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.

Perianal disease: Updates and controversies in closing the gaps.

Perianal complications are common and morbid in children with Crohn's disease. In this review, we describe the epidemiology, the presentation and diagnosis, evaluation and management. We focus on updates such as the increasing frequency of biologic medications and MRI for evaluation. We also highlight controversies on the timing and approaches to surgical techniques. Finally, perianal disease requires the coordination of multidisciplinary care with nursing, radiology, gastroenterology, and surgery to optimize outcomes - both medical and patient-centered.

Complicaciones perianales causadas por agentes modeladores inyectados en glúteos / Perianal complications caused by gluteal injection of modeling agents

En este reporte presentamos tres pacientes en quienes ocurrieron condiciones inflamatorias perianales tardías, luego de la administración de sustancias modeladoras no identificadas en los glúteos. El diagnóstico inicial y supuesto no fue correcto, ya que no se investigó durante la evaluación preliminar el antecedente de la administración de elementos modeladores. Recomendamos que los pacientes con patologías inflamatorias del ano, sobre todo aquellos cuyo curso es extraño, se les pregunte acerca de la administración de agentes modeladores en los glúteos. Esta práctica puede contribuir a la eficacia del diagnóstico de manifestaciones perianales caracterizadas por flogosis, que se presentan de forma inusual. (AU)

In this report we present three patients in which late perianal inflammatory conditions occurred after administration of unidentified modeling agents to the buttocks. The initial diagnosis was not correct because of the administration of modeling agents was not investigated during the initial eval-uation. We recommend inquiring patients with inflammatory pathologies of the anus, especially those whose course is unusual, about the adminis-tration of modeling agents to the buttocks. This approach can contribute to the efficiency of the diagnosis of perianal complaints characterized by inflammation, but rare in its appearance. (AU)

Anorectal Emergencies.

Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections.

Study on the factors influencing the prognosis after perianal abscess surgery.

OBJECTIVE: To study the influence of clinical characteristics and diagnosis and treatment methods of perianal abscess on postoperative recurrence or formation of anal fistula to provide a basis for selecting appropriate surgical and inspection methods for clinical treatment of perianal abscess in the future. METHODS: The clinical data of 394 patients with perianal abscesses were collected, the influencing factors were investigated, and univariate analysis and multivariate logistic regression analysis were performed to further determine the risk factors affecting the prognosis of perianal abscess. RESULTS: The results showed that the rate of preoperative blood routine results in the uncured group was higher (51.16%) than in the cured group (35.61%); the rate of high abscess space in the uncured group (23.26%) was higher than in the cured group (9.11%); the proportion of patients in the uncured group who underwent magnetic resonance imaging (MRI) before surgery (27.90%) was lower than in the cured group (45.30%); the proportion of patients in the uncured group who underwent simple drainage (51.16%) was higher than in the cured group (28.49%). The two groups had significant differences in perineal MRI examination, surgical method, preoperative blood routine, and abscess space (p = 0.030, p = 0.002, p = 0.047 and p = 0.010, respectively). Based on the results of univariate analysis and multivariate logistic regression analysis, the extent of the abscess cavity (OR = 2.544, 95%CI = 1.087-5.954, p = 0.031) and the surgical method (OR = 2.180, 95%CI = 1.091-4.357, p = 0.027) were independent influencing factors for postoperative recurrence of perianal abscess or anal fistula. CONCLUSION: Preoperative assessment of the abscess range and precise intraoperative methods to resolve the infection of the abscess glands in the internal mouth can effectively improve the cure rate.

Identification and reporting of anal pathology during routine colonoscopies

The gold-standard procedure for anal canal examination is anoscopy. Nonetheless, patients are referred for a colonoscopy for many reasons, and a routine exam might provide an opportunity to diagnose anal pathologies, such as hemorrhoids, anal fissures, anal polyps, condylomas, and anal squamous cell carcinoma. It is important to know the main features of these conditions and relevant information to report in order to help guide patient treatment and follow-up.

Levator Ani Syndrome Presenting with Vaginal Pain.

Levator ani syndrome (LAS), also known as levator ani spasm, puborectalis syndrome, chronic proctalgia, pyriformis syndrome and pelvic tension myalgia, produces chronic anal pain. The levator ani muscle is susceptible to the development of myofascial pain syndrome, and trigger points may be elicited on physical examination. The pathophysiology remains to be fully delineated. The diagnosis of LAS is suggested primarily by the clinical history, physical examination and the exclusion of organic disease that can produce recurrent or chronic proctalgia. Digital massage, sitz bath, electrogalvanic stimulation and biofeedback are the treatment modalities most frequently described in the literature. Pharmacological management includes non-steroidal anti-inflammatory medications, diazepam, amitriptyline, gabapentin and botulinum toxin. The evaluation of these patients can be challenging due to a diversity of causative factors. The authors present the case of a nulliparous woman in her mid-30s presenting with acute onset of lower abdominal and rectal pain radiating to her vagina. There was no history of trauma, inflammatory bowel disease, anal fissure or altered bowel habit. Each pain episode lasted longer than 20 min and was exacerbated by sitting. Neurological examination showed no evidence of neurological dysfunction. Rectal examination was unremarkable. During vaginal examination, palpation of the levator ani muscles elicited pain indicating pelvic floor dysfunction. Laboratory investigations including a full blood count and C reactive protein were within normal range. Further investigation with a transabdominal ultrasound scan, CT of the abdomen and pelvis and MRI of the lumbar spine were unremarkable. She commenced treatment with amitriptyline 20 mg once daily. She was referred for pelvic floor physiotherapy. Functional pain syndromes, such as LAS, should be regarded as diagnoses of exclusion and considered only after a thorough evaluation has been performed to rule out structural causes of pain. Knowledge of the pelvic floor and pelvic wall muscles may enable the physician to identify LAS, a possible cause of chronic pelvic pain.

Elderly Patients Managed Non-Operatively with Abscesses of the Anorectal Region Have Five Times Higher Rate of Mortality Compared to Non-Elderly.

This study's purpose was to investigate risk factors for mortality from anorectal abscesses through a more comprehensive examination. This was a retrospective study that evaluated National Inpatient Sample patient data of adult and elderly patients emergently admitted with a primary diagnosis of anorectal abscess. Data was stratified by variables of interest and examined through statistical analysis, including backward logistic regression modelling. Roughly 40,000 adult patients and nearly 7000 elderly patients were admitted emergently with a primary diagnosis of abscess in anorectal regions. The mean age of adult male patients was 43 years while elderly male patients were, on average, 73 years old. Both adult males (69.0%) and elderly males (63.9%) were more frequently seen in the hospital for anorectal abscess compared to females. Mortality rates were lower in adult patients as only 0.2% (n = 62) of adult patients and 1.0% (n = 73) of elderly patients died in the hospital. Age increased the odds of mortality (OR = 1.03; 95% CI: 1.02-1.04, p < 0.001) as did hospital length of stay (OR = 1.02; 95% CI: 1.01-1.03, p < 0.001). Surgical procedure decreased the odds of mortality by more than 50% (OR = 0.49; 95% CI: 0.33-0.71, p < 0.001). Risk factors for mortality from anorectal abscess included age and non-operative management, which leads to prolonged hospital length of stay. Surgical management of anorectal abscesses offered protective benefits.

Human Papillomavirus-Associated Anal Cancer Incidence and Burden Among US Men, According to Sexual Orientation, Human Immunodeficiency Virus Status, and Age.

BACKGROUND: Men who have sex with men (MSM) without HIV are known to be at elevated relative risk for Human papillomavirus (HPV)-associated anal cancer in comparison to men who have sex with women (MSW), but are poorly characterized in terms of anal cancer incidence due to absence of reporting of sexual behavior/identity at a population-level. METHODS: By combining age-specific statistics from multiple data sources (anal cancer incidence among all males; anal cancer incidence among MSM and MSW with HIV; population size of men with HIV by sexual orientation), we developed a mathematical model to estimate anal cancer incidence, annual number of cases, and proportion by (a) sexual orientation (MSM versus MSW), (b) HIV status, and (c) age (<30, 30-44, 45-59, and ≥60 years). RESULTS: Anal cancer incidence (per 100 000) among MSM without HIV was 1.4 (95% uncertainty interval [UI], 0.6 to 2.3), 17.6 (95% UI = 13.8-23.5), and 33.9 (95% UI = 28.3-42.3), at ages 30-44, 45-59 and ≥60 years, respectively. 19.1% of all male anal cancer occurred in MSM without HIV, increasing from 4% of anal cancer diagnosed at 30-44 years to 24% at ≥60 years; 54.3% occurred in MSW without HIV (increasing from 13% at age 30-44 to 67% at >60 years), and the remaining 26.6% in men (MSM and MSW combined) with HIV (decreasing from 83% at age 30-44 to 9% at >60 years). CONCLUSIONS: These findings should inform anal cancer prevention recommendations in male risk groups, including, for the first time, for the important group of MSM without HIV.

Diagnosis and Clinical Features of Perianal Lesions in Newly Diagnosed Crohn's Disease: Subgroup Analysis from Inception Cohort Registry Study of Patients with Crohn's Disease (iCREST-CD).

BACKGROUND AND AIMS: Perianal lesion is a refractory phenotype of Crohn's disease [CD] with significantly diminished quality of life. We evaluated the clinical characteristics of perianal lesions in newly diagnosed CD patients and the impact of perianal lesions on the quality of life in Japanese patients with CD. METHODS: Patients newly diagnosed with CD after June 2016 were included between December 2018 and June 2020 from the Inception Cohort Registry Study of Patients with CD [iCREST-CD]. RESULTS: Perianal lesions were present in 324 [48.2%] of 672 patients with newly diagnosed CD; 71.9% [233/324] were male. The prevalence of perianal lesions was higher in patients aged <40 years vs ≥40 years, and it decreased with age. Perianal fistula [59.9%] and abscess [30.6%] were the most common perianal lesions. In multivariate analyses, male sex, age <40 years and ileocolonic disease location were significantly associated with a high prevalence of perianal lesions, whereas stricturing behaviour and alcohol intake were associated with low prevalence. Fatigue was more frequent [33.3% vs 21.6%] while work productivity and activity impairment-work time missed [36.3% vs 29.5%] and activity impairment [51.9% vs 41.1%] were numerically higher in patients with than those without perianal lesions. CONCLUSIONS: At the time of CD diagnosis, approximately half of the patients had perianal lesions; perianal abscesses and perianal fistulas were the most common. Young age, male sex, disease location and behaviour were significantly associated with the presence of perianal lesions. The presence of perianal lesion was associated with fatigue and impairment of daily activities. CLINICAL TRIALS REGISTRY: University Hospital Medical Information Network Clinical Trials Registry System [UMIN-CTR, UMIN000032237].

Anogenital symptoms and lesions in a series of 20 patients infected with monkeypox virus.

AIM: Monkeypox virus (MPXV) has been spreading in many European countries, the USA and Canada since May 2022. General symptoms, skin and anoperineal lesions have been reported. Anal pain is often reported, but anal canal lesions have yet to be described in these patients. The aim of this study was to describe anoperineal lesions in patients infected with MPXV undergoing systematic margin and anal canal examination at a tertiary care centre in France. METHOD: In this prospective descriptive study, systematic anal examination was performed in 20 patients diagnosed with MPXV infection at Bichat Hospital, Paris, France between 6 and 11 July 2022. Anal swabs were also obtained from all these patients for polymerase chain reaction testing for MPXV. RESULTS: All the patients were men that have sex with men (MSM). Sixteen patients had anal symptoms: 13 reported anal pain, and the other anal symptoms described were anal bleeding (n = 12), pruritus (n = 11), dyschezia (n = 10), tenesmus (n = 13), burning (n = 3), swelling (n = 9) and discharge of mucus (n = 9). Proctological examination detected: (i) anal margin lesions in 14 patients (vesicles, n = 8; pustules, n = 6; ulceration, n = 6); (ii) anal canal lesions in 16 patients (ulceration, n = 13; ulcers, n = 4; pustules, n = 1), seven of whom presented anal hypertonia; and (iii) rectal lesions in 12 patients (congested rectum, n = 6; erythema, n = 10; ulcers, n = 2; not seen in one case). the presence of mucus was noted in 10 patients and the presence of blood in six patients. CONCLUSION: This is the first study to describe anal canal lesions in patients infected with MPXV. Most of the observed lesions were ulceration, accounting for the pain reported.

Anorectal Malignancies Presenting as a Perianal Abscess or Fistula.

BACKGROUND: Acute anorectal abscess and fistula are common conditions that usually presents as a painful lump close to the anal margin. Tumors in the distal rectum and in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. The purpose of this study was to describe patients presenting with acute perianal abscess or fistula who were subsequently diagnosed with anorectal cancer. METHODS: We performed a retrospective, review of all cases presenting with acute perianal abscess or fistula who were subsequently found to have anorectal carcinoma on biopsy in two tertiary centers. We analyzed the data focusing on the clinical features, laboratory values, clinical staging of the tumors, the subsequent management, the pathological staging, and the outcome of each patient. RESULTS: Overall, 3219 patients presenting with anorectal abscess or fistula were reviewed. Cancer was diagnosed in 16 (.5%) patients, 12 with adenocarcinoma of the rectum and 4 with squamous cell carcinoma of the anus. In 5 patients (31.2%), cancer was diagnosed in the setting of chronic perianal fistula, 4 of them had Crohn's disease. In 10 patients (62.5%), cancer was not diagnosed during the initial evaluation of the acute symptoms. CONCLUSIONS: A high index of suspicion is required to make the diagnosis of perianal tumors when assessing patients presenting with perianal sepsis, particularly those with Crohn's disease, a long history of persistent perianal disease, and an advanced age. In most cases, proper drainage followed by proximal diversion are the surgical treatment of choice in the acute setting.

Incidence and Clearance of Anal Human Papillomavirus Infection in 16 164 Individuals, According to Human Immunodeficiency Virus Status, Sex, and Male Sexuality: An International Pooled Analysis of 34 Longitudinal Studies.

BACKGROUND: Understanding the natural history of anal high-risk human papillomavirus (hrHPV) infection is key for designing anal cancer prevention programs but has not been systematically characterized. METHODS: We reanalyzed data from 34 studies including 16 164 individuals in 6 risk groups defined by human immunodeficiency virus (HIV) status, sex, and male sexuality: men who have sex with men (MSM) and people with HIV (MSMWH), HIV-negative MSM, women with HIV (WWH), HIV-negative women, men who have sex with women (MSW) with HIV (MSWWH), and HIV-negative MSW. We used Markov models to estimate incidence and clearance of 13 hrHPV types and their determinants. RESULTS: Human papillomavirus (HPV) 16 had the highest incidence-clearance ratio of the hrHPV types. MSMWH had the highest hrHPV incidence (eg, 15.5% newly HPV-16 infected within 2 years), followed by HIV-negative MSM (7.5%), WWH (6.6%), HIV-negative women (2.9%), MSWWH (1.7%), and HIV-negative MSW (0.7%). Determinants of HPV-16 incidence included HIV status and number of sexual partners for MSM, women, and MSW, and anal sex behavior for MSM only. HPV-16 clearance was lower for people with HIV (PWH) and lower for prevalent than incident infection. Among MSM, increasing age was associated with lower clearance of prevalent, but not incident, HPV-16 infection. CONCLUSIONS: This robust and unifying analysis of anal hrHPV natural history is essential to designing and predicting the impact of HPV vaccination and HPV-based screening programs on anal cancer prevention, particularly in MSM and PWH. Importantly, it demonstrates the higher carcinogenic potential of longstanding anal prevalent hrHPV infection than more recent incident infection.

Drug resistant bacteria in perianal abscesses are frequent and relevant.

Perianal abscesses are frequent diseases in general surgery. Principles of standard patient care are surgical drainage with exploration and concomitant treatment of fistula. Antiinfective therapy is frequently applied in cases of severe local disease and perianal sepsis. However, the role of microbiologic testing of purulence from perianal abscesses is disputed and the knowledge concerning bacteriology and bacterial resistances is very limited. A retrospective cohort study was performed of consecutive patients (≥ 12 years of age) from a tertiary care hospital, who underwent surgical treatment for perianal abscess from 01/2008 to 12/2019. Subdividing the cohort into three groups regarding microbiological testing results: no microbiological testing of purulence (No_Swab, n = 456), no detection of drug resistant bacteria [DR(-), n = 141] or detection of bacteria with acquired drug resistances from purulence [DR(+), n = 220]. Group comparisons were performed using Kruskall-Wallis test and, if applicable, followed by Dunn´s multiple comparisons test for continuous variables or Fishers exact or Pearson's X2 test for categorical data. Fistula persistence was estimated by Kaplan Meier and compared between the groups using Log rank test. Corralation analysis between perioperative outcome parameters and bacteriology was performed using Spearman´s rho rank correlation. Higher pretherapeutic C-reactive protein (p < 0.0001) and white blood cell count (p < 0.0001), higher rates of supralevatoric or pararectal abscesses (p = 0.0062) and of complicated fistula-in-ano requiring drainage procedure during index surgery (p < 0.0001) reflect more severe diseases in DR(+) patients. The necessity of antibiotic therapy (p < 0.0001), change of antibiotic regimen upon microbiologic testing results (p = 0.0001) and the rate of re-debridements during short-term follow-up (p = 0.0001) were the highest, the duration until definitive fistula repair was the longest in DR(+) patients (p = 0.0061). Escherichia coli, Bacteroides, Streptococcus and Staphylococcus species with acquired drug resistances were detected frequently. High rates of resistances against everyday antibiotics, including perioperative antibiotic prophylaxis were alarming. In conclusion, the knowledge about individual bacteriology is relevant in cases of complex and severe local disease, including locally advanced infection with extended soft tissue affection and perianal sepsis, signs of systemic inflammatory response as well as the need of re-do surgery for local debridements during short-term and fistula repair during long-term follow-up. Higher rates of acquired antibiotic resistances are to be expected in patients with more severe diseases.

Risk of Anorectal Cancer Associated with Benign Anal Inflammatory Diseases: A Retrospective Matched Cohort Study.

PURPOSE: The purpose of our study was to evaluate the relationship between benign anal inflammatory diseases and anorectal cancer and assess its risk factors. METHODS: A retrospective matched cohort study was conducted that included data from 2002 to 2013. The National Health Insurance Service National Sample Cohort data from 2002 to 2013 was used for the study. Of a total study population of 143,884 individuals, 28,110 individuals with anal fissures were assigned to the case group, while 115,774 individuals without anal fissures were assigned to the control group based on the 1:4 propensity score matching age, sex, and year (case: diagnosed year, control: health service received year). RESULTS: The risk of anorectal cancer was higher in the case group (hazard ratio [HR]: 1.95, 95% confidence interval [CI]: 1.51-2.53) compared to the control group. After grouping anorectal cancers into anal cancer and rectal cancer, the risk remained higher in the case group (anal cancer HR: 2.79, 95% CI: 1.48-5.27; rectal cancer HR: 1.82, 95% CI; 1.37-2.42). The case group was further categorized into patients with fissures and patients with fistulas; patients with fissures showed a higher risk of developing anorectal cancer than patients with fistulas (HR: 2.05, 95% CI: 1.53-2.73 vs. HR: 1.73, 95% CI: 1.13-2.66). Study participants in their 30s and 40s had a 4.19- and 7.39-times higher risk of anorectal cancer compared to those in the higher age groups (0.64-1.84), while patients who did not have inflammatory bowel disease (IBD) had a higher risk of developing anorectal cancer (HR: 2.09, 95% CI: 1.56-2.80). CONCLUSIONS AND RELEVANCE: Patients with anal fistulas or fissures have an increased risk of being diagnosed with anorectal cancer, especially at a young age and even without IBD.

Chronic anal pain: A review of causes, diagnosis, and treatment.

Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifies 3 main diagnostic categories for chronic anal pain: local causes, functional anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests, and main treatments for each condition are reviewed.