Abscess/ Fistula-in-Ano (Ano-Rectal Fistula) /Anal Pruritis (Anal Itch)

ABSCESS - Basic Information

An ano-rectal abscess usually occurs from trauma when a portion of the stool becomes caught in the anal crypt or anal gland and an infection results. It is often painful and can progress to a dangerous stage if untreated.

In its early stage the infection is called cryptitis. This infection involves sphincter muscles surrounding the anus in which a cavity forms and pus gathers. This is then called a perirectal abscess. The bacterial infection can be mixed. The predominant infectious agents include:

• streptococci
• staphylococci
• bacteroides
• Proteus vulgaris
• Escherichia coli

Often a homosexual male will assume that his abscess is due to anal penetration and out of embarrassment is loath to seek medical attention promptly. Unfortunately postponing medical attention can lead to a worsening of the abscess until it becomes a perirectal abscess. The abscess burrows toward the skin, destroying more tissue in the process. If medical attention is not sought the abscess will eventually break and the pus will drain out. However the cavity is not able to drain fully because the hole is not big enough and pus will once again gather. But in the meantime the infection is killing more and more tissue which can even include the sphincters. The end result could be an inability for the patient to control his or her bowels.

Symptoms

Superficial abscess

• usually very painful
• warm or hot to the touch
• tender to the touch
• swelling
• reddening of the skin

Deep abscess

• pain usually less severe than with superficial abscess
• may cause toxic symptoms

Diagnosis/Treatment

Your health care provider will most usually wish to perform a digital rectal examination which will indicate swelling as external swelling may not be present. Your health care provider will also check for Crohn's disease (inflammatory bowel disease) which is sometimes linked with abscesses. Suppuration is usually present at time of diagnosis.

Treatments with antibiotics are not usually recommended as they have little value. Treatment indicated for perirectal abscess is I&D (incision and drainage) in which a general or regional anesthesia is required. Usually surgery is successful but there are cases of ano-rectal fistulas developing after drainage.

Remember it is important to seek treatment for an abscess promptly as in certain cases sphincter tissues are destroyed leaving patients unable to control their bowels. Also, an abscess can move up along the colon rather than push out toward the skin, causing fever and difficulty in moving with several surgeries required instead of one I&D.

FISTULA-IN-ANO (ANO-RECTAL FISTULA) - Basic Information

A fistula-in-ano is a tube-like tract. One opening is in the perianal skin, the other in the anal canal. They can be caused from either the drainage of a perirectal abscess or by a mild infection burrowing to the skin and bursting like a pimple. They usually begin in the anal-rectal crypts but sometimes result from

• trauma
• diverticulitis
• neoplasm

Though it can be caused by sexual intercourse it's rare. Rectovaginal fistulas can be secondary to obstetric injuries or Chron's disease while infant fistulas are congenital and seen more commonly in boys.

Symptoms

Most symptoms are not severe, disappearing from time to time only to occur again. A patient can feel what seems like a tiny pimple beside his or her anal opening that is usually painful and swells. As pus drains symptoms can be relieved. However, if it does not drain, an abscess will usually occur. That is why treatment is necessary.

Diagnosis/Treatment

Your health care provider will want to take a history of abscesses that have occurred in the patient. Anoscopy and sigmoidoscopy are indicated to determine the depth and condition of the tract.

Treatment is surgical. A fistulotomy opens the fistula and takes away debris, allowing healing to occur from the inside out. Usually surgery is successful and pain is relieved.

Problems can arise if the fistula goes through the sphincter muscles. In this instance surgery is done stage by stage and is more difficult to perform. An unfortunate side effect would be inability to control bowel movements but this is the exception not the rule.

Remember, fistula-in-ano must be treated even if your symptoms do not seem severe.

ANAL PRURITUS (ANAL ITCH) - Basic Information

This is a chronic skin irritation in the perianal skin that can have many causes though the most likely is from an allergic reaction that is irritating the area. Yet other causes can include:

• psoriasis
• atopic dermatitis
• pinworms, scabies, pediculosis
• tetracyclines
• poor hygiene
• tight clothing or warm bed clothing
• diabetes melitis
• draining fistulas

Symptoms

Surrounding skin of the anus reddens and cracks, eventually becomes thick and callused Unfortunately the itch is at its worst during the night and patients scratch the area in their sleep causing cutting, scabbing and bleeding. Secondary infections can occur.

Diagnosis/Treatment

Naturally your health care provider will want to try to determine the cause of your anal or perianal itching before deciding on a treatment plan for you. In all cases the area around the anus should be cleaned with absorbent cotton and moistened with water. Toilet paper should not be used because of skin irritants. Instead Tucks are recommended. Hydrocortisone used lightly is usually beneficial. Topical fungicides may also be recommended.

If parasitic infestations are determined to be the cause of your itching they must be treated with appropriate medication. If there are any suspicious lesions they should be biopsied.

Loose clothing so as not to cling to the anal area is necessary and wearing light clothing during sleep is recommended so that sweating is kept to a minimum.

The usual culprit however is something you are allergic to. By eliminating foods that can irritate your skin when they come out in your stool the offending culprit may be found. Your health care provider may recommend this process of elimination of stopping all likely offending foods, then adding them bit by bit over time to see which you can tolerate and which suddenly makes your itching worse. That way you will identify the irritant that is causing your itch. The most likely foods that cause irritation include:

• alcohol, especially wine
• caffeine, especially coffee
• spicy foods
• acidic foods, especially juices
• milk (if you have a problem digesting it)

Remember, after eliminating possible causes of your itch which include chemicals or perfumes as well as foods and your itch does not go away your health care provider will evaluate if a more serious problem could be a possible cause. That is why it is important to follow up with your health care provider the status of your anal or perianal itching and the affecting irritants that you have consciously avoided

If you have or suspect you have any of these ano-rectal disorders, please consult promptly with your health care provider.