Disorders of the Anus and Rectum

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Proctitis
Proctitis is an inflammation of the lining of the rectum (rectal mucosa).

In ulcerative proctitis, a common form of proctitis, ulcers appear in the inflamed rectal lining. The condition may affect 1 to 4 inches of the lower rectum. Some cases readily respond to treatment; others persist or recur and require prolonged treatment. Some cases eventually evolve into ulcerative colitis.

Proctitis, which is becoming increasingly common, has several causes. It may result from Crohn's disease or ulcerative colitis. It also can result from a sexually transmitted disease (such as gonorrhea, syphilis, Chlamydia trachomatis infection, herpes simplex, or cytomegalovirus infection), especially in homosexual men. Anyone whose immune system is impaired is also at increased risk of developing proctitis, particularly from infections caused by the herpes simplex virus or cytomegalovirus. Proctitis may be caused by a specific bacterium, such as Salmonella, or by the use of an antibiotic that destroys normal intestinal bacteria and allows other bacteria to grow in their place. Another cause of proctitis is radiation therapy directed at or near the rectum.

Symptoms and Diagnosis
Proctitis typically causes painless bleeding or the passage of mucus from the rectum. When the cause is gonorrhea, herpes simplex, or cytomegalovirus, the anus and rectum may be intensely painful.

To make the diagnosis, a doctor looks inside the rectum with a proctoscope or sigmoidoscope and takes a tissue sample of the rectal lining for examination. The laboratory then can identify bacteria, fungi, or viruses that may be causing the proctitis. A doctor also may examine other areas of the intestine using a colonoscope or barium x-rays.

Treatment
Antibiotics are the best treatment for proctitis caused by a specific bacterial infection. When proctitis is caused by using an antibiotic that destroys normal intestinal bacteria, metronidazole or vancomycin should destroy the harmful bacteria that have displaced the normal ones. When the cause is radiation therapy or isn't known, the person may get relief from a corticosteroid, such as hydrocortisone, and mesalamine, another anti-inflammatory drug. Both can be taken as an enema or as a suppository. Cortisone, a type of corticosteroid, comes in a foam that can be inserted with a cartridge and plunger. Sulfasalazine or a similar drug may be taken orally at the same time. If these forms of therapy don't relieve the inflammation, oral corticosteroids may help.

Pilonidal Disease
Pilonidal disease is an infection caused by a hair that injures the skin at the top of the cleft between the buttocks.

A pilonidal abscess is a collection of pus at the infection site; a pilonidal sinus is a chronic draining wound at the site.

Pilonidal disease usually occurs in young, hairy white men. To distinguish it from other infections, a doctor looks for pits tiny holes in or next to the infected area. A pilonidal sinus can cause pain and swelling. Generally, a pilonidal abscess must be cut and drained by a doctor. Usually, a pilonidal sinus must be removed surgically.

Rectal Prolapse
Rectal prolapse is a protrusion of the rectum through the anus.

Rectal prolapse causes the rectum to turn inside out, so that the rectal lining is visible as a dark red, moist, fingerlike projection from the anus.

A temporary prolapse of only the rectal lining (mucosa) often occurs in otherwise normal infants, probably when the infant strains during a bowel movement, and is rarely serious. In adults, prolapse of the rectal lining tends to persist and may worsen, so that more of the rectum protrudes.

Procidentia is a complete prolapse of the rectum. It occurs most often in women over age 60. To determine the extent of a prolapse, a doctor examines the area while the person stands or squats and while the person strains. By feeling the anal sphincter with a gloved finger, a doctor often detects diminished muscle tone. A sigmoidoscopy and barium enema x-rays of the large intestine may reveal an underlying disease, such as disease in the nerves that supply the sphincter.

Treatment
In infants and children, a stool softener eliminates the urge to strain. Strapping the buttocks together between bowel movements usually helps the prolapse heal on its own.

In adults, surgery is needed to correct the problem. Surgery often cures procidentia. During one kind of abdominal operation, the rectum is lifted, pulled back, and attached to the sacral bone. In another, a segment of the rectum is removed.

For people who are too weak to undergo surgery because of old age or poor health, a wire or plastic loop can be inserted to encircle the sphincter; this technique is called the Thiersch procedure.

Anal Itching
Itchy skin around the anus (pruritus ani) can result from many causes:

Skin disorders such as psoriasis and atopic dermatitis

Allergic reactions such as contact dermatitis caused by anesthetic preparations applied to the skin, various ointments, or chemicals used in soap

Certain foods such as spices, citrus fruits, coffee, beer, and cola as well as vitamin C tablets

Microorganisms such as fungi and bacteria

Infestation by parasites such as pinworms and, less commonly, scabies or lice infestation (pediculosis)

Antibiotics, especially tetracycline

Diseases such as diabetes or liver disease, anal disorders (for example, skin tags, cryptitis, draining fistulas), and cancers (for example, Bowen's disease)

Poor hygiene that leaves irritating feces or excessive rubbing and use of soap

Warmth and excessive sweating because of pantyhose, tight underwear (especially noncotton underwear), obesity, or hot weather

Anxiety-itch-anxiety cycle

People with large external hemorrhoids may have itching because the area is difficult to keep clean.

Treatment
After bowel movements, the anal area should be cleaned with absorbent cotton, which may be moistened with plain warm water. Frequent dusting with baby powder or cornstarch may combat moisture. Corticosteroid creams, antifungal creams such as miconazole, or soothing suppositories may be used. Foods that can cause anal itching are avoided for a while to see if the condition improves. Clothing should be loose and bed linens light. If the condition doesn't improve and a doctor suspects cancer, a skin specimen may be obtained for examination.

Foreign Objects
Swallowed objects, such as toothpicks, chicken bones, or fish bones; gallstones; or a hard lump of feces may become lodged at the junction between the anus and rectum.

Also, objects may be inserted intentionally. Enema tips, thermometers, and objects inserted for sexual stimulation may become lodged in the rectum. These larger objects usually become lodged in the midrectum.

Sudden, excruciating pain during bowel movements suggests that a foreign object, usually at the junction between the anus and rectum, is penetrating the lining of the rectum or anus. Other symptoms depend on the size and shape of the object, how long it has been there, and whether it has caused an infection or perforation.

A doctor can feel the object by probing with gloved fingers during an examination. An abdominal examination, sigmoidoscopy, and x-rays may be needed to make sure the wall of the large intestine hasn't been perforated.

Treatment
If a doctor can feel the object, a local anesthetic is usually injected under the skin and lining of the anus to numb the area. The anus can then be spread wider with a rectal retractor, and the object can be grasped and removed.

Natural movements of the wall of the large intestine (peristalsis) generally bring the foreign object down, making the removal possible. Occasionally, if a doctor can't feel the object or if the object can't be removed through the rectum, exploratory surgery is needed.

The person is given regional or general anesthesia, so that the object can be gently moved toward the anus or the large intestine can be cut open to remove the object. After the object is removed, the doctor performs a sigmoidoscopy to determine whether the rectum has been perforated or otherwise injured. n

Submitted By:
DR. F. I. BISWAS
The author is based in Otowa, Canada.

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