Background

Anorectal disorders refer to several diseases that manifest in the anorectal area, which includes the anus, rectum, and in some cases, the structures in the surrounding vicinity. These disorders are known to affect the quality of life of an individual owing to symptoms like pain, bleeding, itching, and incontinence. 

Epidemiology

The research findings show that the occurrence of these anorectal disorders is not constant. Still, it is influenced by some factors, such as age, sex, or lifestyle.  

Hemorrhoids 

Current statistics of adults in the United States showed that 4.4 % adults are affected, especially people in the age group of 45- 65 years. 

Hemorrhoids affect 50 percent of the American population by the age of 50; approximate 10.4 million affected in the U.S. 

Anatomy

Pathophysiology

Hemorrhoids 

Hemorrhoids are swollen blood vessels that develop in the lower rectum or anus neck. They occur due to the raised pressures within the pelvic and rectal veins because of pushing during defecation, hard stool, or sitting cross-legged for a very long time or due to pregnancy. This pressure leads to varicosity of the veins, and sometimes they bulge out of the anus. 

Factors: Lack of exercise, side sleep position, long plane travel, age, eating processed foods low in fiber, stress. 

Anal Fissures 

Anal fissures are small lesions that occur at the mucosa of the anal canal and are mainly a result of trauma experienced at the time of defecation through hard and large stools. This trauma results in a tear that can cause severe pain and bleeding. 

Factors: Constipation over a long period, extensive and complex passing feces, Inflammatory bowel diseases, and infections that affect the anus. 

Anorectal Abscesses 

Anorectal abscesses are pus collections localized in the anorectal region, that is, the tissues between the anus and the rectum. They originate from an infection of the glands in the anus that affects other tissues nearby. Not adequately drained, they create a threat of chronic infection or fistula formation. 

Factors: Infection of the anal glands, inflammatory bowel disease that is characterized by Crohn’s disease, and infections that are transmitted through sex. 

Etiology

Congenital Causes: 

• Anorectal Malformations: These are congenital and may range from the imperforate anus or anal atresia These are present from birth. 

Traumatic Causes: 

• Injury or Surgery: Injuries to the anorectal region through accidents or surgery may present complications that include fecal incontinence or narrowing of the bowel. 

Infectious Causes: 

• Sexually Transmitted Infections: Sexually transmitted diseases, including anal warts, whereby are caused by HPV, Syphilis, Gonorrhea, and Chlamydia, are conditions that affect the anorectal region. 
• Bacterial Infections: Such cases as abscesses or fistulas may be caused by bacteria. 

Inflammatory Causes: 

• Inflammatory Bowel Disease (IBD): Diseases such as Crohn’s disease and ulcerative colitis can involve the anorectal area. 
• Proctitis: Causes of rectal inflammation; radiation therapy and Infections can cause inflammation of the rectum. 

Neoplastic Causes: 

• Anal and Rectal Cancer: Tumors and malignancies can develop in the anorectal region. 
• Benign Tumors: Other actual diseases might be traced such as polyps or adenomas. 

Functional Causes: 

• Constipation: They include hemorrhoids, fissures, and rectal prolapse and are a result of chronic constipation. 
• Pelvic Floor Dysfunction: Any dysfunction of the muscles that are involved in the pelvic organs’ support can result in disorders such as fecal incontinence. 

Genetics

Prognostic Factors

• Severity of Symptoms: More severe symptoms often indicate a poorer prognosis without intervention. 
• Type and Location: The extent of abscess (perianal, ischiorectal, etc.) and fistula (intersphincteric, transsphincteric, etc.) determines the outcome of the disease. 
• Stage at Diagnosis: Positive outcomes can be observed in people with stages I and II of cancer, while negative results relate to stages III and IV. 

Clinical History

Age Group: 

It is more commonly diagnosed in adults as compared to children. 

Physical Examination

Anorectal manometry  

Ballon expulsion test 

Defecography 

Colonic transit study 

Age group

Associated comorbidity

Irritable Bowel Syndrome (IBS) 

Pelvic Floor Disorders:  

Anal Fissures 

Chronic Constipation or Diarrhea 

Associated activity

Acuity of presentation

Hemorrhoids: 

• Acute Presentation: Painful, swollen, prolapsed hemorrhoids identified and characterized by a sudden onset. Thrombosis of external hemorrhoids will be very painful. 
• Chronic Presentation: Sometimes, hematologic problems, pain, itching, and swelling around the tumor zone. 

Anal Fissures: 

• Acute Presentation: Constant and sudden pain before, during and after defecation and appearance of blood in stool. 
• Chronic Presentation: Some symptoms include pain that does not disappear after some time, itching, and return of bleeding. 

Anorectal Abscess: 

• Acute Presentation: Persistent stinging pain in the perianal area, painful or swollen glands, redness, fever, and general illness. 
• Chronic Presentation: Recurrent abscesses, fistula formation with intermittent drainage. 

Differential Diagnoses

Perianal Abscess 

Anal Fistula 

Rectal Prolapse 

Anorectal Infections 

Inflammatory Bowel Disease (IBD) 

Anal Cancer 

Proctitis 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Hemorrhoids 

Treatment Options: 

• Lifestyle Changes: Eat more high fiber foods, ensure to take a lot of water, do not force yourself when passing stool. 
• Medications: Topical preparations without prescription like creams, ointments or suppositories. 
• Minimally Invasive Procedures: Rubber band ligation, sclerotherapy, and infrared coagulation. 
• Surgical Procedures: Hemorrhoidectomy, stapled haemorrhoidopexy. 

Anal Fissures 

Treatment Options: 

• Lifestyle Changes: Diet high in fiber, intake of more fluids, and sitz bath. 
• Medications: Topical preparations, creams, and ointments. 
• Surgical Procedures: Lateral internal sphincterotomy. 

Anal Abscess and Fistula 

Treatment Options: 

• Drainage: Chronic subacute abscess treatment includes surgical drainage with or without a graft. 
• Antibiotics: For infection management. 
• Fistula Treatment: Fistulotomy, seton placement, fibrin glue, advancement flap procedures, LIFT (Ligation of Intersphincteric Fistula Tract) procedure. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

lifestyle-modifications-in-treating-anorectal-disorders

• Diet: Diet rich in fibre is advisable in the prevention of constipation which is a characteristic in anorectal diseases. Another important factor is the amount of consumed fluids, they have to drink water and other necessary fluids in order to avoid dehydration which is the main cause of constipation. 
• Hygiene: An appropriate anal hygiene includes washing softly with water and medicated topical gels after defecation to decrease inflammation. 
• Physical activity: It also known that exercising helps the digestion and thus there will be no constipation. 
• Avoiding straining: The worsening of existing conditions is a problem that can come from straining during bowel movements. 
• Posture: Correct posture on the toilet may return easier bowel movement; this could be squatting or using of a footstool. 
• Medication: Certain drugs cause constipation, while others cause diarrhea, that is why management of the drugs should be done under doctor’s prescription. 
• Stress management: There are some instances that stress can alter normal bowel movement, therefore, relaxation exercises or counseling will help. 

Use of corticosteroids for treating Hemorrhoids

Hydrocortisone 

Corticosteroid creams and ointments like hydrocortisone are utilised, to reduce inflammation and pain. 

Effectiveness of topical local anesthetics for treating Hemorrhoids

Lidocaine 

These relieve burning pain and pruritus. 

Effectiveness of antihistamines in treating Pruritus

Diphenhydramine 

This drug is utilised in the treatment of pruritus and helps in reducing the symptoms associated with pruritus. 

Role of antiviral creams in treating anal warts

Podofilox 

A topical agent called podofilox acts by preventing the development of the wart tissue.
The external genital and anal warts are treated immediately with it. 

role-of-intervention-with-procedure-in-treating-anorectal-disorders

• Hemorrhoids: Treatment options are rubber band ligation, sclerotherapy, infrared coagulation, or surgery (hemorrhoidectomy). 
• Anal Fissures: Surgery may be required, and this may include sphincterotomy, where the circular muscles of the anus are incised to allow for the passage of the fissure and promote healing. 
• Fistulas and Abscesses: First and foremost, the abscess is drained, and then, at times, a fistulotomy is made to facilitate adequate drainage of the wound. 
• Rectal Prolapse: Surgery might involve various processes like rectopexy, which is the process of fixing the position of the rectum. 

role-of-management-in-in-treating-anorectal-disorders

Initial Evaluation and Diagnosis: 

• History Taking: These include asking for patient symptoms, their duration, their severity, and any medical history. 
• Physical Examination: Such a digital rectal exam and may include anoscopy or proctoscopy. 
• Diagnostic Tests: Including sigmoidoscopy, colonoscopy, or imaging studies if required.
  Non-surgical Management: 
• Lifestyle Modifications: Fluid intake, nutritional intake modifications, use of fiber. 
• Topical Treatments: For treating the hemorrhoids or anal fissures using creams, ointments, or suppositories. 
• Medical Therapy: Such as laxatives, analgesics, and antibiotics if infection persists.
  Minimally Invasive Procedures: 
• Sclerotherapy: Sclerotherapy in which a sclerosing solution is injected to shrink the size of hemorrhoids. 
• Rubber Band Ligation: For the management of hemorrhoids that are extruding and producing signs and symptoms. 
• Laser Therapy or Infrared Coagulation: Applied to the interior part of the body for the management of internal hemorrhoids.
  Post-treatment Care: Surgical drainage for anal abscesses. 
• Follow-up: For checking up on one’s healing process and to also see if there is a likelihood of relapse. 
• Continued Symptom Management: Controlling the degree of pain and avoiding constipation and diarrhea. 

Medication

Future Trends

Media Gallary

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6027829/