Anal Health Care Basics
Jason Chang, MD; Elisabeth McLemore, MD, FACS, FASCRS;
Talar Tejirian, MD, FACS
Perm J 2016 Fall;20(4):15-222
Despite the fact that countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Unfortunately, this leads to incorrect diagnoses and treatments. When treating a patient with an anal complaint, the primary goals are to first diagnose the etiology of the symptoms correctly, then to provide an effective and appropriate treatment strategy.
The first step in this process is to take an accurate history and physical examination. Specific questions include details about bowel habits, anal hygiene, and fiber supplementation. Specific components of the physical examination include an external anal examination, a digital rectal examination, and anoscopy if appropriate.
Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags. However, each problem presents differently and requires a different approach for management. It is of paramount importance that the correct diagnosis is reached. Common errors include an inaccurate diagnosis of hemorrhoids when other pathology is present and subsequent treatment with a steroid product, which is harmful to the anal area.
Most of these problems can be avoided by improving bowel habits. Adequate fiber intake with 30 g to 40 g daily is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases.
In this Special Report, we provide an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists.
Despite the fact that countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Unfortunately, this leads to incorrect diagnoses and treatments. This problem is compounded by the stigma associated with suffering from anal problems, which discourages patients from seeking help and getting the appropriate care.
When treating a patient with an anal complaint, the primary goals are to
- diagnose the etiology of the symptoms correctly
- provide an effective and appropriate treatment strategy
- confirm with a follow-up appointment that the problem has resolved or is under control. If symptoms have not improved, additional evaluation may be needed.
The chief complaint and history of the present illness are the first pieces of the puzzle to put together to reach the correct diagnosis. Obtaining specific information from the patient is imperative. For example, a chief complaint and history of present illness of “hemorrhoids” is not sufficient and frequently is counterproductive.
Discovering the patient’s main symptom(s) is key: pain, bleeding, itching, tissue prolapse, excessive tissue, and drainage are some of the most common symptoms of underlying anal disease. Investigating the details of the patient’s symptoms is important because “hemorrhoids” comprise less than half of the diseases causing these anal symptoms. For example, although there are many problems that can lead to anal pain, one of the most common is an anal fissure, which is frequently misdiagnosed as hemorrhoidal disease.1
Important history questions:
- How often do you have a bowel movement?
- What is the quality and consistency of the bowel movement (ie, hard, soft, watery)?
- How long do you sit on the toilet?
- Do you read or play games on your phone while having a bowel movement?
- Do you have anal pain/bleeding/incontinence to stool or gas?
- How do you clean the area? Do you use any wipes or ointments?
- Do you currently take a fiber supplement? If yes, which type and how much?
Anal Health Physical Examination
The physical examination comprises three components:
1. External Visual Examination
- Thorough visual inspection is important. This requires manual retraction of the surrounding buttocks with both of your gloved hands to expose the peri-anal skin.
- Look for signs of acute or chronic skin irritation, contact dermatitis, a punctate external fistula opening, erythema and painful raised area (abscess), or thrombosed external hemorrhoid with or without overlying skin ulceration.
- Be knowledgeable about the difference between an anal skin tag, an external hemorrhoid, and a sentinel skin tag adjacent to a fissure that might not be evident.
- Evaluation for anal fissure can be difficult as the patient typically has anal hypertonia (anal spasm) as well. You may need an assistant to help you fully retract the peri-anal skin and efface the anal canal for a complete visual examination. If you find an anal fissure, do NOT proceed with digital rectal examination or anoscopy at this time; digital examination and anoscopy are extremely painful examinations for the patient with an anal fissure. You should perform a digital examination and anoscopy after the patient’s symptoms resolve (typically six to eight weeks later with appropriate treatment).
2. Digital Anal Canal and Lower Rectal Examination
- Although it is uncomfortable, most patients without an active fissure, abscess, or thrombosed external hemorrhoid are able to tolerate this examination.
- If a patient reports too much pain to attempt or tolerate the examination and external pathology is not seen (except skin tags), then reexamine the external area and gently press with your finger or a cotton swab to place pressure on all soft tissue circumferentially around the anal area to check for an area of maximum tenderness. If such an area is found, occasionally the more thorough external examination alone reveals the source, such as a fissure or deeper abscess.
Do NOT perform anoscopy if any of the following are present:
- The patient has a midline (anterior or posterior) anal fissure.
- The patient is having anal pain during digital examination or cannot tolerate a digital examination.
- A tender purple marble-like “ball” that is firm is present—it is likely a thrombosed external hemorrhoid.
- A red, fluctuant, tender area is present—it is likely an abscess.
Key point: If a mass is seen on external examination or anoscopy and there is any question of pathology such as malignancy, the area should be evaluated by a physician familiar with diseases of the anus and rectum to further determine whether biopsy is indicated.
Common Anal Problems
Benign Anal Disease
Many problems may be categorized as hemorrhoids by the general public. However, the etiologies and management can vary, so it is important to differentiate between entities such as anal itching (Table 1), anal fissure (Figure 1, Table 2), hemorrhoids (Table 3), and anal abscess/fistula (Figure 2, Table 4). Another benign anal problem that patients may attribute to hemorrhoids is anal incontinence (Table 5).2-26
Common Anal Masses
Similarly, not all masses near the anus represent hemorrhoids, though the difference can be subtle. Anal skin tags (Figure 3, Table 6) are usually the result of excess skin after repeated scarring (such as healing from an anal fissure), and anal warts
(Figure 4, Table 7) are commonly outgrowths of tissue caused by viral infection.
Dietary and Lifestyle Changes
The Industrial Revolution has resulted in a diet lacking in sufficient fiber. People tend to lack knowledge about how much fiber they are consuming, or how much they should consume.27 In addition, fiber is typically marketed as a “laxative,” and patients with diarrhea or loose stool are frequently nervous about taking a product that is for “constipation.” Fiber works by absorbing and retaining fluid, thereby softening hard stool and thickening loose stool. Adequately fiber-bulked stool results in more complete evacuation with bowel movements, less sputtering of bowel movements, less straining with bowel movements, and more regularity with bowel movements.
The US Department of Agriculture and US Department of Health and Human Services recommend that you eat 25 g to 40 g of fiber daily,28 but most people get less than half this recommendation. Adequate fiber intake is important for many reasons:
- Fiber helps regulate bowel movements by softening hard stool to reduce constipation and adding bulk to loose stool to reduce diarrhea
- Common anal problems such as fissures and hemorrhoids are caused by inadequate fiber and water intake
- Adequate fiber will reduce the risk of developing colorectal cancer, diverticulosis, and complications of diverticulitis
- Adequate fiber will reduce cholesterol.
When advising patients regarding increasing fiber intake (Table 8)
- stress the fact that most people do not consume adequate fiber
- advise patient to keep a log of the daily fiber intake for one week to see exactly how much the intake really is
- ask them to read food labels thoroughly to check fiber content instead of assuming labels such as “whole wheat” mean a high fiber content
- adding fiber supplements is helpful, but caution is needed when choosing the fiber supplement. Commonly used supplements like “fiber pills” and orange-flavored psyllium are inadequate. Reading the labels of these products, including the serving size and fiber content, is important. For example, most fiber pills have half a gram of fiber. Therefore to get 20 g of additional daily fiber, someone would need to take 40 pills a day
- increasing water intake to at least 64 oz daily is needed so fiber can work properly. Daily intake of caffeinated beverages would increase the need for water intake owing to caffeine’s diuretic properties.
Proper Bowel Movements
When advising patients on a proper bowel movement, the following key points should be emphasized:
- Spending excessive time on the toilet is harmful. Avoid sitting on the toilet more than two minutes
- The rectum empties better when in a squatting position. When using a Western toilet, place a stool under your feet and lean forward to mimic that position
- Do not clean excessively and avoid cleansing wipes. Use water without chemicals. Using a bidet attachment eases the cleaning process in a quick and simple manner.
Most anal health problems are a result of inadequate fiber and water intake along with poor bowel and bathroom habits. With improved awareness and understanding on the physician’s part, and guided changes in dietary intake and bathroom behavior modifications on the patient’s part, most patients will have complete resolution of their symptoms. Accurate evaluation and diagnosis are the key. This can be achieved with a thorough history and physical examination. The assumption by patients and physicians that most anal problems are caused by “hemorrhoids” leads to an error in diagnosis, incorrect management strategies, worsening of disease-related symptoms, development of new symptoms such as contact dermatitis, and delay in accurate diagnosis and resolution of symptoms. Avoiding harmful products such as anal wipes and steroid ointments or suppositories is important because contact dermatitis is associated with worsening of the anal symptoms and delayed symptom improvement, once an accurate diagnosis has been made. If there is a question as to the correct diagnosis or treatment, referral to a specialist in diseases of the anal and rectal area can be helpful. Online resources may be found in the Sidebar: Useful Online Resources
The author(s) have no conflicts of interest to disclose.
Mary Corrado, ELS, provided editorial assistance.
How to Cite this Article
Chang J, McLemore E, Tejirian T. Anal health care basics. Perm J 2016 Fall;20(4):15-222. DOI: https://doi.org/10.7812/TPP/15-222.
1. Grucela A, Salinas H, Khaitov S, Steinhagen RM, Gorfine SR, Chessin DB. Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience. Dis Colon Rectum 2010 Jan;53(1):47-52. DOI: https://doi.org/10.1007/dcr.0b013e3181bbfc89.
2. Boyapati A, Tam M, Tate B, Lee A, Palmer A, Nixon R. Allergic contact dermatitis to methylisothiazolinone: exposure from baby wipes causing hand dermatitis. Australas J Dermatol 2013 Nov;54(4):264-7. DOI: https://doi.org/10.1111/ajd.12062.
3. Timmermans A, De Hertog S, Gladys K, Vanacker H, Goossens A. ‘Dermatologically tested’ baby toilet tissues: a cause of allergic contact dermatitis in adults. Contact Dermatitis 2007 Aug;57(2):97-9. DOI: https://doi.org/10.1111/j.1600-0536.2007.01161.x.
4. Gardner KH, Davis MD, Richardson DM, Pittelkow MR. The hazards of moist toilet paper: allergy to the preservative methylchloroisothiazolinone/methylisothiazolinone. Arch Dermatol 2010 Aug;146(8):886-90. DOI: https://doi.org/10.1001/archdermatol.2010.114.
5. Zoli V, Tosti A, Silvani S, Vincenzi C. Moist toilet papers as possible sensitizers: review of the literature and evaluation of commercial products in Italy. Contact Dermatitis 2006 Oct;55(4):252-4. DOI: https://doi.org/10.1111/j.1600-0536.2006.00919.x.
6. Ulrich G, Schmutz JL, Trechot P, Commun N, Barbaud A. Sensitization to petrolatum: an unusual cause of false-positive drug patch-tests. Allergy 2004 Sep;59(9):1006-9. DOI: https://doi.org/10.1111/j.1398-9995.2004.00452.x.
7. Adams BB, Sheth PB. Perianal ulcerations from topical steroid use. Cutis 2002 Jan;69(1):67-8.
8. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol 2014 Aug;109(8):1141-57. DOI: https://doi.org/10.1038/ajg.2014.190.
9. Sajid MS, Whitehouse PA, Sains P, Baig MK. Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure. Colorectal Dis 2013 Jan;15(1):19-26. DOI: https://doi.org/10.1111/j.1463-1318.2012.03042.x.
10. Schiano di Visconte M, Munegato G. Glyceryl trinitrate ointment (0.25%) and anal cryothermal dilators in the treatment of chronic anal fissures. J Gastrointest Surg 2009 Jul;13(7):1283-91. DOI: https://doi.org/10.1007/s11605-009-0889-4.
11. Goldman L, Kitzmiller K. Perianal atrophoderma from topical corticosteroids. Arch Dermatol 1973 Apr;107(4):611-2. DOI: https://doi.org/10.1001/archderm.1973.01620190083022.
12. Tejirian T, Abbas MA. Sitz bath: where is the evidence? Scientific basis of a common practice. Dis Colon Rectum 2005 Dec;48(12):2336-40. DOI: https://doi.org/10.1007/s10350-005-0085-x.
13. Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev 2012 Feb 15;2:CD003431. DOI: https://doi.org/10.1002/14651858.cd003431.pub3.
14. Moesgaard F, Nielsen ML, Hansen JB, Knudsen JT. High-fiber diet reduces bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum 1982 Jul-Aug;25(2):454-6. DOI: https://doi.org/10.1007/bf02553653.
15. Alonso-Coello P, Mills E, Heels-Ansdell D, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol 2006 Jan;101(1):181-8. DOI: https://doi.org/10.1111/j.1572-0241.2005.00359.x.
16. Alonso-Coello P, Guyatt G , Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 2005 Oct 19;(4):CD004649. DOI: https://doi.org/10.1002/14651858.cd004649.pub2.
17. Johannsson HO, Graf W, Påhlman L. Bowel habits in hemorrhoid patients and normal subjects. Am J Gastroenterol 2005 Feb;100(2):401-6. DOI: https://doi.org/10.1111/j.1572-0241.2005.40195.x.
18. Sakakibara R, Tsunoyama K, Hosoi H, et al. Influence of body position on defecation in humans. Low Urin Tract Symptoms 2010 Apr;2(1):16-21. DOI: https://doi.org/10.1111/j.1757-5672.2009.00057.x.
19. Dimmer C, Martin B, Reeves N, Sullian F. Squatting for the prevention of heamorrhoids? Townsend Letter for Doctors and Patients 1996 Oct;(159):66-70.
20. Sikirov D. Comparison of straining during defecation in three positions: results and implications for human health. Dig Dis Sci 2003 Jul;48(7):1201-5. DOI: https://doi.org/10.1023/A:1024180319005.
21. Rad S. Impact of ethnic habits on defecographic measurements. Arch Iran Med 2002 Apr;5(2):115-7.
22. Greenspon J, Williams SB, Young HA, Orkin BA. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Dis Colon Rectum 2004 Sep;47(9):1493-8. DOI: https://doi.org/10.1007/s10350-004-0607-y.
23. Clinical Practice Committee, American Gastroenterological Association. American Gastroenterological Association medical position statement: diagnosis and treatment of hemorrhoids. Gastroenterology 2004 May;126(5):1461-2. DOI: https://doi.org/10.1053/j.gastro.2004.03.001.
24. Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD, Rafferty JL; Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum 2011 Sep;54(9):1059-64. DOI: https://doi.org/10.1097/dcr.0b013e318225513d.
25. Russell MM, Ko CY. Management of hemorrhoids: mainstay of treatment remains diet modification and office-based procedures [Internet]. Rockville, MD: National Guideline Clearinghouse, Agency for Healthcare Research and Quality; 2012 Jul 16 [cited 2016 Mar 18]. Available from: www.guideline.gov/expert/expert-commentary.aspx?id=37828.
26. Norton C. Fecal incontinence and biofeeedback therapy. Gastroenterol Clin North Am 2008 Sep;37(3):587-604. DOI: https://doi.org/10.1016/j.gtc.2008.06.008.
27. Clemens R, Kranz S Mobley AR, et al. Filling America’s fiber intake gap: summary of a roundtable to probe realistic solutions with a focus on grain-based foods. J Nutr 2012 Jul;142(7):1390S-401S. DOI: https://doi.org/10.3945/jn.112.160176.
28. US Department of Agriculture, US Department of Health and Human Services. Dietary Guidelines for Americans, 2010 [Internet]. 7th Edition, Washington, DC: US Government Printing Office, 2010 Dec [cited 2016 Apr 18]. Available from: http://health.gov/dietaryguidelines/dga2010/dietaryguidelines2010.pdf