anorectal disorders

importance of anorectal disorders

- 5% of US population affected

- 10 million people report symptoms annually

- 1/3 will visit a provider for treatment

- peak prevalence: 45-65 years

- in 2017, $136 million spent on preparation H worldwide

definition of anorectal disorders

- involvement of the perianal area, anal canal and lower rectum

- benign to very severe

- hemorrhoids

- anal fissures

- fecal incontinence

- malignancy

pathophysiology of anorectal disorders

- anal canal (upper half of the canal and lower half of canal)

- dentate line

- anal sphincter

- rectum

upper half of anal canal

- Zona columnaris

- simple columnar epithelium

- painless - internal hemorrhoids

lower half of anal canal

- Zona hemorrhagica -- stratified squamous non-keratinized cells

- Zona cutanea -- stratified squamous keratinized cells

- painful - external hemorrhoids

- 2.5 to 5 cm in length

dentate line

divides the upper and lower half

anal sphincter

- external: voluntary muscles

- internal: involuntary muscle

rectum

- 12-15 cm long

- highly vascularized

- remember medications absorbed

hemorrhoids

- bulging, blood vessels

- skin/supporting tissue

- mucous membranes

- areas of cushions

- disease when swollen/inflamed

- internal vs. external compared to dentate line

internal hemorrhoids

- usually painless rectal bleeding

- become painful with thrombosis and necrosis

- first-degree

- second-degree

- third-degree

- fourth-degree

first-degree internal hemorrhoids

enlarged but do not prolapse into anal canal

second-degree internal hemorrhoids

protrude into anal canal on defecation and returns spontaneously

third-degree internal hemorrhoids

protrude into anal canal on defecation and return manually

fourth-degree internal hemorrhoids

permanent prolapse and cannot be reintroduced into anus

external hemorrhoids

- nonthrombosed: pink, bleeding, itching

- thrombosed: bluish, purple, pain

- not to be confused with skin tags

- fibrotic skin that persists after a thrombosed external hemorrhoid

nonhemorrhoidal anorectal disorders

- anal abscess

- anal fistula

- anal fissure

- anal neoplasms

- pruritus ani

anal abscess

- pain, swelling, drainage, fever, painful defecation

- risk of sepsis if untreated

anal fistula

- persistent drainage, pain, itching, stool leakage

- usually requires surgery

anal fissure

- severe pain with defecation, anal spasms, rectal bleeding

- common in young and middle-aged adults

anal neoplasms

- bleeding, bowel habit changes, anal mass, pain

- rare; some forms have poor prognosis

pruritus ani

- persistent perianal itching and scratching

- more common in men

self-treatable anorectal symptoms

- itching (sign/symptom)

- common hemorrhoids, poor hygiene, diarrhea, infections, allergies, diet (comments)

- discomfort (sign/symptom)

- burning, itching, pain (comments)

- burning (sign/symptom)

- hemorrhoids (comments)

- inflammation (sign/symptom)

- swelling (sign/symptom)

medical referral anorectal symptoms

- pain (sign/symptom)

- bleeding (sign/symptom)

- seepage (sign/symptom)

- change in bowel pattern (sign/symptom)

- prolapse (sign/symptom)

- thrombosis (sign/symptom)

- severe pain-anal fissure (comments)

- GI bleed (comments)

- inflammatory bowel disease, colorectal CA (comments)

treatment goals for anorectal disorders (self-care)

- primary: resolve associated symptoms of pain, discomfort, and burning

- maintain soft stools (reduce constipation)

- prevent straining with a bowel movement

- reduce discomfort

- maintain disease remission

- prevent complications

assessment for self-care of anorectal disorders nonpharmacologic

- diet

- perianal hygiene

assessment for self-care of anorectal disorders pharmacologic

- local anesthetics

- vasoconstrictors

- protectants

- astringents

- keratolytics

- analgesics

- antipruretics

- corticosteroids

nonpharmacologic therapy for anorectal disorders

- avoid heavy lifting

- discontinue foods that aggravate symptoms (EtOH, caffeine, citrus, spicy or fatty foods)

- ensure adequate hydration

- increase dietary fiber (increase to at least 25-35 g/day) -- increase slowly

- caution with NSAIDS/aspirin -- bleeding risk

- proper bowel habits (avoid straining)

- good hygiene (clean area)

- sitz bath

- surgery -- large and prolapsed hemorrhoids/banding

combination products for self-care of anorectal disorders

- two or more active ingredients allowed

- each ingredient must contribute to the "claim"

- must keep efficacy and safety

- provides adequate directions for target population

product selection reminders

- cost

- route of administration

- allergies

- comorbid conditions

pharmacologic therapy: local anesthetics for self-care of anorectal disorders

- temporary relief of external anal symptoms

- mechanism of action: block transmission of nerve impulses

- adverse effects: allergic reactions; rapidly absorbed through abraded skin so avoid placing on open sores -- can cause CV and CNS effects

- Benzocaine 5-20% -- up to 6x/day

- Benzyl alcohol 1-4% -- up to 6x/day

- Dibucaine 0.25-1% -- up to 3-4x/day

- Dyclonine HCl 0.5-1% -- up to 6x/day

- Lidocaine 2-5% -- up to 6x/day

- Pramoxine HCl 1 -- up to 5x/day

- Tetracaine 0.5-1% -- up to 6x/day

pharmacologic therapy for self-care of anorectal disorders: vasoconstrictors

- similar to endogenous epinephrine/norepinephrine

- mechanism of action: stimulate alpha-adrenergic receptors, constricts arterioles, decreases swelling

- temporary relief of itching, discomfort and irritation; shrink and decrease swelling of hemorrhoidal tissue

- ephedrine 0.1-1.25% -- up to 4x/day for external and intrarectal use

- epinephrine 0.005-0.01% -- up to 4x/day for external use only

- phenylephrine 0.25% -- up to 4x/day for external and intrarectal use

- rectally administered

- increase blood pressure

- caution with MAO-inhibitors, TCA -- lead to stroke

- caution in diabetics, thyroid, heart disease, hypertension, enlarged prostate

pharmacologic therapy for self-care of anorectal disorders: vasoconstrictors adverse effects of ephedrine/epinephrine

- depends on systemic absorption

- increased cardiac rate

- bronchodilation

- nervousness

- sleeplessness

- loss of appetite

- nausea

products: Preparation H

- glycerin

- phenylephrine

- pramoxine

- white petrolatum

pharmacologic therapy for self-care of anorectal disorders: protectants

- physical protective barrier

- soften anal canal and prevent irritation

- temporary relief of discomfort, irritation, burning with hemorrhoids

- aluminum hydroxide gel -- up to 6x/day for external and internal use

- cocoa butter -- up to 6x/day for external and internal use

- glycerin -- up to 6x/day for external use only

- lanolin/kaolin -- up to 6x/day for external and internal use

- mineral oil -- up to 6x/day for external and internal use

- petrolatum -- as often as needed for external and internal use

- calamine -- up to 6x/day for external and internal use

- cod/shark liver oil -- up to 6x/day for external and internal use

- zinc oxide -- up to 6x/day for external and internal use

- minimal adverse effects

- usually in combination with other classes of medications

pharmacologic therapy for self-care of anorectal disorders: astringents

- promote coagulation of surface protein in the skin cells and forms a protective layer -- protects tissue

- dries environment

- temporary relief of itching, irritation and burning with hemorrhoids

- witch hazel -- up to 6x/day for external use

- calamine -- up to 6x/day for external and internal use

- zinc oxide -- up to 6x/day for external and internal use

witch hazel

- leaf, bark and twigs of Hamamelis virginiana

- Tannins reduce swelling

- adverse effects: stinging sensation, contact dermatitis

calamine and zinc oxide

- Calamoseptine -- calamine, zinc oxide, menthod and lanolin

- Boudreaux's Butt Paste -- zinc oxide

- adverse effects: zinc toxicity

pharmacologic therapy for self-care for anorectal disorders: keratolytics

- cause sloughing/exfoliation of epidermal cells

- soft keratin --> improve the skin's ability to bind moisture

- use in combination with other agents

- benefits needs to outweigh adverse effects (local skin irritation, allergic reactions, systemic toxicity)

- Alcloxa (allantoin) -- up to 6x/day look for in the ingredient list

- Resorcinol -- up to 6x/day look for in the ingredient list

pharmacologic therapy for self-care for anorectal disorders: analgesics, anesthetics, antipruritics

- pain relief

- "counterirritants": distract mind from current sensation to a new sensation

- temporary relief of itching and inflammation

- menthol -- up to 6x/day external use only

- juniper tar -- up to 6x/day external use only

- camphor -- up to 6x/day external use only (readily absorbed)

pharmacologic therapy for self-care of anorectal disorders: corticosteroids

- antipruritic and anti-inflammatory

- temporary relief of minor external anal itching caused by minor irritation or rash

- longer onset of action but also longer duration of effect

- hydrocortisone -- up to 3-4x/day 0.25%-1%

pharmacologic therapy for self-care of anorectal disorders: stool softeners

- avoid straining and constipation

- fiber and water

- docusate sodium (colace)

administration tips of docusate

- no difference in dosage forms and efficacy

- suppositories: lie on left side with knees bent for at least 15-20 minutes for product to dissolve, harden in fridge if needed, generally not recommended as first-line dosage form

pregnancy/breastfeeding

- uterus puts pressure on pelvic veins

- common particularly in 3rd trimester

- may develop in labor

- must avoid constipation

- recommend products for external use only

- internal use -- protectants but not glycerin

summary for self-treatment of anorectal disorders

- OTC may be used for minor symptoms

- treatment duration is 7-days

- encourage good bowel habits

exclusions for self-treatment of anorectal disorders

- patients