Perianal Disease: Not Everything down there is a Hemorrhoid (Cortez, 11/20/2024)

 A recording of this presentation is available HERE. 

Many thanks to Dr. Allen Cortez for an excellent presentation on perianal disease. I learned a lot and was really impressed by how much Dr. Cortez, a long-time local general surgeon, knows and cares about a region of the body that many people are pretty uncomfortable talking about. I recommend you watch his presentation, the link above. 

My notes:

Hemorrhoids are extremely common -- 5-10% of the population, >2.2 million people per year with over 2 million prescriptions per year that add up to over $43 million in healthcare costs. But many patients are being treated for hemorrhoids when there may be other things going on down there, including: fissures, fistula, abscess, pruritis, and rectal prolapse. 

Dr. Cortez reminded us to go back to the basics: 1) listen to the patient (e.g. hemorrhoids generally don't hurt, so if the patient is complaining of pain, broaden your ddx) and 2) examine the patient.

Fiber

Encourage fiber! All our patients need more fiber. And fiber isn't good for just the perianal region. Fiber decreases risk of cardiovascular disease, decreases risk for colon cancer. "The best fiber out there is the one you'll take". Really, the only downside is increased flatulence.

Fiber options abound, including: psyllium husk, benefiber (can sprinkle on yogurt), fiber capsules or gummies (e.g. Kirkland brand, 2-4 gummies 2x per day, with LOTS of water).

Once you start a fiber supplement, don't make any changes for 5 days.

Miralax is good too, but it shouldn't replace fiber. Use miralax PRN for constipation. 

Dr. Cortez reminded us that the increased pressure of diarrhea can also contribute to hemorrhoids. The goal is ONE nice big healthy bowel movement per day, no more than 4-5 minutes sitting on the pot. It is better to return 3 or more times than sit for prolonged period of time on the toilet.

When you are going to examine a patient for perianal complaints: put them in L lateral decubitus (better to see than lithotomy). Look externally for tags, fissures/openings, thickened skin, ulcerations, masses. If you see a fissure stop there (you can make it worse). Use anoscopy and a digital exam to check for tone, masses, blood, etc. 

Dr. Cortez is not a fan of donuts for any perianal condition. In his eloquent words: "Gravity tries to push your liver right out your butt"

Hemorrhoid Treatment 

1) Banding (in office), no prep, effective, can be done several times, no downtime, no severe pain

2) Hemorrhoidectomy (surgical) is always a last resort, very pain ful but most effective. Stapled hemorrhoidectomies are not superior.

Thrombosed hemorrhoids, which present as big purple extremely painful lumps should be unroofed in first 2-3 days for pain control (in ED or office). If it has been > 5 days, healing is equivalent and intervention is not indicated.

Fissures

Perianal fissures, which are tears in the anoderm exposing the sphincter muscles, are extremely painful. Patients may describe symptoms as "crapping out glass" or "jamming a knife in my butt". 73% present midline posteriorly. If you visualize a lateral fissure, that patient needs a work-up, including testing for Crohn's, HIV, syphillis, TB and more. 

Acute fissures (< 6 months) can be treated with fiber, fiber and fiber, as well as hydration and sitz baths. This takes time! Topicals can sooth and manage symptoms, including topical nitroglycerine. Dr. Cortez's preferred topical is compounded diltiazem/nifedipine cream (locally can get compounded at Dollar Drug). Can be rx'd TID.

Chronic fissures (>6 months) require treatment with chemo-denervation, including Botox, which is effective and stops spasm. Some people need surgical intervention: with sphincterotomy or anocutaneous flap.

Perianal abscess

Perianal abscesses can also be extremely painful. 30-70% of abscesses have an accompanying fistula. 40-50% will develop a fistula over time.

 Treatment of perianal abscess is I&D, and usual management with packing is not effective because the skin often heals over before the abscess heals. Instead make a BIG incision (this may require sedation-- need to happen in ED?) and may need an initial packing but then should probably not be packed . Perianal abscesses can occur in several locations: ischiorectal, intersphincteric, perianal and supralevator. No antibiotics are indicated once drainage (i.e. source control) is achieved. Many fistulas will heal themselves and not all perianal abscesses need CT imaging. But if you are concerned, send to surgeon for further assessment. 

Malignancy

Finally, malignancies can present in the perianal region and the only way to diagnose them is to look for them. These can include squamous cell carcinomas and melanomas. See images below for some examples.