, Franz Raulf2 and Horst Mlitz3
(1)
Department of Proctology, Clinic for Dermatology at RWTH Aachen University, Aachen, Germany
(2)
Medical Center of Coloproctology, Münster, Germany
(3)
Medical Center of Coloproctology, Saarbrücken, Germany
8.1 Diagnostics
8.1.1 Anamnesis
A tentative diagnosis is often confirmed by a typical anamnesis: strong pain during and/or after defecation as well as a blood strip on the stool column and/or traces of blood on toilet paper.
Many patients are afraid of the next bowel movement. Therefore, they sometimes reduce food intake to delay defecation.
Latency between the first occurrence of complaints and the presentation at the doctor’s office shows an astonishing range (see Chap. 2.5).
8.1.2 Medical Examination
Generally, an anal fissure becomes visible already when the buttocks are parted and the patient exerts pressure at the same time. The ensuing digital examination should be carried out with caution. If it is too painful, the fissure can be injected subcutaneously with a local anesthetic, for example, 2 ml 2% lidocaine. The exact location of the fissure can be identified using a cotton swab. Imbued with a topical anesthetic preparation, the swab is gently introduced into the anal canal. After its removal, a blood strip on the cotton carrier shows the location of the fissure (Fig. 8.1).
Fig. 8.1
Location of anal fissure by use of a cotton carrier
A complete proctological examination at an early stage using anal speculum, probe, proctoscope, and rectoscope is advised to detect possible secondary changes and to rule out other disorders.
8.2 Differential Diagnosis
8.2.1 Preliminary Note
Under the aspect of rectal pain, pain syndromes like proctalgia fugax, coccygodynia, anogenital syndrome abscesses due to periproctitis, anal thrombosis, and proctitides have to be excluded in differential diagnosis. With regard to morphology, distinctions have to be made in particular between erosion, rhagades, anal ulcerations, and anal carcinoma. For differential diagnostic and therapeutic reasons, a chronic fissure must be distinguished from secondary fissures as described in Chap. 3.
8.2.1.1 Erosions
If the lining of the anal canal is inflamed (anitis), occurrence of erosions can be solitary or multifocal. Erosions are superficial as well as exuding tissue defects which heal without scarring. In this case, the epithelium in the anal canal is edematous, exuding, and hyperemic. The causes can be multiple: anal eczema, hemorrhoidal disease, herpes simplex, gonorrhea, syphilis, chlamydia infection, papillitis, cryptitis, prolapse disorders, and also chronic diarrhea. Excessive anal hygiene can also lead to erosions.
Patients complain of secretion, often with an addition of mucus and/or blood, intra-anal burning, persistent pruritus ani, and soiling.
8.2.1.2 Rhagades
Rhagades are solitary, slit-like, deep skin cracks which can be caused by excessive stretching of the anoderm and the perianal skin when the elasticity of the anal canal is reduced. They heal without scarring, and they are found particularly in patients with a narrow anal canal. In most cases, they cause a slightly burning pain. But if pain is felt, it will not be as violent and cramp-like as the pain caused by an anal fissure. Rhagades heal quickly when silver nitrate solution (AgNO3, 1%) is applied.
8.2.1.3 Anal Ulcers
Anal fissures can also result traumatically after anal intercourse (Pradel et al. 1985; Marino 1964; Nzimbala and Bruynin 2007; Pierce 2004). However, a variety of other anal and perianal ulcers must be excluded in differential diagnosis: those induced by infections (syphilis, chlamydia, haemophilus ducreyi, cytomegalovirus, herpes simplex virus, tuberculosis, HIV), and also neoplasia such as the squamous epithelium carcinoma, lymphomas, leukemia, Kaposi sarcoma (Marino 1964; Pierce 2004; Pradel et al. 1985).
8.2.1.4 Anal Carcinoma
Under differential diagnostic aspects, the exclusion of a malign finding is extremely important. A suspicion should already be nourished during the clinical examination. On palpation, the carcinoma of the anal verge appears distinctly firmer than a fissure, and the infiltration of subcutaneous tissue can also be felt. The carcinoma of the anal canal shows the same palpatory criteria, and during proctoscopy of advanced tumors, one can often sense its growth below the covering epithelium. The tumor is felt to be significantly more extended in the deep than near the surface, and it infiltrates the deeper layers of the wall of the anal canal (NCCN Clinical Practice Guidelines in Oncology 2008) (Fig. 8.5).
Fig. 8.5
Anal carcinoma at 12 o’clock
The histological structure of the malignomas (squamous epithelial carcinoma and its variant, the verrucous carcinoma, adenocarcinoma, basalioma, and melanomas as well as malign lymphomas) is different and does not convey a macromorhologically typical picture.
It is difficult to macroscopically evaluate the tumor entities without the formation of tumor mass, like, for instance, the forms of anal Morbus Paget which imitate rather an eczema, or the bowenoid papulosis or the Morbus Bowen, as it was formerly known. The last-mentioned tumors of various grades of malignancy are nowadays defined as anal intraepithelial neoplasia (AIN) with its grading scheme AIN 1, 2, and 3 (Hartschuh et al. 2012). Malign lesions of the anal edge and the anal canal do not show the same preference for the central location as the anal fissure, but can nevertheless be situated at 6 or 12 o’clock.
Yet, tissue which is supposedly scarred or altered by inflammation is excised as “anal fissure” again and again, but subsequent histological preparation and analysis disclose very surprisingly a carcinoma or AIN. This underlines the necessity of a histological examination of all excision preparations taken from the anus. Inversely, this means that a biopsy must be taken into consideration after every clinically unclear finding of a chronic eczema or a therapy-refractory anal fissure or unclear knotty alterations (Jehle et al. 2003; Roelofsen 2002).
8.2.1.5 Anorectal Pain Syndromes
The disorders described below are characterized by suddenly occurring, permanent, or recurring pain, without the evidence of a lesion in the anal canal.
Proctalgia Fugax
Proctalgia fugax is defined as an extremely painful disease without a discernible pathomorphological substrate. It can only be diagnosed on the basis of the intermittent symptoms which the afflicted patients describe during the anamnesis. Their account is almost always the same and limited only by their command of language. Proctalgia fugax was first described by A. S. Myrtle in 1883. The term “proctalgia fugax” goes back to the Danish physician T. E. H. Thaysen (1935) who published an exact description of the characteristic symptoms in 1935. The following synonyms are today obsolete: perineal neuralgia, perineal cramp, cramp of the anal sphincter muscle, nervous rectalgia, neuralgia pudendo-analis, or paroxysmal proctalgia.
Prevalence
Proctalgia fugax is by no means uncommon. Its prevalence is given within a range between 2 and 21% of the respective collectives (Ibrahim 1961; Mlitz 2003; de Parades et al. 2007; Boyce et al. 2006; Thompson and Heaton 1980; Schmulson et al. 2006). It occurs mainly in patients between 40 and 50 years of age (Boisson et al. 1966) and lasts for more than 11 years on average (Pilling et al. 1965).
Referring to their systematic review, Jeyarajah et al. (2010) stated a prevalence rate between 4 and 18% in the general population. Various causes are discussed to trigger the disease (Table 8.1).
Table 8.1
Synopsis of 13 studies on the causes of proctalgia fugax
Author | Assumed causes |
|---|---|
Guy et al. (1997) | Hypertrophy of internal anal sphincter muscle |
Rao and Hatfield (1996) | Hyperkinesis of musculature |
Harvey (1979) | Increased contractions in rectosigmoid |
Marti (1992) | Stenosing edema of colonic mucosa |
Kamm et al. (1991) Celik et al. (1995) Martin et al. (1990) König et al. (2000) | Hereditary myopathy of internal anal sphincter muscle |
Eckhardt et al. (1996) | Spasm of internal anal sphincter muscle |
Takano (2005) | Pudendal neuropathy |
Lans (1994) | Concurrent symptom of hemorrhoidal disease |
Mlitz (2003) | Rare symptom of hemorrhoidal disease |
Pilling et al. (1965) | Psychosomatic disorder |
Symptoms
A distinction is made between diurnal and nocturnal attacks, the latter occurring mostly in the early hours of the morning and rudely awakening the patient (Wienert 1980). The duration of the attacks varies between some minutes and 1 h or more (Mlitz 2003). In the case of severe attacks, the circulatory system occasionally reacts with vertigo, excessive perspiration, nausea, or even physical collapse. Contrary to anal fissure pain, proctalgia fugax induced pain is not connected with defecation.
Anogenital Syndrome (AGS)
Various conditions of pain in the area of the pelvic organs which concern the subject areas of proctology and urology are subsumed under the term “anogenital syndrome (AGS).” But a sufficiently precise definition of AGS is not found in the respective medical literature. In the case of prostatic complaints without a tangible correlate, the only recommendation in differential diagnosis is to consider the anorectal symptom complex (hemorrhoidal disease, anal fissure, cryptitis, etc.). Synonyms of AGS (Brühl and Hansen 1986; Persson-Jüneman and Alken 1995; Müller 1975) are anourogenital syndrome (Becker 1995), prostatitis-like syndrome (Ikeuchi et al. 1991), prostatoanal syndrome (Puigvert 1975), and urogenital syndrome (Persson-Jüneman and Alken 1995). The authors emphasize the interdisciplinary character of the signs and symptoms of AGS. In the differential diagnosis of anal fissure, AGS must be taken into consideration and, if necessary, a urological clarification should follow.
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