomata acuminata after high-dose chemotherapy and autologous hematopoietic stem cell transplantation for follicular non-Hodgkin's lymphoma. Anal warts were particularly disabling, refractory to the treatment and finally imposed diversion colostomy. The role of cellular immunodeficiency observed after high-dose chemotherapy and autologous hematopoietic stem cell transplantation as etiology of anal condylomata is discussed.

Condyloma acuminata in infants and children. A survey of colon and rectal surgeons

PURPOSE

Condyloma acuminata are anogenital warts caused by a human papillomavirus. Human papillomavirus is a tissue-specific, site-specific, double-stranded DNA virus, which is capable of inducing high-grade genital intraepithelial neoplasia and malignancy. The incidence of anogenital warts in the pediatric age group is rising, and sexual abuse has been implicated as a potential cause.

METHODS

Accumulated data from separate questionnaires sent to practicing colorectal surgeons who are members of The American Society of Colon and Rectal Surgeons and fellows in colon and rectal training programs have been analyzed.

RESULTS

Thirty percent of those polled responded to our survey. Of the respondents, 93 percent see less than two pediatric cases per year. Seventy-two percent stated that tissue specimens would be sent routinely for histopathologic identification. Although 73 percent of surgeons consider anogenital warts a potentially sexually transmitted disease, only 26 percent reported screening for other sexually transmitted diseases. A diagnostic and therapeutic protocol is followed by 19 percent of respondents. Patient follow-up varied from six months (43 percent) to lifelong examinations (3 percent). Sixty-four percent of respondents agreed that a diagnostic and therapeutic protocol based on current knowledge would be beneficial.

CONCLUSION

We conclude that colon and rectal surgeons have a low exposure to anogenital warts in infants and children. Furthermore, we believe that a diagnostic and therapeutic protocol based on the current literature would be helpful.

[Transanal ultrasonography in the study of fistulas of perianal abscess]

The fistulous tracks and abscesses may be related anatomically to the anal sphincters and levator ani muscles. Defining the anatomical relationship between the fistulous lesion and the anal sphincters and/or adjacent organs is essential for correct management. Clinical examination can suggest possible sepsis or the direction of the fistulous track. We report the results of anal endosonography in the evaluation of 54 patients affected by perianal sepsis and fistula in ano. Anal endosonography has correctly identified 22 of 22 internal openings seen at the surgery, 14 of 16 intersphincteric tracts while only 7 of the 9 trans-sphincteric tracks described by anal endosonography were present at the surgery. All the abscesses were correctly identified. Anal endosonography provides a high-resolution image of the anatomy of anal canal and defines the anatomy of tracks and abscesses in relation to the sphincters, determines if there has been trans-sphincteric extension of the sepsis and assesses the state of the sphincters. We have observed a good correlation between the preoperative AES findings and those at surgery. We conclude that anal endosonography is a useful diagnostic procedure in patients with perianal sepsis.

Treatment of perianal infection following bone marrow transplantation

PURPOSE

Bone marrow transplantation (BMT) is often associated with profound neutropenia. Allogeneic transplant recipients also have defects in both humoral and cellular immunity and thus are subject to increased risk of serious, often life-threatening, infection even beyond the period of granulocyte recovery. The current study was undertaken to evaluate patients who required operative intervention for perianal sepsis following BMT.

METHODS

The bone marrow transplant database at a single institution was used to identify all patients diagnosed with perianal infections after autologous or allogeneic BMT. Charts were reviewed in a retrospective manner.

RESULTS

Over a ten-year period ending in November 1993, 963 BMT were performed at the City of Hope National Medical Center. Twenty-four patients were diagnosed with perianal infections following their transplants. Fifteen patients did not have purulent collections requiring drainage and were treated with antibiotics and supportive measures alone. Nine patients (37.5 percent) required surgical intervention between 10 and 380 days following transplantation. At the time of surgical intervention, seven patients had purulent collections and two patients had acute and chronic inflammation, tissue necrosis, and fibrosis. Of the two patients with an absolute neutrophil count less than 1,000, a purulent collection was found in one of the patients. Cultures taken from perianal abscesses were almost all polymicrobial, and the most common organisms were Escherichia coli, Bacteroides, Enterococcus, and Klebsiella. For those patients undergoing surgical intervention, mean time to complete wound closure by secondary intention was 37.6 days; five patients healed in less than 15 days, two patients healed at 93 and 114 days, and two patients had persistent, open wounds at time of death, which was unrelated to their perianal disease. Five patients were receiving systemic steroids at time of surgical intervention; this did not appear to affect time to wound healing.

CONCLUSIONS

Perianal infections are a rare complication of BMT. Majority of these infections are polymicrobial, and organisms isolated are similar to those seen in the perianal infections of nonimmunosuppressed patients. Despite steroid use, granulocytopenia does not exclude the possible presence of purulent collections, and clinical examination should guide the decision for surgical drainage. In general, perianal wound healing is not prolonged in BMT patients.

[Perianal manifestations in Crohn's disease]

A total of 114 of 195 patients with Crohn's disease had perianal involvement. The average age at the beginning of symptomatology was 30.3 years. The interval between symptoms and diagnosis was 3.1 years. PAC was associated with colonic disease and in these patients, was multiple. PAC preceded intestinal disease in 11 percent, was coincident in 66 percent and appeared later in 23 percent. Sixty one patients (53.5%) were operated on 104 times (1.7 operations per patient). None of these patients developed faecal incontinence. Two patients were treated with hyperbaric oxygenation. The association of perianal disease and extra-intestinal manifestation occurred in 76 patients. There was no association in 38 patients. Forty patients had extra-intestinal manifestation without perianal disease. Twenty two patients had panproctocolectomy because of perianal disease. Twenty one had a stoma, with or without intestinal resection. The stoma improved perianal symptoms, but all remain defunctioned. After mean follow-up of 8.8 years, 45 patients present some kind of perianal complication.

CONCLUSION

the surgical treatment of perianal disease well indicated and performed don't result in incontinence; PAC combined with colonic or rectal disease is associated with higher need of performing a proctocolectomy or a defunctioning stoma. Only 22.8 percent presented resolution of perianal disease maintaining anal sphincter function.

Disturbed anal sphincter function following vaginal delivery

BACKGROUND

Recently interest in idiopathic (neurogenic) faecal incontinence has swung from denervation of the external anal sphincter to the internal sphincter.

AIMS

To evaluate the effects of vaginal delivery on the internal sphincter.

SUBJECTS

1372 mothers were studied antenatally and 1202 were accepted into the study.

METHODS

Sphincter pressures were measured antenatally, in the early postnatal period, and six to 10 weeks later in selected patients.

RESULTS

755 of 1202 subjects assessed antenatally were primiparous women and 447 multiparous women. Some 320 previous spontaneous vaginal deliveries (SVD) (mean 59 mm Hg) and 67 previous forceps deliveries (mean 58 mm Hg) had lower resting pressures than 755 primiparous women (mean 66 mm Hg) (p < 0.01). A total of 493 subjects were reassessed postnatally. There were 372 SVDs, 47 vacuum extractions, 20 forceps, and 54 caesarean deliveries. All vaginal deliveries but not caesarean sections dropped their resting anal pressures from antenatal values (p < 0.001). Some 227 first SVDs had a much greater fall than 145 subsequent SVDs. In 162 subjects who had undergone their first vaginal delivery and who were followed up there was some recovery but the resting pressures were still lowered at six to 10 weeks post partum.

CONCLUSIONS

The first vaginal delivery causes a permanent lowering of resting anal pressures. The possible reasons for this are discussed.

Hereditary presacral teratoma

A case of hereditary presacral teratoma involving father and daughter is described. The use of magnetic resonance imaging in the diagnosis of this condition is illustrated and a review of the literature of this unusual condition is presented.

Prevalence and factors influencing hemorrhoids, anorectal varices, and colopathy in patients with portal hypertension

BACKGROUND AND STUDY AIMS

Little is known about the colon in patients with portal hypertension. The present study was carried out in order to assess the prevalence of, and factors influencing, hemorrhoids, anorectal varices, and colopathy in these patients.

PATIENTS AND METHODS

Seventy patients with cirrhosis and portal hypertension, and seventy controls, were prospectively studied. Full-length colonoscopy was carried out in all cases, and the presence of hemorrhoids, anorectal varices, and colopathy was noted.

RESULTS

Hemorrhoids and anorectal varices were seen in 36% and 40% of patients, compared to 40% and 0% in the controls. The difference was statistically significant only for anorectal varices (p < 0.001). Neither hemorrhoids nor anorectal varices were associated with the Child's grade of cirrhosis, the grade of esophageal varices, the presence of gastric varices, portal hypertensive gastropathy, or whether or not patients received sclerotherapy. Nor were they associated with each other. Colopathy was seen in 48.5% of the patients and 3% of the controls (p < 0.001). It was seen more frequently in patients with large esophageal varices compared to those with small varices (87% vs. 28.5%; p < 0.001), and more often in those with gastric varices than those without (71% vs. 28.5%; p < 0.001). It had no association with the severity of liver disease, the presence of hemorrhoids, portal hypertensive gastropathy, or whether or not patients received sclerotherapy.

CONCLUSIONS

It is concluded that the prevalence of hemorrhoids is not increased in patients with portal hypertension. However, the prevalence of anorectal varices and colopathy is higher in these patients. Portal colopathy occurs more commonly in patients with large esophageal varices, those with gastric varices, and those who do not have anorectal varices.

[Anorectal diseases in patients with human immunodeficiency virus (HIV) infection]

BACKGROUND

The incidence of VIH-related disease has arisen dramatically in the last decade. Many of these patients will present with specific anorectal complaints.

PURPOSE

This review paper was performed to discuss the diagnostic and therapeutic implications of anorectal diseases in patients with VIH infection.

RESULTS

A detailed sexual history is important in order to document the mode of transmission. The nature of the anorectal complaint is then evaluated and classified as infectious, neoplastic or idiopathic. Treatment should be planned accordingly.

CONCLUSIONS

In the 1990's it's important that the physician who cares for patients with anorectal complaints be familiar with VIH-related diseases and their treatment plans.

Faecal incontinence with transitory absence of anal contraction in two sexually or physically abused women

OBJECTIVE

To report two cases of faecal incontinence caused by transitory absence of anal voluntary contraction without anal anomalies.

PATIENTS

Two women referred to our gastroenterology department with faecal incontinence. One patient had been sexually abused by her father; the other had been physically abused by her husband.

RESULTS

Clinical and manometric anal contraction was absent despite normal anal endosonography and normal electrophysiological perineal study. Anal contraction was completely normalized after biofeedback, and the patients recovered from the faecal incontinence.

CONCLUSION

Transitory absence of anal contraction is very uncommon as the origin of faecal incontinence. It was observed in two abused women.

Recurrent perianal warts and anal carcinoma

Images

Anal sphincter defects in fecal incontinence: correlation between endosonography and surgery

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound provides accurate information about the anatomy of the anal sphincter. The purposes of this study were to evaluate the use of flexible echo endoscopes to examine the anal sphincters, to validate the diagnosis of internal and external sphincter defects obtained using echo endoscopes by comparison with surgical findings, and to assess the outcome after surgical sphincter repair.

PATIENTS AND METHODS

Twenty-eight patients (13 women, 15 men, median age 50 years, range 30-83) with fecal incontinence--which was of traumatic origin in all but one (childbirth: n = 8; anorectal surgery: n = 17; biopsy of the prostate: n = 2; no trauma: n =1)--were prospectively investigated by endosonography using an echo colonoscope (n = 14) or an echo gastroscope (n = 14) (CF-UM20, GF-UM20, Olympus Optical). The location and extent of the defects of the internal or external sphincters, or both, were compared with the surgical findings in all patients. The surgical outcome was defined as excellent, improved, or unchanged.

RESULTS

At surgery, 25 of the 28 patients had an isolated internal sphincter defect (n = 15) or combined sphincter defect (n = 10). Endoscopic ultrasound identified all of the external anal sphincter defects (n = 10), and correctly excluded a defect in 15 of 18 patients (sensitivity, specificity, and accuracy 100%, 83% and 89%, respectively). All of the internal sphincter defects (n = 25) were detected by endosonography. In three patients, a postulated intact internal sphincter was confirmed by surgery (accuracy 100%). In two patients, the extent of the sphincter defect was underestimated. Despite good visualization of the internal and external anal sphincters, as well as of the puborectal muscle in all patients, the shape, diameter, and full radial image sector (360 degrees) of the echo gastroscope made this instrument more practicable than the echo colonoscope. Nineteen of 25 patients who underwent surgery (76%) with proved sphincter defects experienced improvement, the figure reaching 87% (13 of 15) in patients who received isolated internal sphincter defect repair.

CONCLUSIONS

Anal endosonography, even using flexible echo endoscopes, is an accurate method for identifying anal sphincter defects, and is the method of choice for preoperative sphincter mapping with special regard to internal sphincter repair, which can be carried out with excellent results.

[Evaluation of sexual abuse in an infant with condyloma acuminatum]

Condyloma acuminatum is a skin infection affecting the anogenital area caused by the human papilloma virus and is usually sexually transmitted in adults. The disease in children is rare and the mode of transmission is controversial. Because of the possibility that children with condyloma acuminatum have been sexually abused, a thorough medical and social evaluation is essential. However, the physician should bear in mind the possibility of nonsexual transmission. Effective management of condyloma acuminatum in prepubertal children involves a multidisciplinary approach and cooperation. We present an 11-month-old girl with genital lesions of condyloma acuminatum. Similar lesions were found in her father's penile area. These findings suggested the possibility of sexual abuse as the cause of the infection. However, detailed, meticulous investigation of the case did not support this suspicion. Our final impression was that transmission was probably nonsexual, as there was no evidence for sexual abuse.