Anal disorders in pregnant and postpartum women: epidemiological, diagnostic and therapeutic aspects in 10 maternities of Bamako in Mali

Bowel transit disturbances favored by pregnancy and injuries during childbirth would be triggering or aggravating factors for anal pathologies. The objective of this work was to study the epidemiology, diagnosis, and treatment of anal pathologies during pregnancy and 6 weeks after delivery. We carried out a prospective, multi-centric, and analytical study in 10 obstetric units in Bamako from June 1st, 2019, to May 31st, 2020. After informed consent, we enrolled all first-trimester pregnant women admitted to the hospitals and who were followed up through the postpartum. We conducted a rectal examination in each participant and an anoscope in those with an anal symptom. Hemorrhoidal diseases were diagnosed in the case of external hemorrhoids (thrombosis or prolapse) or internal hemorrhoids. During the study period, we followed up 1,422 pregnant women and we found 38.4% (546) with anal pathologies (hemorrhoidal diseases in 13% (192), anal fissure in 10.5% (150) and anal incontinence in 8.6% (123). Risk factors for the hemorrhoidal disease were age of patient ≥30 years old aRR=5.77, 95% CI 4.57-7.34; p=0.000; a existence of chronic constipation aRR=2.61, 95% CI 1.98-3.44; p=0.000; newborn weight >3500 g aRR= 1.61, 95% CI 1.25-2.07; p=0.000 and fetal expulsion time >20 minutes aRR= 6.04, 95% CI 5.07-7.27; p=0.000. The clinical signs observed were constipation, anal pain, bleeding, and pruritus. The treatment was based on counseling on hygiene and diet, the use of laxatives, local topicals, and analgesics along perineal rehabilitation. Anal pathologies were common during pregnancy and 6 weeks after delivery. Pregnant women must be screened systematically for such pathologies. Early diagnostic and appropriate treatment would reduce serious complications.

Incidence and Characterization of Rectal Complications From Fecal Management Systems

BACKGROUND

Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature.

OBJECTIVE

The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at a large academic medical center.

PATIENTS

All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included.

MAIN OUTCOME MEASURES

We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy.

RESULTS

A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy.

LIMITATIONS

The study was limited by its retrospective design and single institution.

CONCLUSIONS

This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698.

INCIDENCIA Y CARACTERIZACIN DE LAS COMPLICACIONES RECTALES DE LOS SISTEMAS DE MANEJO FECAL

ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.

Conservative Management of Chronic Anal Fissure. Results of a Case Series at 2-years Follow-up and Proposition of a New Classification

BACKGROUND

Anal fissure is a common proctological condition that is usually defined as an anodermal ulcerative process starting from the posterior commissure to the dentate line. The objective of this study was to evaluate the resolution rate of anal fissure through the use of conservative management in patients grouped according to our newly proposed classification. A secondary purpose was to quantify the recurrence rates at 2-years follow-up in each group.

METHODS

A retrospective analysis was carried out on patients in our general database. Diagnosis was based on symptoms, clinical observation, anal manometry and transanal ultrasounds. After application of inclusion and exclusion criteria, patients were assigned to different groups. Follow-up was carried out at 3, 6, 12 and 24 months.

RESULTS

A total of 136 patients (54 female and 82 male) were included in the statistical analysis. At the end of the treatment period, all patients in groups 1 and 2 had a complete resolution of illness and a normal basal sphincterial tone, while those in groups 3 and 4 had a higher rate of recurrence at the 2-year follow-up.

CONCLUSION

Based on our series, we propose a definitive non-surgical management for all group 1 and 2 anal fissures according to our protocol. For groups 3 and 4, we recommend a primary non-surgical approach with follow-up. This was a retrospective study and further randomized controlled studies will be necessary to confirm our results.

Non-surgical treatments for anal fissure in adults

An anal fissure is defined as a linear tear or ulcer of the anal mucosa. Patients typically describe a sharp pain 'like passing broken glass' on defaecation, followed by a burning pain in the anus lasting a few hours. Pain and bleeding during and after the passage of stool are the usual presenting features. Fissures are most common in young to middle-aged adults and are also commonly seen in pregnant and postpartum women. The lifetime incidence of anal fissure is around 11%. Here, we review the evidence on the efficacy and safety of non-surgical treatments for anal fissure.

Anal fissures in infants may be a pathognomonic sign of infants with cow's milk allergy

OBJECTIVE

To study the association between analfissures and cow's milk allergy (CMA) in infants. METHODS AND METHOD: In a prospective study, 72 confirmed cases of CMA in infants were examined for anal fissure by pediatricians with five years' experience. A positive finding was defined as when an anal fissure was detected by at least two out of three examiners.

RESULTS

Of infants with CMA with and without gastrointestinal GI symptoms, 79% and 83% had anal fissures, respectively The prevalence of anal fissure in these infants is significantly higher than in normal infants.

CONCLUSION

Anal fissure may be a pathognomonic sign of cow's milk allergy in infants.

Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal

BACKGROUND

The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years.

METHODS

Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment.

RESULTS

Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications.

CONCLUSIONS

Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.

Why the most potent toxin may heal anal fissure

An anal fissure is a painful linear ulcer in the lower part of the anal canal. It is very often referred to as an ischemic ulcer. Anodermal blood flow is negatively correlated with resting pressure of the anus. Increased activity of the internal anal sphincter may decrease the anodermal blood supply by compressing arterioles. Surgical procedures and botulinum treatment for patients with chronic anal fissure produce a temporary reduction in anal pressure, reverse sphincter spasm, and promote fissure healing. However, recent studies have shown that fissure healing does not appear to be dependent on reduction in mean resting anal pressure. On the basis of the published literature, this article attempts to explain this phenomenon in detail. The mechanism of action of botulinum toxin on the internal anal sphincter is not yet fully understood. This review focuses on problems associated with anal fissure treatment and presents them from the wider angle of science about botulinum toxin. In our opinion, anodermal blood flow depends not only on the "mechanical" force of sphincters but also on biochemical processes that occur in the fissure region.

Risk factors associated with hemorrhoidal symptoms in specialized consultation

Epidemiology and risk factors of hemorrhoidal disease are not well defined.

AIMS AND METHODS

Past history and events occurring during the last two weeks before a medical visit for acute hemorrhoidal symptoms were analyzed and compared with controls consulting for any other diagnosis without exclusion.

RESULTS

Among complete inquiries returned by 931 private gastroenterologists, files from 1033 patients (542 males) and 1028 controls (504 males) were randomly selected. Hemorrhoidal disease patients were younger (47 +/- 14.5 vs. 52 +/- 16.5 yrs; P<0.0001); sex ratio was not different from controls. Factors significantly associated with hemorrhoidal crisis were: past history of hemorrhoidal symptoms, age<50 yrs, past history of anal fissure, occupational activity (OR 5.17; 1.95; 1.72; 1.43; P<0.1) and recent unusual events: spicy diet, constipation, physical activity, alcohol intake (OR 4.95; 3.93; 2.79; 1.99; P<0.1). Stress protected against hemorrhoids (OR 0,49; P<0.0001). For women aged less than 40 yrs, no significant risk factor related with genital activity was found for hemorrhoidal disease.

CONCLUSION

For young patients, especially those with a past hemorrhoidal history, spice or alcohol intake and constipation are risk factors for hemorrhoidal crisis. For young women, prevention is essentially based on treatment of constipation associated with genito-obstetrical events.

Magnetic resonance imaging of perianal fistulas

Most cases of fistula-in-ano are nonspecific and result from inflammation of anal glands and crypts (cryptoglandular). The classification of cryptoglandular fistulas depends on the degree of involvement of the anal sphincter complex and determines the type of treatment. Studies have shown that preoperative MR imaging revealed important additional information compared with surgery alone and better predicts clinical outcome of patients with fistula-in-ano than initial surgical exploration. With the emergence of novel surgical treatments like MRI-guided surgery, laser, and adhesive treatments, MR imaging is a mainstay for preprocedural and intraoperative evaluation to ensure the adequacy of the procedure.

Cows milk consumption in constipation and anal fissure in infants and young children

OBJECTIVE

To examine daily cows milk consumption and duration of breastfeeding in infants and young children with anal fissure and constipation.

METHODS

Two groups of 30 consecutive children aged between 4 months and 3 years were evaluated retrospectively. Group I comprised children with chronic constipation and anal fissure in whom surgical causes were excluded, and group II comprised normal children. The daily consumption of cows milk, duration of breastfeeding and other clinical features of the children were investigated

RESULTS

The mean daily consumption of cows milk was significantly higher in group I (756 mL, range 200-1500 mL) than group II (253 mL, range 0-1000 mL) (P < 0.001). Group I children were breastfed for a significantly shorter period (5.8 months, range 0-18 months) than group II (10.1 months, range 2-24 months) (P < 0.006). The odds ratios for the two factors - children consuming more than 200 mL of cows milk per day (25 children in group I, 11 children in group II) and breastfeeding for less than 4 months (16 children in group I, 5 children in group II) - were calculated to be 8.6 (95% confidence interval [CI]: 0.23-0.74, P = 0.0005) and 5.7 (95% CI: 0.37-0.66, P = 0.007), respectively.

CONCLUSIONS

Infants and young children with chronic constipation and anal fissure may consume larger amounts of cows milk than children with a normal bowel habit. Additionally, shorter duration of breastfeeding and early bottle feeding with cows milk may play a role in the development of constipation and anal fissure in infants and young children.

[Epidemiology of anal lesions (fissure and thrombosed external hemorroid) during pregnancy and post-partum]

Thrombosed external hemorrhoids (TEH) and anal fissure (AF) are 2 frequent sources of anal pains during childbirth. We are going to define their incidences as available in publications and in our experience in Bichat hospital. Then we will define their risk factors. According to Martin's and Corby's studies, AF was observed in 10% of the delivered women. In Bichat hospital we performed a proctological assessment to 165 pregnant women during the last third of pregnancy and within the 2 months following delivery. We observed 2 AF (1,2%) during the first period and 25 (15,2%) during the second. Rouillon et al. reported an incidence of TEH in 12,2% (20/164), while Pradel and al. reported 34% (18/52) of it. In Bichat hospital, 13 women (7,9%) were presenting with TEH during the last third of pregnancy and 33 (20%) in post-partum period. Two studies looked for a statistical correlation between AF and obstetrical, foetal or maternal factors. Corby et al. only pointed the role of constipation. In our study, terminal constipation was the most important risk factor for AF with 5.7 (2.7-12), odds ratio (95% confidence intervals). Rouillon et al. observed more TEH among women with a prolonged first stage labor and a big baby. In our study, a big baby and mother little lips tears were observed more often among women with TEH (P <0,05). Also, we observed only one TEH among the 25 women with caesarean section (4%). Finally, observation that TEH arise immediately after delivery is another argument to support the role of traumatic delivery. We also demonstrated the role of terminal constipation as risk factor for TEH after delivery. To conclude, 1/3 of pregnant women develop AF or TEH after delivery. These 2 pathologies are strongly correlated to terminal constipation. TEH seems equally furthered by traumatic delivery.

Anal fissure and thrombosed external hemorrhoids before and after delivery

PURPOSE

Thrombosed external hemorrhoids and anal fissures are common and are responsible for severe discomfort during childbirth. However, the real incidence of these lesions is unknown. The aim of our study was to evaluate their incidence and the risk factors for these lesions during childbirth.

METHODS

A prospective study with proctologic examination during the last 3 months of pregnancy and after delivery (within 2 months) was performed in 165 consecutive pregnant females.

RESULTS

Fifteen females (9.1 percent) with anal lesions (13 thrombosed external hemorrhoids and 2 anal fissures) were observed during pregnancy. Fifty-eight females (35.2 percent) with anal lesions (33 thrombosed external hemorrhoids and 25 anal fissures) were observed during the postpartum period. Ninety-one percent of thrombosed external hemorrhoids were observed during the first day after delivery, whereas anal fissures were distributed, with no peak, over the two months after delivery. The 2 independent risk factors for anal lesions (among obstetric, baby's, and mother's information) were dyschezia, with a 5.7 odds ratio (95 percent confidence interval, 2.7-12), and late delivery, with a 1.4 odds ratio (95 percent confidence interval, 1.05-1.9). Furthermore, many thrombosed external hemorrhoids were observed after superficial perineal tears and heavier babies (P < 0.05). Only 1 of the 33 patients with thrombosed external hemorrhoids who were observed underwent a cesarean section.

CONCLUSION

One third of females have thrombosed external hemorrhoids or anal fissures in the postpartum period. The most important risk factor is dyschezia. Traumatic delivery appears to be associated with thrombosed external hemorrhoids.

Pathophysiology of anorectal dysfunction

Anorectal disorders are the cause of significant discomfort and embarrassment in women. The onset typically follows childbirth and symptoms increase with age. Anal incontinence, rectovaginal fistula, rectal prolapse, anal fissure, and constipation are considered.

[Country-wide survey of therapeutic procedures in hemorrhoids and anal fissure]

A survey among coloproctologists was performed to assess current therapeutic concepts for the treatment of hemorrhoidal disease and anal fissure. A total of 261 clinical and non-clinical proctologists participated, representing the entire range of therapies in hospital and practise. A wealth of widely differing, in some aspects contradictory concepts were recorded, leaving almost no subject entirely undisputed. There are controversies regarding the different therapeutic alternatives as well as indications for surgery and choice of operative procedure. Future research has to address the existing controversies in order to reach a higher degree of standardization in the therapy of these common proctological disorders.

The effect of breakfast on minor anal complaints: a matched case-control study

With the objective of exploring the association between breakfast and minor anal complaints, an age, sex and pregnancy matched case-control study was carried out in the out-patient clinics at Birmingham Heartlands Hospital. Patients were selected after personal interviews using a structured questionnaire in out-patient clinics. Information on age, sex, occupation and breakfast habits, as well as on haemorrhoids and anal fissure, was obtained. Patients who had haemorrhoids or anal fissure were placed in the case group; the remainder were controls. Any patient with diverticulosis, inflammatory bowel disease, colon cancer or bowel resection for any reason was excluded from the study. The main outcome measures were the odds of developing haemorrhoids or fissure in patients who did not eat breakfast. The results are based on 47 cases that were age, sex and pregnancy matched. Of the case group, 36% did not eat breakfast, compared with 11% in the control group. The analysis demonstrated a 7.5-fold increase in the odds of suffering from haemorrhoids or anal fissures in matched subjects who did not eat breakfast, with a very high level of significance (P = 0.0036). This indicates that there is a very strong association between failure to eat breakfast and haemorrhoids or anal fissure. It is anticipated that educating the public to eat breakfast would lead to a long-term fall in the incidence of anal complaints, in the attendant morbidity for the patients and in the cost to the health service.

Re-examination of clinical manifestations and response to therapy of fissure-in-ano

PURPOSE

This study was designed to reassess clinical manifestations of fissure-in-ano, in particular, the frequency of constipation and rate of response to medical management.

METHODS

Records of 876 patients with fissure-in-ano seen between February 1975 and December 1993 were reviewed. Information gathered included age, gender, site, symptoms, bowel habits, associated anorectal problems, response, failure, and recurrence rates.

RESULTS

There were 439 women (51.1 percent) and 437 men (49.9 percent); mean age was 39.9 (range, 13.5-95) years. The fissure was located in the posterior mid line in 644 patients (73.5 percent), the anterior mid line in 144 patients (16.4 percent), both in 23 patients (2.6 percent), and only tenderness documented in 65 patients (7.4 percent). The fissure was located in the anterior midline in 12.6 percent of women and 7.7 percent of men. Dominant presenting symptoms included pain in 90.8 percent and bleeding in 71.4 percent of patients. Infrequent hard bowel movements (> or = 3 days) occurred in only 13.8 percent of patients. Mean follow-up was 26 (range, 0.5-215) months. A total of 44.7 percent of patients responded to nonoperative therapy, 60 percent of them in the first two months; of these, 18.6 percent developed recurrent symptoms. Of the latter group, 60 percent responded to further medical therapy, and 20 percent underwent a lateral internal sphincterotomy. Of the patients who initially did not respond to medical treatment (50.5 percent), lateral internal sphincterotomy was recommended.

CONCLUSION

Anterior fissures are much more common in both men and women than previously reported, and constipation and hard bowel movement are not universally present in patients with fissure-in-ano.

The management of infectious and noninfectious anorectal complications in patients with leukemia

BACKGROUND

Infectious and noninfectious anorectal complications may occur in patients undergoing therapy for leukemia. Controversy surrounds the treatment of this problem in immunocompromised patients.

STUDY DESIGN

A retrospective review of the medical records of 83 patients with acute or chronic leukemia in whom anorectal disease developed during inpatient therapy for leukemia was performed to determine the initial signs and symptoms, treatment, and outcomes.

RESULTS

During a 12-year period, 92 patients with anorectal complications were treated. This series included 25 patients with perirectal abscesses, 22 patients with anal fissures, 18 patients with symptomatic external hemorrhoids, 12 patients with perianal ulcerations, 12 patients with symptomatic internal hemorrhoids, and three patients with fistulas in ano. Overall, 79 (86 percent) of the 92 anorectal complications resolved in 68 of the 83 patients. Increasing periods of neutropenia did not adversely affect the resolution of anorectal disease. Thirteen patients (16 percent) required surgical intervention, most commonly secondary to a perirectal abscess. Incision and drainage was necessary in ten (40 percent) of 25 patients with perirectal abscess, which included five patients with fluctuation and five patients in whom infection failed to respond to medical therapy.

CONCLUSIONS

Noninfectious anorectal complications in patients with leukemia respond to nonoperative intervention and rarely progress to a life-threatening infection. Nonoperative intervention in the form of systemic antibiotics and sitz baths is successful in the treatment of infectious anorectal complications. Incision and drainage should be performed when fluctuation is present and in patients whose complications fail to respond to medical therapy.

Anal cancer incidence: genital warts, anal fissure or fistula, hemorrhoids, and smoking

We conducted a study of 126 patients with anal and rectal squamous cell carcinoma and 372 randomly selected control subjects in the San Francisco Bay Area (CA) to test the hypothesis that these tumors are related to a history of anal intercourse, the presence of sexually transmitted diseases and other conditions of the anal area, treatment of these diseases or conditions, and history of use of cigarettes or other substances. The relative risk (RR) of cancer was elevated for men with a history of homosexual activity (RR = 12.4, P less than .001). However, after adjustment for other risk factors, this risk was reduced to 2.7 (P = .28). Risk was elevated for homosexual male patients who reported a history of genital warts (RR = 12.6, P = .03), anal fissure or fistula (RR = 9.1, P = .05), and cigarette smoking (RR = 1.9 for 20 pack-yr, P less than .001; RR = 5.2 for 50 pack-yr, P less than .001). (Pack-year is a unit of cigarette use equal to 365 packs.) There was also elevated risk for heterosexual male and female patients who reported a history of genital warts (RR = 4.4, P = .003), anal fissure or fistula (RR = 2.4, P = .03), and more than 12 episodes of hemorrhoids (RR = 2.6, P less than .001). These findings suggest that anal cancer risk is etiologically related to human papillomaviruses that cause genital warts. In addition, constant irritation, chronic inflammatory changes, and repeated epithelial regeneration that accompany noninfectious conditions may be related to risk of anal cancer. The higher risk among homosexual men is related to the higher prevalence of anal cancer risk factors for this group.

Anorectal diseases in Western Nigerian adults. A field survey

A survey of anorectal diseases in parts of Western Nigeria was performed by examining 336 adults in various locations. It was concluded that anorectal diseases are more common among the population than is suggested in reviews of hospital cases--a fact largely due to poor health awareness and consequently poor hospital attendance. The fairly generally high prevalence of these diseases does, in fact, mirror holoendemic conditions such as schistosomiasis, amebiasis, and intestinal tuberculosis. In spite of known western influence on food preparation and dietary habits, particularly among the urban dwellers, it is probably too early to expect any impact on bowel habits and large-bowel and anorectal diseases. In view of the significant association, the author suggests than any disturbance in bowel action should prompt a thorough investigation for anorectal diseases.