Anorectal Disorders PDF

Anorectal Disorders Dr. Ibrahim Al-Adham Dr. Dania Alhyari Taken from Handbook of Nonprescription Drugs > Chapter 17 1 Anorectal disorders Anorectal disorders involve the perianal area, anal can...

Anorectal Disorders Dr. Ibrahim Al-Adham Dr. Dania Alhyari Taken from Handbook of Nonprescription Drugs > Chapter 17 1 Anorectal disorders Anorectal disorders involve the perianal area, anal canal, and lower rectum. Many signs and symptoms associated with hemorrhoids may be related to non-hemorrhoidal anorectal disorders. Pathophysiology of Anorectal Area: Anorectal disorders occur in the perianal area (the portion of the skin immediately surrounding the anus), the anal canal, and the lower portion of the rectum. The anal canal is about 2.5-5 cm long and connects the rectum with the outside of the body 2  Pathophysiology of Anorectal Area The rectum, which lies above the anal canal, is about 12- 18 cm long and is the terminal portion of the large intestine. The highly vascular rectal mucosa is lined with a semipermeable membrane to protect the body from fecal bacteria. Three hemorrhoidal arteries and their accompanying veins are the most prominent parts of the vasculature. The arteries and veins lying above the dentate line are referred to as internal and those below as external. Blood returns to the heart through the hemorrhoidal veins; therefore, rectal medications may be absorbed and enter the systemic circulation without passing 3 through the liver.  HEMORRHOIDS Hemorrhoids are large, bulging, symptomatic conglomerates of hemorrhoidal vessels, supporting tissues, and overlying mucous membranes in the anorectal region. Hemorrhoids are believed to develop as a result of inflammation of vascular cushions. The cushions (located circumferentially around the anal canal, above the dentate line) contain blood vessels, smooth muscle, and supportive connective tissue that project into the lumen and cause a downward pressure during defecation. With increasing age or poor bowel habits (e.g., prolonged sitting and straining at defecation), muscle fibers may weaken and cause vascular cushions to slide, become congested, bleed, and eventually protrude. Downward pressure during defecation and a high resting anal pressure are common in the development of hemorrhoids. Internal hemorrhoids originate from the superior hemorrhoidal vein and are located above the dentate line, an area that is covered 4 with columnar epithelium and lacks sensory fibers. Hemorrhoids Hemorrhoids are graded by severity of prolapse into the anal canal using a degree system: First degree hemorrhoids are enlarged but do not prolapse into the anal canal. Second degree hemorrhoids protrude into the anal canal and return spontaneously on defecation. Third degree hemorrhoids protrude into the anal canal on defecation but can be returned to their original position manually. Fourth degree hemorrhoids are permanently prolapsed and cannot be reintroduced into the anus. 5 Hemorrhoids External hemorrhoids develop from the inferior hemorrhoidal vein and originate below the dentate line, which is covered with squamous epithelium These hemorrhoids are visible as bluish lumps at the external or distal boundary of the anal canal (known as the anal verge). The blue color may be caused by thrombosed blood vessels, which cause symptoms ranging from minimal discomfort to severe pain. 6 Disorders of the anorectal canal 7 Disorders of the anorectal canal 8 Nonhemorrhoidal Anorectal Disorders Potentially serious nonhemorrhoidal anorectal disorders (e.g., abscesses, fistulas, fissures, neoplasms, polyps, and pruritus ani) may present as haemorrhoid like symptoms; these disorders should not be self treated but referred for immediate medical evaluation 9  Non-Hemorrhoidal Anorectal Disorders Disorder Definition Common Signs and Symptoms Comments Anal Collection of pus causing an Pain, perirectal swelling, discharge, fever, or Possible life threatening Abscess obstruction of the anal glands, chills; pain worsens with sitting and sepsis if not identified and resulting in a bacterial infection defecation treated promptly Anal fistula Abnormal internal opening that Chronic, persistent drainage; pain; possible Surgical repair required ‫ناسور‬ connects with an external opening bleeding on defecation; perianal itching; (or groove) (i.e., tube like appearance between stool seeping through external opening the rectum and anus) Anal Slit like ulcer in anal canal resulting Severe or burning pain during and after Young, middle aged fissure from a traumatic tear during defecation, lasting several minutes to hours; individuals; equal in women passage of stool or explosive anal spasms; blood may be seen on toilet and men diarrhea tissue 10 Non-Hemorrhoidal Anorectal Disorders Disorder Definition Common Signs and Symptoms Comments Anal Include a variety of Rare and usually asymptomatic in Relatively uncommon, accounting neoplasms histologic types 25% of patients; bleeding; changes in for 1%-2% of all GI malignancies; classified as epidermoid bowel habits; anal discharge; anal most are curable, but poor carcinomas mass; pain; pruritus; rash prognosis with anorectal melanomas Pruritus ani Itching sensation Persistent itching, scratching in More common in men localized in anorectal perianal region; more bothersome at area bedtime or when patient is not preoccupied 11  The Food and Drug Administration (FDA) Advisory Review Panel identified signs and symptoms for which a nonprescription anorectal product is indicated. Clinical These symptoms include itching, discomfort, Presentation irritation, burning, soreness, inflammation, pain, dry anal tissue, and swelling in the of Anorectal perianal area. Disorders In contrast, abdominal pain, bleeding, seepage, change in bowel patterns, prolapse, and thrombosis may indicate a more serious condition requiring immediate medical attention 12  Signs and Symptoms of Anorectal Disorders Sign/Symptom Definition/Etiology Usually Self Treatable Itching Mild stimulation of sensory nerve fibers; associated with many anorectal disorders, including hemorrhoids (typically with a (pruritus) mucoid discharge from prolapsing internal hemorrhoids). Common causes include poor hygiene (e.g., incomplete wiping/cleaning after defecation); diarrhea; parasitic or fungal infections; allergies (e.g., sensitivity to fabrics, soaps, laundry detergents, dyes, perfumes in toilet tissue); anorectal lesions; moisture in anal area. May be secondary to swelling; diet (e.g., caffeinated beverages, chocolate, citrus fruits); oral broad spectrum antibiotics. Rare cause includes psychogenic origins. Irritation Uncomfortable feeling associated with stimulation of sensory nerve fibers. Burning Greater degree of irritation of sensory nerve fibers than seen in anal itching; often associated with hemorrhoids; sensation of warmth or intense heat. May be constant or occur only at defecation. Discomfort May result from burning, itching, pain, irritation, inflammation, and swelling 13 Signs and Symptoms of Anorectal Disorders Sign/Symptom Definition/Etiology Usually Self Treatable Inflammation Tissue reaction characterized by heat, redness or discoloration, pain, and swelling; often associated with trauma, allergy, or infection. Swelling Temporary enlargement of cells and/or tissue resulting from excess fluid; may be accompanied by pain, burning, and itching. 14  Signs and Symptoms of Anorectal Disorders Sign/ Symptom Definition/Etiology Requires Medical Referral Pain Intense stimulation of sensory nerve fibers caused by inflammation or irritation. Internal hemorrhoids usually are painless; external hemorrhoids often cause mild pain; acute, severe perianal pain may be from a thrombosed external hemorrhoid. Pain from anal fissure during bowel movement often described as “being cut with sharp glass.” Other possible causes of pain include abscess, fistula, or anorectal neoplasm. Bleeding Hemorrhoids are most common cause of minor anorectal disorders (e.g., from straining or passage of hard stool, or ulceration of perianal skin overlying thrombosed external hemorrhoid). Often appears as bright red spots or streaks on toilet tissue, or bright red blood around stool or in toilet. Black or tarry stools (melena) may indicate a possible upper GI bleed (e.g., PUD, erosive esophagitis, or gastric varices). Large amounts of red blood (hematochezia) in toilet bowl indicative of lower GI bleeding (e.g., fissure, IBD, polyps, malignant disease of the colon or rectum). Possible indications of large volume blood loss include shortness of breath, dizziness, fatigue, or light headedness, especially upon standing (orthostatic hypotension). 15  Signs and Symptoms of Anorectal Disorders Sign/ Definition/Etiology Symptom Requires Medical Referral Seepage Involuntary passage of fecal material or mucus caused by an incompletely closed anal sphincter; may include discharge of pus or feces from a fistula connecting the rectum to the anal canal. Change in bowel pattern Unexplained change in bowel frequency or in stool form; may signal serious underlying GI disorder (e.g., IBD) or colorectal cancer. Prolapse Protrusion of hemorrhoidal or rectal tissue of variable size into anal canal; usually appears after (protrusion) defecation, prolonged standing, unusual physical exertion, or swelling of hemorrhoidal tissue with loss of muscular support; painless except when accompanied by thrombosis, infection, or ulceration. Thrombosis Strangulation of protruded (external) hemorrhoid by anal sphincter, possibly leading to thrombosis; pain is most acute during first 48-72 hours but usually resolves after 7-10 days. Minimal pain with thrombosed internal hemorrhoids; patient likely to be unaware of condition unless sudden change in bowel habits occurs. If a thrombosed hemorrhoid persists, ulcers or gangrene may develop and cause bleeding, especially during defecation. 16 Key: GI = Gastrointestinal; IBD = inflammatory bowel disease; PUD = peptic ulcer disease. Treatment of Anorectal Disorders The primary goal of treatment is to maintain soft stools to prevent straining while having a bowel movement. Treatment Additional goals for patients with symptoms associated with anorectal disorders are to: Goals: (1) alleviate and maintain remission of anorectal symptoms and (2) prevent complications. 17 Non-pharmacologic Therapy Nondrug measures for treating anorectal disorders include dietary modifications, surgical interventions, and non operative methods. Patients diagnosed with or suspected of having hemorrhoids should avoid lifting heavy objects, discontinue foods that aggravate symptoms (e.g., alcohol, caffeinated beverages, citrus, and spicy foods), and increase dietary fiber. Nonsteroidal anti-inflammatory drugs or aspirin may promote bleeding and therefore should be avoided. 18  Non-pharmacologic Therapy Proper bowel habits should be encouraged, and avoiding urges to defecate should be discouraged because doing so may lead to constipation Avoidance of sitting on the toilet for long periods of time reduces strain and decreases pressure on the hemorrhoidal vessels. Proper hygiene of the anal area (e.g., cleaning the area regularly and after each bowel movement using mild, unscented soap and water, or using commercially available hygienic and lubricated wipes or pads) may relieve anorectal symptoms. Excessive scrubbing should be discouraged to minimize aggravation. 19  Pharmacologic Therapy Local anesthetics, vasoconstrictors, protectants, astringents, keratolytics, analgesics, anesthetics, antipruritics, and corticosteroids are commonly used to relieve anorectal symptoms. Certain astringents, protectants, and vasoconstrictors may be used only intrarectally and should be administered with an applicator (i.e., “pile pipe”) so that the product may reach the affected area. Suppositories may be considered another way of administering drug to the anal area; however, their effectiveness is in question, as suppositories may not “stay in place” after insertion. The remaining agents are for external use only and are not indicated for the relief of anorectal pain, bleeding, seepage, prolapse, or thrombosis. 20 Guidelines for Applying or Inserting Anorectal Products Clean affected anorectal area after bowel movement with mild, nonmedicated, unscented soap and warm water; rinse thoroughly. Clean anorectal area prior to applying products containing aluminum hydroxide gel or kaolin. Be sure to remove any previously used petrolatumcontaining or greasy ointment. Dry anorectal area gently by patting or blotting with unscented and uncolored toilet tissue or a soft cloth prior to applying product. Apply a thin layer to the perianal area and anal canal when using an external anorectal product. Insert anorectal products indicated for intrarectal use by using an intrarectal applicator or a finger. Intrarectal applicators are preferred to digital application because an applicator enables the drug product to be applied to the rectal mucosa (which cannot be reached with a finger). Ensure intrarectal applicators have lateral openings and holes in the tip to facilitate anorectal application and coverage of the rectal mucosa. Lubricate intrarectal applicator by spreading product around the applicator tip prior to inserting into the anorectal area. Avoid using the intrarectal applicator in the anorectal area if it causes additional pain. Do not exceed the recommended daily dosage unless directed by a primary care provider. 21  Dosage Guidelines for Anorectal Products Ingredient Concentration per Dosage Unit (%) Frequency of Use (maximum daily dosage) Local Anesthetics Benzocaine 5-20 Up to 6 times/day (2.4 g) Benzyl alcohol 1-4 Up to 6 times/day (480 mg) Dibucaine, dibucaine hydrochloride 0.25-1 Up to 3-4 times/day (80 mg) Dyclonine hydrochloride 0.5-1 Up to 6 times/day (100 mg) Lidocaine 2-5 Up to 6 times/day (500 mg) Pramoxine hydrochloridea 1 Up to 5 times/day (100 mg) Tetracaine, tetracaine hydrochloride 0.5-1 Up to 6 times/day (100 mg) Vasoconstrictors Ephedrine sulfate 0.11.25 Up to 4 times/day (100 mg) Epinephrine hydrochloride/epinephrine 0.005-0.01 Up to 4 times/day (800 mg) Phenylephrine hydrochloride 0.25 Up to 4 times/day (2 mg) 22  Dosage Guidelines for Anorectal Products Ingredient Concentration per Frequency of Use (maximum daily dosage) Dosage Unit (%) Protectants Aluminum hydroxide gel, cocoa butter, glycerin, --- Petrolatum/white petrolatum as often as needed; hard fat, kaolin, lanolin, mineral oil, white other protectants up to 6 times/day or after each petrolatum, calamine, petrolatum, shark liver bowel movement oil, zinc oxide, topical starch, cod liver oil Astringents Calamine 5-25 Up to 6 times/day or after each bowel movement Zinc oxide 5-25 Up to 6 times/day or after each bowel movement Witch hazel 10-50 Up to 6 times/day or after each bowel movement Keratolytics 0.2-2 Up to 6 times/day Alcloxa Resorcinol 1-3 Up to 6 times/day 23  Dosage Guidelines for Anorectal Products Ingredient Concentration per Dosage Unit (%) Frequency of Use (maximum daily dosage) Analgesics, Anesthetics, Antipruritics Menthol 0.1-1 Up to 6 times/day Juniper tar 1-5 Up to 6 times/day Camphor 0.1-3 Up to 6 times/day Corticosteroids Hydrocortisone 0.25-1 Up to 3-4 times/day 24 Local Anesthetics Local anesthetics are approved for the temporary relief of external anal symptoms (e.g., itching, irritation, burning, discomfort, and pain); they provide relief by reversibly blocking transmission of nerve impulses These products should be used with caution, as they may mask the pain of more severe anorectal disorders. Local anesthetics may produce allergic reactions (e.g., burning and itching) that are indistinguishable from the anorectal symptoms. Several cases of contact dermatitis have been reported with hemorrhoidal anesthetics, including benzocaine, dibucaine, and lidocaine. 25 Local Anesthetics Local anesthetic preparations must carry a warning stating that allergic reactions may occur. These agents should be avoided on open sores because they are rapidly absorbed through abraded skin and may cause cardiovascular and central nervous systemic effects. Accidental oral ingestion of dibucaine containing anorectal products has been reported in children, resulting in lethargy, seizures, and cardiorespiratory arrest. All anorectal products containing any local anesthetic should be kept out of children’s reach. 26 Vasoconstrictors Vasoconstrictors are structurally related to the endogenous catecholamines epinephrine and norepinephrine. When ephedrine or epinephrine is applied to the anorectal area, stimulation of alpha adrenergic receptors in the vascular beds constricts arterioles, producing a modest and transient reduction of swelling. These agents are indicated for relief of itching, discomfort, and irritation and to shrink and decrease swelling of the hemorrhoidal tissues. Ephedrine sulfate and phenylephrine hydrochloride are safe and effective for external and intrarectal use, and epinephrine hydrochloride is approved for external use. 27 Vasoconstrictors Adverse effects of ephedrine and epinephrine include increased cardiac rate and contractility, as well as bronchodilation if absorbed systemically. In contrast, because phenylephrine HCl is structurally related to norepinephrine, effects on the central nervous system and cardiac rhythm are minimal. When used in recommended dosages, vasoconstrictors may cause nervousness, tremors, sleeplessness, nausea, and loss of appetite. 28 Vasoconstrictors Serious adverse effects (e.g., elevation of blood pressure, aggravation of hyperthyroidism, cardiac arrhythmias, and irregular heart rate) are less likely to occur with topical than with oral administration. Prolonged use may lead to rebound vasodilatation, anxiety, and (rarely) paranoia. Rectally administered vasoconstrictors may attenuate the effects of oral antihypertensive agents and increase blood pressure. Alternatively, the hypertensive effects of vasoconstrictors may be potentiated by monoamine oxidase inhibitors and tricyclic antidepressants. Concomitant use may lead to serious and even lethal outcomes, including cerebral hemorrhage or stroke. Patients with diabetes, thyroid disease, heart disease, hypertension, or enlarged prostate, as well as those taking antidepressants, antihypertensive agents, or cardiac medications, should not use hemorrhoidal agents with 29 vasoconstrictors without first consulting their primary care provider.  PROTECTANTS Protectants are ingredients that provide a physical protective barrier and soften the anal canal by preventing fecal matter from irritating the perianal mucosa. This drug class includes absorbents, adsorbents, demulcents, and emollients. Approved indications for most protectants include the temporary relief of discomfort, irritation, and burning with external and internal hemorrhoids (one exception is glycerin, which is for external use only) Kaolin or aluminum hydroxide gel is indicated for the temporary relief of itching associated with moist anorectal conditions. Systemic absorption of protectants is minimal; therefore, adverse reactions as a class are uncommon. Lanolin is a natural product obtained from the fleece of sheep, and it may cause allergic reactions. A warning statement for anorectal products says that, because of their greasy properties, petrolatum or greasy ointments should be removed prior to applying products containing aluminum hydroxide gel or kaolin. 30  ASTRINGENTS Astringents are products that promote coagulation of surface protein in the anorectal skin cells to protect the underlying tissue. Astringents also act to decrease cell volume, making the affected environment drier. To prevent further irritation, astringents form a thin protective layer over the injured mucosal membrane. Astringents are approved for the temporary relief of itching, irritation, and burning symptoms associated with anorectal disorders. Witch hazel (known as hamamelis water prior to January, 1, 1995) is indicated for external use, whereas calamine and zinc oxide may be used for external and internal anorectal disorders. Adverse effects with the topical use of astringents are uncommon. If calamine or zinc oxide is used for prolonged periods of time (especially for internal anorectal disorders), systemic zinc toxicity (nausea, vomiting, lethargy, and/or severe pain) may develop. 31  Keratolytics Keratolytics are agents that cause desquamation and debridement (or sloughing) of epidermal surface cells. By fostering cell turnover and loosening surface cells, low concentrations of keratolytics may expose the underlying tissue. When other anorectal ingredients are used in combination with keratolytics, they reduce itching and inflammation. Because mucous membranes do not contain a keratin layer, intrarectal use is not justified and may be harmful. With repeated dosing, the absorption of the keratolytic resorcinol has led to methemoglobinemia, exfoliative dermatitis, death in infants, and myxedema (swelling of the skin and underlying tissues giving a waxy consistency) in adults. Other adverse effects range from tinnitus, increased pulse rate, diaphoresis, and shortness of breath to circulatory collapse, unconsciousness, and convulsions. 32  Keratolytics Products containing resorcinol must list the following warnings to minimize absorption through abraded mucosal lining and to decrease the potential for systemic toxicity: (1) “Certain persons can develop allergic reactions to ingredients in this product. If the symptoms being treated do not subside, or if redness, irritation, swelling, pain, or other symptoms develop or increase, discontinue use and consult a doctor.” (2) “Do not use on open wounds near the anus.” Although keratolytics are available in selected anorectal preparations, their use must be weighed against their potentially serious adverse effects. 33  Analgesics, Anesthetics, and Antipruritics Formerly classified as “counterirritants,” menthol, juniper tar, and camphor are safe and effective when used for external perianal disorders. These agents are approved for the temporary relief of itching and inflammation by producing a cool, warm, or tingling sensation. The agents should not be used internally because the rectum has no identifiable nerve fibers. Menthol containing products must have the following warning: “Certain persons can develop allergic reactions to ingredients in this product. If the symptoms being treated do not subside, or if redness, irritation, swelling, pain, or other symptoms develop or increase, discontinue use and consult a doctor.” 34 Analgesics, Anesthetics, and Antipruritics Extensive application of menthol to the trunk of the body has caused laryngospasm, dyspnea, and cyanosis; therefore, menthol should be used only sparingly. Juniper tar, which contains phenol, also should be used only sparingly; it should not be ingested orally because organ failure and cardiac rhythm abnormalities may result. Camphor is readily absorbed through mucous membranes, and it stimulates the central nervous system, which may cause convulsions or death. The latter is seen mostly with accidental oral ingestion, especially in children 35  Corticosteroids Approximately 60% of the topical anorectal agents contain corticosteroids, which act as a vasoconstrictor and antipruritic by producing lysosomal membrane stabilization and antimitotic activity. The onset of action may take up to 12 hours, but the effect has a longer duration than that of most other agents (e.g., local anesthetics). Hydrocortisone, in concentrations of no more than 1%, is the only corticosteroid approved for nonprescription use in anorectal preparations for the temporary relief of minor external anal itching caused by minor irritation or rash. Local adverse effects include rare skin reactions and skin atrophy with prolonged use. Hydrocortisone may mask the symptoms of bacterial and fungal infections. 36 Combination Products A nonprescription anorectal product may combine two or more active ingredients; combination products generally are recognized as safe and effective when: (1) each active ingredient contributes to the claimed effect; (2) the combination of active ingredients does not decrease the safety or effectiveness of any individual active ingredient; and (3) the combination, when listing adequate directions for use and warning against unsafe use, provides rational, concurrent therapy for a significant proportion of the target population 37 Combination Products Selection of a product should be based on: (1) the type, location, and severity of the anorectal disorder; (2) diseases or significant past medical history; (3) medications; (4) allergies; (5) ability to apply or insert the medication (considering physical, mental, and emotional limitations); and (6) any other factors that may affect treatment (e.g., diet, daily activities, and the cost of the product). 38  Special Populations Pregnant and breastfeeding women should use products recommended for external use; exceptions include the recommended protectants, which may be used internally. Recommending nonpharmacologic interventions, including increasing dietary fiber and fluid intake to minimize constipation, may be of benefit throughout the trimesters. Children younger than 12 years who have hemorrhoids or any other anorectal disorder should be referred for further medical evaluation. Because constipation is more common in the older population, these patients may be more prone to hemorrhoids and anal fissures. Treatment for this population is similar to treatment of young patients. Patients who have a positive family history of colon cancer should be referred for further medical evaluation 39  Complementary Therapies Dietary supplements used to treat hemorrhoids have been researched poorly, although several have evidence of efficacy to support their use. The combination of diosmin and hesperidin (a micronized purified flavonoid fraction) has been used to stop acute bleeding and decrease symptoms associated with hemorrhoids. The mechanism of action is still in question, but animal models suggest this product inhibits prostaglandin and thromboxane mediators, thereby decreasing the inflammatory processes. The combination appears safe when both are taken orally for less than 6 months, with the most common adverse effects being abdominal pain, diarrhea, and gastritis. Purified diosmin without hesperidin administered orally or topically has been shown as effective in reducing pain, bleeding, and swelling with hemorrhoids 40 Patient Education for Anorectal Disorders The objectives of self treatment are to: (1) relieve specific signs and symptoms and (2) prevent complications leading to serious problems. For most patients, carefully following product instructions and the selfcare measures listed here will help ensure relief of symptoms. 41 Thank You! 42