aids-hospice-mouroir-sida-medical-protocol-anus-en

4- Anal Area

Don't confuse hemorrhoids, herpes, prolapse, condyloma acuminata, chancre, fissures... Not all anal pains are hemorrhoids and hemorrhoids can be painless. A simple look at the lesion may allow an accurate diagnosis!

Hemorrhoids

(axx002) (axx009) (axx010)

Local hygiene with normal soap.
Hemorrhoid cream/suppository containing corticoids should not be used if herpes/fungus wounds are present in the area (creams with corticoids are not indicated for viral/fungal wounds). Creams containing analgesics only, e.g. xylocaine may be used and are helpful in controlling pain.

NB We sometimes forget that hemorrhoids can be the result of intra vascular accretion. If inflammation is not a problem, and if psychologically possible, a soft anal massage/dilatation with 3-4 fingers (+ aqua soluble cream) can often improve symptoms.

Rectal prolapse

(axx003) (axx004) (axx028...)

Often no pain. No serious inflammatory signs. Often mildly incontinent.

Try to reintroduce rectum inside body, slowly, with hand (using "aqua soluble gel" (KY) to make reduction without pain), allowing gravity to assist (head down, pelvis up position).

Parasites (pinworms, etc.) can cause rectal prolapse... It is never dangerous to give mebendazole 100mg 2x/day for 3days or 100mg 6x/day for one day.

If the problem is long-standing and not painful, there is nothing we can do with the technology we have here.

Fistula

(axx019...) (axx024) (axx031)

You infuse a liquid into the "abnormal hole" and the liquid goes out by the anus... Treat any abscess in the anal area (axx040) aggressively to prevent the formation of a fistula...

Fissure

//axx039 //

Pain!!! Often needs a stool emollient and local xylocaine gel before passing stool... If cause is not evident, treat for worms and constipation...

Dr Catton's addendum (experience & photos in Black Africa)

Afr-axx01 (black patients)

I believe it is dangerous (i.e. contra-indicated) to do an anal stretch for fissure in an HIV patient. The reasons are:

There is a huge risk of permanent incontinence - HIV patients often have debilitating diarrhoea.
The fissure is "internal" rather than "external" and arises from a different pathology to the classical anal fissure due to straining with a constipated stool, and there is generally no anal spasm . Thus treatments with GTN, diltiazem, or nifedipine creams (all very expensive anyway) don't work.
The cause of the fissure is unclear: it may be cryptococcal or more likely from herpes, in which case acyclovir may help.
The fissure may deepen and produce a large fistula, through which you can even pass a little finger!
In such case, a defunctioning colostomy will render a patient smell-free with a controllable bowel action. (It is actually cheaper than repeat washings of towels & nappies)

Condyloma "Acuminata" & "Lata"

axx006- axx011- axx012- axx013- axx016- axx017- axx018-

Granular warts.

Condyloma Lata has a large root with flatter flesh that is less granular than Condyloma Acuminata. C.Acuminata looks more like a small "cauliflower" and C. Lata more like a big "granulous papule". Confusion often occurs, especially if lesions are new/immature.

Condyloma Lata is a symptom of syphilis and has to be treated as syphilis (see 37-Specific Protocol)

Condyloma Acuminata should be treated with podophilin if available, but a doctor must demonstrate the procedure the first time because errors can cause painful deep wounds! But!!! (As is the case for gonorrhea/chlamydia), association of condyloma acuminata with syphilis is common. It may therefore be better to treat it as an "invisible syphilis"! In other words, the best policy may be to treat any condyloma as syphilis and treat with podophilin the condyloma that will not improve with syphilis treatment.

Dr Catton's addendum:

afr-axx002 (black patient) Gross condylomata. Best not to tackle all in one sitting, unless you make a big elliptical incision and close with flaps (risky in the HIV patient without ARV treatment). Healing is good despite extensive disease, after diathermy excision, but anal stenosis may result: so do the excision in 2,3,4 stages, and provide an anal dilator.