Common anorectal conditions: evaluation and treatment

The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure

INTRODUCTION

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.

METHODS

A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.

CONCLUSIONS

In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

A Pain in the Butt: Hemorrhoids, Fissures, Fistulas, and Other Anorectal Syndromes

Painful and bothersome anorectal syndromes can be a diagnostic and therapeutic challenge for clinicians because structural and functional abnormalities may often coexist and require a multidisciplinary approach to management. Although it is often difficult to attribute all of a patient's anorectal symptoms to a singular disorder with definitive intervention and cure, improving quality of life, treating coexistent conditions such as functional constipation and/or defecation disorders, addressing psychological comorbidities if present, and confirming there is no evidence of inflammatory or malignant conditions are top priorities.

Video anoscopy: results of routine anal examination during colonoscopies

Background and study aims  Anal examination and video anoscopy (VA) are rarely performed during colonoscopies. The aim of this study is to demonstrate that anal examination and VA provide important information in all routine colonoscopies. Patients and methods  A cross-sectional study was conducted on 12,151 patients screened by VA which were performed during routine outpatient colonoscopy between 2006 and 2018. The aspects studied were: normal examination; hemorrhoidal disease; thrombosed hemorrhoids; anal fissure; perianal Crohn's Disease; perianal fistula; condyloma; polyps; neoplasms; stenosis; bleeding. Results  Of the colonoscopies performed on 12,151 patients, 9,364 cases (77.06 %) presented some alterations. Internal I degree hemorrhoids (5911 - 48.65 %); internal hemorrhoids of II, III and IV degrees (2362 - 19.44 %); thrombosed hemorrhoids (120 - 0.99 %); bleeding (56 - 0.46 %); fissure (415 - 3.42 %); perianal fistula (42 - 0.35 %); perianal Crohn's Disease (34 - 0.28 %); condylomas (18 - 0.15 %); anal stenosis (30 - 0.25 %); other findings (310 - 2.55 %); polyps (62 - 0.51 %), one of which was adenomatous with high-grade dysplasia; four cases of anal canal neoplasia (0.03 %): two cases of squamous cell carcinoma and two cases of adenocarcinoma. Conclusion  The association of routine video anoscopy during colonoscopy improved diagnosis of neoplastic anal lesions, allowed correct classification of the degree of hemorrhoidal disease, helped to confirm the bleeding site and detected other anal pathologies. The main findings were hemorrhoidal diseases, fissures and perianal fistulas. The study suggests that VA should be used in all colonoscopies.

Application of 'tying, binding and fixing operation' in surgical treatment of severe mixed hemorrhoids

The aim of the present study was to examine the clinical value of ‘tying, binding and fixing operation’ in treating severe mixed hemorrhoids. A total of 160 patients with severe mixed hemorrhoids were selected and randomly divided into the experimental (n=80) and control (n=80) groups. The groups were treated using ‘tying, binding and fixing operation’ and Doppler ultrasound-guided hemorrhoidal artery ligation (DG-HAL), respectively. The results showed that the average operative time of the experimental group (35.57±6.17) was significantly higher than that of the control group (12.73±4.92). There was no significant difference of blood loss during the operation between the two groups (P>0.05). There was also no significant difference in improving the hemorrhage symptom between the two groups (P>0.05). In addition, concerning improvement of prolapse symptoms and reduction of the volume of hemorrhoids, the experimental group were significantly improved as compared to the control group. No anal function damage in the two groups was identified, and the length of stay in hospital for the two groups was not significantly different (P>0.05). However, the hospitalization cost in the experimental group (5,334.77±875.54) was significantly lower than that of the control group (8,551.81±1,806.54) and satisfaction degree was significantly higher than that of the control group. The incidences of perianal pain, anal edema and dysuria between two groups were not significantly different (P>0.05). There were 10 cases of secondary hemorrhage and 18 cases of infection in the experimental group, and 12 cases of secondary hemorrhage and 14 cases of infection in the control group, although the differences between the two groups were not statistically significant (P>0.05). The incidence rate of local hematoma in the experimental group (1.2%) was significantly lower than that in the control group (15.0%). The recurrence rate of the control group (22.5%) was also significantly higher than that of the experimental group (2.5%). In conclusion, tying, binding and fixing operation is a promising method that may be employed for the treatment of sever mixed hemorrhoids, and it is better than DG-HAL in improving the prolapse and reducing the volume of hemorrhoids.

Female perineal diseases: spectrum of imaging findings

The female perineum, which is divided into the anterior urogenital triangle and the posterior anal triangle, is a surface structure often overlooked. Female perineal diseases may present with nonspecific clinical signs due to its close anatomical relationship between the different compartments. Diagnosis of the origin of a perineal disorder may also be a difficult problem encountered in pelvi-perineal imaging. Therefore, a precise knowledge of the female perineal anatomy and the associated disease processes is essential to radiologists, pathologists, and surgeons alike who are involved in the evaluation of the patient who presents with a perineal mass. Cross-sectional imaging plays a crucial role for proper management. Due to the robust contrast resolution of MR, MR imaging is the modality of choice for evaluation of the extent of a complex perineal lesion, its relationship to the adjacent structures. It has a greater sensitivity and specificity for the diagnosis than the other non-invasive imaging techniques and is helpful in guidance for surgical planning. The purpose of this article is to highlight the spectrum of imaging findings of female perineal diseases.