[Diagnostic in anorectal disorders]

Anorectal disorders which often lead to fecal incontinence are a frequent problem especially in elderly patients. Direct risk factors for fecal incontinence are higher age, female sex and co-morbidity with reduced health status. Anorectal disorders cause significant socio-economic burden. Impairment of the structural and functional integrity of the anorectum are mostly multifactorial (integrity of the muscles, sensory function, stool consistency) leading to depression and fear with reduction in quality of life. A basic diagnostic work up is sufficient to characterize the different manifestations of anorectal disorders in most of the cases. This includes patient history with daily stool protocol, clinical and endoscopic investigation. Follow-up investigations include anorectal manometry, anal sphincter-EMG, conduction velocity of the pudendal nerve, needle-EMG, barostat investigation, defecography and the dynamic MRT. Therapeutic interventions are focussed on the individual symptoms and should be provided in close cooperation with gastroenterologists, surgeons, gynecologists, urologists, physiotherapeutics and psychologists (nutritional-training, food fibre content, pharmacological treatment of diarrhea/constipation, toilet-training, pelvic floor-gymnastic, anal sphincter training, biofeedback). Indication for surgical therapy is rarely seen and should be decided only after complete diagnostic work-up and only when all conservative treatment options have failed. Surgical treatment should be provided only in experienced clinical centres.

[Treatment of anorectal diseases]

HAEMORRHOIDAL DISEASE: Stage orientated treatment of haemorrhoidal disease using conservative and operative measures provides high healing rates with low complication- and recurrence rates. ANAL FISSURE: Muscle relaxing ointments (Nitrates, Ca-channel-blocker) are the treatment of choice for chronic anal fissure. In cases of insufficiency fissurectomy provides high healing rates. ABSCESS AND ANAL FISTULA: Anal fistulae are treated with respect of their involvement of the anal sphincters. Distal fistulae are completely excised reaching high healing rates, proximal fistulae are treated using local flap procedures with healing rates reaching 50 to 80%. ANAL INCONTINENCE: Treatment of anal incontinence is depending on the severity and on the etiology of the disease. The following procedures are used: conservative: improving consistency, physical exercises, electrostimulation Biofeedback-Training surgical: Sphincterreconstruction, Pre-anal Repair, Post-anal Repair, Total Pelvic Floor Repair, Dynamic Graciloplasty, Artificial Anal Sphincter, Sacralnervestimulation, Stoma

Bowel symptoms in women planning surgery for pelvic organ prolapse

OBJECTIVE

The objective of the study was to measure associations between bowel symptoms and prolapse.

STUDY DESIGN

Baseline data were analyzed from 322 women in the Colpopexy And Urinary Reduction Efforts trial of sacrocolpopexy with or without Burch colposuspension. Women completed the Colorectal-Anal Distress Inventory and Colorectal-Anal Impact Questionnaire and underwent Pelvic Organ Prolapse Quantification. Associations between symptoms and questionnaire scores and Pelvic Organ Prolapse Quantification measures were assessed.

RESULTS

Mean age was 61 +/- 10 years. Pelvic Organ Prolapse Quantification stages were II (14%), III (67%), and IV (19%). Colorectal-Anal Distress Inventory symptoms did not increase with prolapse stage. Colorectal-Anal Distress Inventory obstructive subscale scores were higher in stage II women (median 29 [interquartile range 8,92] versus 17 [0,33] and 25 [0,38] for stages III and IV, respectively; adjusted P = .01). The few statistically significant correlations between symptoms and vaginal descent were negative and weak (less than 0.2).

CONCLUSION

Bowel symptoms and questionnaire scores do not increase with prolapse stage in women presenting for sacrocolpopexy.

[A case report: Severe bone marrow suppression caused by 6-mercaptopurin in Crohn's disease patient]

A 23-year-old man was admitted for treatment of acute exacerbation of ileitis and perianal abscess caused by Crohn's disease. After incision and drainage of the abscess, coupled with antibiotic therapy, 6-mercaptopurine (6-MP) was commenced. His white blood cell (WBC) count on day 12 after initiation of 6-MP was not decreased. However, on day 24 he was re-admitted because of severe myelosuppression (WBC: 300/microl), which was complicated by the recurrence of the perianal abscess. Myelosuppression was prolonged and required the administration of granulocyte colony stimulating factor (G-CSF). G-CSF was continued for 17 days to achieve recovery of his WBC count to a normal level.

[Severe (RTOG grades 3 or 4) long-term complications of adjuvant radiotherapy after total prostatectomy]

OBJECTIVE

Study of the incidence of severe long-term gastrointestinal (GI) and genitourinary (GU) complications of conformal radiotherapy after total prostatectomy for localized prostatic adenocarcinoma.

MATERIAL AND METHOD

From 1991 to 2000, 114 patients with a mean age of 62 years (range: 45-82 years) were treated by total prostatectomy followed by adjuvant radiotherapy. The mean dose of radiotherapy was 65 Gy (range: 58-72 Gy). The mean interval between prostatectomy and radiotherapy was 10 months (range: 2-28 months). Patients were reviewed every 6 months. We studied severe complications (RTOG grade 3 or 4) occurring after treatment. The mean follow-up was 74 months (range: 32-132 months).

RESULTS

Eight patients (7%) treated by adjuvant radiotherapy with a mean dose of 65.5 Gy (range: 59-70 Gy) developed long-term severe complications. The mean time to onset of complications was 25 months (range: 5-72 months). Three patients developed gastrointestinal complications (2 cases of radiation proctitis and 1 anal stricture). Five patients developed genitourinary complications (4 cases of radiation cystitis and 1 urethral stricture). These eight patients received multiple transfusions and required surgical or endoscopic procedures. Most patients were hospitalized on several occasions for periods ranging between 3 days and 1 month.

CONCLUSION

Adjuvant radiotherapy after total prostatectomy is associated with severe long-term complications in 7% of cases. When they occur, these complications generally require repeated major urological and gastrointestinal surgery.

Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients

BACKGROUND

Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area. Studies on the epidemiology of causative factors are rare.

METHODS

Over a 4-year period we prospectively studied 126 patients with a presumptive diagnosis of anal eczema. The diagnostic algorithm comprised medical history, inspection, microbiology, laboratory chemistry, patch tests, proctoscopy, and biopsy if appropriate.

RESULTS

The age range was 7-82 years and the majority of patients were male (57.1%). Periods of anal symptomatology ranged from 6 days to 120 months and most of the patients (51.6%) had complaints for more than 12 months. The clinical diagnosis in 68 patients (54%) was: intertrigo/candidiasis (42.9%), atopic dermatitis (6.3%), pruritus ani (5.6%), psoriasis (3.2%), skin atrophy from steroid use (2.4%), lichen sclerosus et atrophicus (n = 2), herpes simplex (n = 1), and condylomata acuminata (n = 1). Contact eczema was suspected in 58 patients (46%), but 25 of these (43.1%) showed no contact sensitization.

CONCLUSION

The majority of patients with symptoms of anal eczema suffer from intertrigo/candidiasis, and relevant, causative contact sensitization may be found in only some of them. Patch-testing is a valuable investigative tool only when the patients' own products are included in the test series. Most patients suffer from their perianal complaints for more than 12 months, therefore diligent evaluation is warranted.

New Zealand's early experience in stapled haemorrhoidopexy

AIM

Stapled haemorrhoidopexy is being increasingly integrated into the available options for treatment of haemorrhoidal disease. This study aimed to investigate the postoperative complications encountered in New Zealand up to December 2003.

METHOD

A postal survey was conducted of surgeons who perform stapled haemorrhoidopexy in New Zealand.

RESULTS

28 of 29 surgeons responded. Reports on complications, including postoperative bleeding, urinary retention, sepsis, rectovaginal fistula, faecal incontinence, faecal urgency, anal stricture and persistent anal pain, and incidence of residual disease were encouraging and comparable with other studies.

CONCLUSION

Stapled haemorrhoidopexy is becoming increasingly accepted by New Zealand surgeons as data and experience continue to be reassuring on the safety and efficacy of the procedure.

delta-Storage pool disease: a pitfall in the forensic investigation of sudden anal blood loss in children: a case report

We present the case of a 3.5-year-old boy with sudden anal blood loss at school. Sexual abuse was suspected, and, apart from anal fissures seen on sigmoidoscopy, no other clinical signs of any sort of disorder were present. As no medical explanation for the blood loss could be given, penetrating anal trauma was suggested. During follow-up consultations, there were complaints of occasional blood loss. Platelet aggregation tests and electron microscopy finally helped diagnose a delta-storage pool disease which is a rare haemostatic disorder involving the dense granules of the platelets. Although exclusion of well-known blood diseases through routine laboratory testing is a common practice in children with sudden blood loss, this case illustrates the value of more specialised investigation both from a diagnostic and forensic point of view.

Perianal ulceration: a case of tuberculosis cutis orificialis

BACKGROUND

Tuberculosis cutis orificialis is an extremely rare variant of cutaneous tuberculosis. Perianal location is a possible site of presentation.

METHODS

We describe the management of a young male with a painless non-specific perianal ulcer, who presented an asymptomatic disseminate pulmonary and intestinal tuberculosis. He had a history of pulmonary sarcoidosis and long-term corticosteroid therapy.

RESULTS

Healing of the ulcer was achieved after three-drug antituberculous therapy, with an improvement of the radiographic pulmonary alterations.

CONCLUSIONS

Tuberculous origin should be considered in persistent perianal ulcers to avoid delays in the treatment of this rare form of tuberculosis.

Diagnosis of anal sphincter tears to prevent fecal incontinence: a randomized controlled trial

OBJECTIVE

Maternal anal sphincter tears after vaginal delivery are frequently not diagnosed clinically and are associated with subsequent fecal incontinence. This study examined whether diagnosis of these tears by ultrasonography, followed by immediate surgical repair, reduces the occurrence of incontinence.

METHODS

We conducted a randomized trial involving 752 primiparous women without a clinically evident anal sphincter tear to evaluate the benefit of adding endoanal ultrasonography immediately after vaginal delivery to the standard clinical examination of the perineum. When a sphincter tear was diagnosed, the perineum was surgically explored and the sphincter sutured. The main outcome evaluated was fecal incontinence 3 months postpartum graded by the Wexner incontinence scale, which measures incontinence to flatus and liquid or solid stools, need to wear a pad, and lifestyle alterations.

RESULTS

Among women assessed by ultrasonography, 5.6% had a sphincter tear. Severe incontinence was reported 3 months after childbirth by 3.3% of women in the intervention group compared with 8.7% in the control group (risk difference -5.4%; 95% confidence interval -8.9 to -2.0; P = .002). The benefit of the intervention persisted 1 year after delivery, with 3.2% severe incontinence in the intervention group compared with 6.7% in the control group (risk difference -3.5%; 95% confidence interval -6.8% to -0.3%; P = .03). Ultrasonography needs to be performed in 29 women to prevent 1 case of severe fecal incontinence.

CONCLUSION

Ultrasound examination of the perineum after childbirth improves the diagnosis of anal sphincter tears, and their immediate repair decreases the risk of severe fecal incontinence.

LEVEL OF EVIDENCE

I.

Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis--an effective but not risk-free procedure: a prospective study of 33 patients

PURPOSE

This prospective study evaluated the efficacy and safety of local formalin application in chronic refractory radiation-induced hemorrhagic proctitis.

METHODS

All patients were treated under anesthesia by direct application of 4 percent formalin to the affected rectal areas.

RESULTS

The study included 33 patients (17 women) and was conducted between January 1994 and December 2001. There were 11 anal cancers (33 percent), 11 prostate cancers, 9 cervical or endometrial cancers, 1 bladder cancer, and 1 rectal cancer. The mean number of daily rectal bleeds was 2.7 (range, 0.5-15). Nineteen patients (58 percent) were blood transfusion dependent. Twenty-three patients had only one formalin application and 10 patients required a second application because of the persistent bleeding. The treatment was effective in 23 cases (70 percent): 13 patients had complete cessation of bleeding and 10 patients had only minor bleeding. Six anal or rectal strictures occurred: 4 patients had been treated for anal cancer (36 percent) and 2 patients had been treated for other cancers (9 percent). None of the strictures was malignant. Anal incontinence worsened in 5 patients of the 11 who had been treated for anal cancer (45 percent) and occurred in 4 of the 22 other patients (18 percent).

CONCLUSION

Formalin application is an effective treatment for chronic radiation-induced hemorrhagic proctitis. However, local morbidity is not negligible. This result may be related to the high proportion of anal cancers in the series. In our opinion, therefore, formalin application should be reserved for severe hemorrhagic proctitis refractory to medical treatment and should be thoroughly discussed in cases of anorectal radiation-induced stricture, prior anal incontinence, or treated anal cancer.

Ferguson hemorrhoidectomy: long-term results and patient satisfaction after Ferguson's hemorrhoidectomy

PURPOSE

Perioperative morbidity and long-term results after hemorrhoidectomy (Ferguson's technique) were evaluated as a basis for comparison with new methods such as stapled hemorrhoidectomy.

METHODS

All records of patients who underwent conventional hemorrhoidectomy between January 1, 1993 and December 31, 1997 (five years) were retrospectively analyzed. The surgical technique was Ferguson closed hemorrhoidectomy. Long-term results were evaluated with a standardized questionnaire that was sent to all patients.

RESULTS

Five-hundred-fourteen patients (195 female, 319 male) with a mean age of 52 (range, 22-96) years were evaluated. Postoperatively, seven patients had a relevant hemorrhage, and two had to undergo reoperation (reoperation rate within 30 days, 0.4 percent). In 15 cases (3 percent) patients received urinary catheters for postoperative urinary retention. Mortality was 0 percent. The questionnaire was returned by 403 patients (78.4 percent). The mean follow-up was 4.7 (range, 2.1-7.8) years. The leading symptom was relieved in 275 patients (67.4 percent), ameliorated in 111 (27.2 percent), and unchanged or worse in 22 (5.4 percent). Incontinence (soiling) was not present in 291 (71.7 percent) patients, light in 86 (21.2 percent), moderate in 25 (6.1 percent), and severe in 4 (0.98 percent). Reoperation rate for recurrent hemorrhoids was 0.8 percent. Patients evaluated the surgical result as excellent in 286 (70.5 percent) cases, good in 87 (21.4 percent), moderate in 25 (6.2 percent), and bad in 8 (1.9 percent) cases.

CONCLUSION

Ferguson closed hemorrhoidectomy results in very low rates of perioperative morbidity. Long-term results demonstrate high patient satisfaction and low incontinence and reoperation rates. It could be the gold standard to which other techniques are compared.

Fecal incontinence: a review of prevalence and obstetric risk factors

Anal incontinence (AI) is a significant problem that causes social and hygienic inconvenience. The true prevalence of AI is difficult to estimate due to inconsistencies in research methods, but larger studies suggest a rate of 2-6% for incontinence to stool. There is a significant association between sonographically detected anal sphincter defects and symptoms of AI. The intrapartum factors most consistently associated with a higher risk of AI include: forceps delivery, third or fourth degree tears, and length of the second stage of labor. Fetal weight of > 4,000 g is also associated with AI. Repair of the sphincter can be performed in either an overlapping or an end-to-end fashion, with similar results for both methods. The role of cesarean delivery for the prevention of AI remains unclear, and further study should be devoted to this question.

Prévalence des condylomes anaux chez les patients infectés par le VIH

BACKGROUND

In the general HIV-infected population, there are few data on the prevalence and risk factors for anal condyloma, precursor lesions for anal cancer.

METHODS

Screening for perianal and endoanal condyloma with an anoscopy was systematically proposed to 516 consecutive outpatients, followed in a university hospital in Paris. For each point, HIV characteristics and sexual behaviors assessed through semi-directive questionnaire were collected.

FINDINGS

The 473 (92%) examined patients, consisted of 200 homosexual men, 123 heterosexual men, 150 women; 76% were receiving HAART, HIV-RNA was<50 copies/ml in 60%, mean (+/-SD) CD4 cell count were 484 (+/-274)/mm(3). Overall, 108 (23%) pts had histologically-confirmed anal condyloma (36, 15 and 11% of the respective populations), including 51 (47%) pts with only endoanal localisation. Intraepithelial neoplasia of grade I was noted in 59 patients, of grade II in 10 and of grade III in 2 and an invasive endoanal cancer in 1. In multivariate regression analysis, condyloma independent risk factor were history of gonococcia or syphilis (OR=0.54 (0.29-0.99)), and history of previous anal condyloma (OR=2.05 (1.07-3.92) in homosexual men, history of previous penis condyloma (OR=26.8 (2.3-309.6), and unprotected sexual intercourse (OR=7.5 (2.1-26.3)) in heterosexual men and CD4 cell count below 200/mm(3), (OR=8.9 (1.5-51.6)), receptive anal intercourse (OR=6.7 (1.7-25.8)) and history of previous anal condyloma (OR=25.4 (3.4-188.2)) in women.

INTERPRETATION

In the HAART era, systematic screening revealed a high rate of anal condyloma in all HIV positive pts (not only in homosexual men). Anal examination should be proposed systematically to all HIV-infected patients.

Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques

OBJECTIVE

This study was undertaken to compare surgical techniques for the primary repair of obstetric anal sphincter lacerations.

STUDY DESIGN

Patients with complete third- or fourth-degree lacerations were recruited and randomly assigned to either an end-to-end or overlapping repair. Data collection included demographic data, obstetric history, and intrapartum events. Postpartum, women completed incontinence questionnaires and underwent physical and ultrasound examinations. To detect a 36% difference between groups with an alpha = .05 and beta = .20, 30 patients were required. Data were analyzed with Student t test and chi2 analysis.

RESULTS

Forty-one women were randomly assigned; 23 to an end-to-end and 18 to an overlapping repair. Twenty-seven percent of women underwent episiotomy and 61% operative vaginal delivery. Follow-up was limited to 26 of 41 patients. On physical examination, 3 patients had a separated anal sphincter. On ultrasound, overall 85% of patients had intact sphincters, with no difference between groups (all P > .05). Forty-two percent of women complained of anorectal symptoms with no differences between groups (all P > .28).

CONCLUSION

We found no difference in anal incontinence symptoms, physical examination, or translabial ultrasonography findings between the 2 groups. Incontinence symptoms were common in both groups.

Anti-TNF-alpha (infliximab) used as induction treatment in case of active proctitis in a multistep strategy followed by definitive surgery of complex anal fistulas in Crohn's disease: a preliminary report

PURPOSE

This study was designed to assess the healing rate of complex perianal fistulas in Crohn's disease after a multistep strategy, including induction treatment with Infliximab in case of active proctitis, followed by definitive surgery.

METHODS

From 2000 to 2003, all consecutive patients with complex fistulas and Crohn's disease underwent pretreatment with noncutting setons and, in case of severe recurrent fistulas or abscesses, a diverting stoma. Infliximab was added in cases of active proctitis. After definitive surgical treatment, patients were examined.

RESULTS

Seventeen patients were included (median age, 34 (range, 22-58) years). Seven patients were treated by surgery only, and in ten patients Infliximab was added. After a median follow-up of 19 (range, 8-40) months, fistula healing was observed in 17 patients (100 percent). One patient of the Infliximab group developed a recurrent fistula (10 percent) after 24 months, and in one patient (10 percent) soiling occurred. Two patients of the surgical group developed a recurrent fistula (29 percent) and soiling occurred in two patients (29 percent).

CONCLUSIONS

A multistep strategy followed by definitive surgery for the treatment of complex perianal fistulas in patients with Crohn's disease is a promising treatment modality. The preliminary results of this study suggest that Infliximab treatment has a beneficial additive effect in the multistep treatment followed by definitive surgery of complex anal fistulas and active proctitis in Crohn's disease.

Local injection of Infliximab for the treatment of perianal Crohn's disease

PURPOSE

Perianal disease is a serious complication of Crohn's disease and its surgical management is still controversial. It has been suggested that the local injection of infliximab has resulted in some potential benefit. This pilot study analyzed the feasibility and safety of such therapy in selected patients with severe perianal Crohn's disease.

METHODS

The study included 15 patients with complex perianal Crohn's disease in which sepsis was not controllable using surgical and medical therapy. Among them, four had previously undergone intravenous infusion of infliximab with no significant response, nine had contraindications for intravenous infusion, and two had associated stenosing ileitis and severe coloproctitis. The injection of 15 to 21 mg of infliximab, associated with surgical treatment, was performed at the internal and external orifices and along the fistula tract. Efficacy was measured by a complete morphologic evaluation using a personal score.

RESULTS

No major adverse effects were reported. Ten of 15 patients healed after 3 to 12 infusions.

CONCLUSIONS

Local injection of infliximab adjacent to the fistula tract of perianal Crohn's disease is safe and may help in fistula healing. A controlled, randomized trial is required to prove the value.