Anorectal: Anal Incontinence & Pruritis

Anal Incontinence

Definition

  • Involuntary Loss of Feces/Gas
  • Requirements:
    • ≥ 4 Years Old
    • No Mental Disability or Had Previously Achieved Continence

Specific Causes

  • Obstetric Injury/Delivery
    • Most Common Cause
    • Often See Thin Perineal Body
  • Abdominoperineal Descent (Anus Below Levator)
    • From Chronic Damage to Levator Muscle & Pudendal Nerve
    • Most Common in Obese or Multiparous
  • Fecal Impaction
    • Often from Chronic Constipation
    • Tx: Disimpaction & Routine Enemas
  • Chronic Diarrhea
  • Neurogenic Incontinence (Gaping Hole)
    • Responds Poorly to Tx
  • Anorectal Surgery
  • Rectal Prolapse
  • Trauma

Management

  • Initial Tx: Lifestyle Modification & Antidiarrheal Medication
    • Lifestyle Modifications:
      • Perianal Skin Care
      • Barrier Creams
      • Dietary Changes
      • Physical Therapy to Strengthen the Pelvic Floor
    • If Fails: Dx
  • Dx: EUS or MRI
    • Intact Sphincter: High-Fiber Diet
      • If Fails: Surgery
    • Defective Sphincter: Surgery
  • Surgical Options:

Pruritis Ani

Definition

  • Anal Itching & Burning

Etiology

  • Primary/Idiopathic (50-90%)
    • Poor Hygiene – Most Common Cause
      • Worse in Warm Weather from Increased Moisture
    • Dietary Foods
      • Caffeine
      • Carbonated Beverages
      • Energy Drinks
      • Beer
      • Dairy
      • Citrus Fruits
      • Chocolate
      • Tomatoes
      • Spicy Foods
    • Local Irritation
    • Medications
  • Secondary
    • Infection
    • Lichen Planus/Sclerosis
    • Psoriasis
    • Contact Dermatitis
    • Radiation-Induced Dermatitis
    • Diabetes
    • Chronic Kidney Disease
    • Anorectal Disease – Hemorrhoids, Abscess, Fistula, Fissure, etc.
    • Malignancy, Paget’s Disease or Bowen’s Disease

Washington Staging Criteria

  • Stage 0: Normal Appearing Skin
  • Stage I: Erythema & Inflammation
  • Stage II: White-Lichenified Skin
  • Stage III: Lichenified Skin with Erosion & Ulceration

Treatment

  • Primary Tx: Lifestyle Modifications
    • Modifications:
      • Improve Hygiene
      • Avoid Pruritic-Inducing Foods
      • Avoid Moisture or Tight-Fitting Clothes
    • If Secondary Treat Underlying Condition
  • If Lifestyle Modifications Fail After 2 Weeks: Topical Steroids
  • Intractable Disease:
    • Consider Bx
    • Consider Methylene Blue Injection – Destroys Perianal Nerve Terminations