Pathologies

incontinence

What is incontinence?

incontinence is the inability to control gas, liquid stool or solid stool during different life situations. The severity of this pathology ranges from the simple loss of gas during exertion to the loss of stool formed at night. It is a common condition that affects 10 to 15% of the population. It is associated with urine loss (urinary incontinence) 1 time out of 2.

What causes incontinence?

The main causes are damage to the sphincter muscles of the anus and pelvic floor, damage to the nerves of the sphincters, weakness of the pelvic floor causing prolapse of the pelvic organs. These lesions are often generated by childbirth. Incontinence occurs many years after the trauma when the musculature weakens with the phenomenon of aging.

What symptoms do patients suffer from?

Some lose their feces without feeling it (passive incontinence). Others feel the urgent need to evacuate but cannot hold it back to the toilet (emergency incontinence). Finally, others notice oozing that stains their underwear after defecating (post-defecatory incontinence).

What investigations and tests are necessary to diagnose incontinence ?

A questionnaire and a proctological clinical examination should be performed by a specialist. An anorectal physiological assessment and an endo-and/or perineal ultrasound (ultrasound) will then be decided if necessary. In case of suspicion of prolapse causing symptoms, a defecography and / or MRI defecography may be required to ensure the diagnosis. In case of urinary disorders, a urological consultation will be requested.

What therapeutic solutions can be offered ?

In 80% of cases, simple hygiene-dietary measures are sufficient. They consist of firming the stool by an appropriate diet, and / or by medication. Patients who do not see improvement by these simple measures can benefit from pelvic floor physiotherapy. This specific physiotherapy must be entrusted to professionals trained in perineology (www.aspug.ch).

If symptoms persist, a surgical approach is discussed. A simple isolated lesion of the internal sphincter can be corrected by injecting a volume agent.

In the event of greater sphincter damage, sphincter reconstruction (performed by a surgeon trained in this careful technique) gives good results.

Sacral neuromodulation is indicated for incontinence whose cause is neurological.

Surgeries to restore disorders of the statics of the perineum are proposed during major damage to the muscles of the perineum or in case of prolapse of the perineal organs (descent of organs). These reconstructions are carried out at the same time by pooling the skills of the various perineum specialists. Working as a team, they will have first consulted each other to study, analyse and decide on the best therapeutic strategy. 

Tumors of the area

Are all tumors cancers?

No. A tumour is any lump  in the anal canal or at the anal margin, which gradually increases in size over a few weeks. With rare exceptions, tumours arise from the surface coating, the type of which varies with depth. Deep in the rectum and the deep part of the anal canal, the mucosa will see the appearance of intestinal polyps that are initially benign and can slowly turn into cancer. Further outside, an area of the anoderm will pass through a pre-cancer stage (dysplasia area) but without carrying a tumor. Secondarily it will evolve into a so-called squamous cancer, meaning a local invasion. The perianal skin it can make classic skin tumors, such as squamous cell cancer and melanoma.

How common are these diseases?

No. Fortunately, cancer accounts for only 1% of cancers of the digestive tract. However, their incidence tends to increase and groups with risky sexual behaviour are particularly affected. The incidence of colorectal cancer in Switzerland is around 50 cases/100,000 inhabitants.

How is the diagnosis made?

The diagnosis of any benign or malignant tumour should be based on one or more samples called biopsies (needle, endoscopic or  surgical). The stage of advancement of the disease will be defined by the size of the tumor, the involvement of the lymph nodes and the presence of distant metastases. An anoscopy, rectoscopy, endoanal and inguinal ultrasound, MRI, CT scan and blood test are usually required.

Are there any risk factors?

The appearance of rectal cancer is essentially related to the genetic characteristics of the individual. Individuals with polyps or who have previously had digestive cancer, those with relatives who are carriers of colorectal cancer, and people with intestinal polyposis, Lynch syndrome or inflammatory bowel disease are at risk.

Squamous cell cancer of the anus is linked to a local HPV infection (viruses whose oncogenic subtypes have the power to promote dysplasias).

So can I prevent the development of cancer?

Yes. Direct examination of the perianal skin, rigid anoscopy and rectal endoscopies can detect pre-cancer changes (polyps, erosions and dysplasia). Specific search for high-risk HPV by direct sampling is now possible. People at risk (see above) must enter a specific detection program.

What is the treatment for tumors?

Polyps of the rectum and anus must be imperatively and completely resected. Areas of advanced anoderm dysplasia should also be excised.

Surgery is the main treatment for digestive cancers (rectum and deep anal canal). A pre- or post-operative complement of combined chemotherapy and radiotherapy may be added.

Squamous cell cancers respond favorably to radiotherapy, which is often combined with radiosensitizing chemotherapy. In case of failure, an operation must be discussed. 

Chronic anoperineal pain

What is anoperineal pain?

Anoperineal pain is divided into 2 groups:

• Anatomical substrate pain, that is to say whose origin is clear, (fissure, abscess, hemorrhoidal thrombosis, perineal static disorders ...) are described in the chapters relating to these pathologies 
• So-called essential pain (5% of pains)

What are the main causes of anoperineal pain?

• anorectal spasms or fugax proctalgia,
• myofasciodynia or coccygodynia in relation to musculo-ligament overloads often generated by poor posture 
• Pudendal nerve compression pain can be comparable to carpal tunnel syndrome

What symptoms do patients suffer from?

The type of pain varies from patient to patient.
Proctalgia usually gives pain such as nocturnal spasms.
Myofasciodynia generates pain when sitting with sometimes falling asleep of the perineal region.
Nerve compressions shame of burning-type pain aggravated when sitting.

What are the investigations and tests necessary for the diagnosis of essential pain?

A questionnaire and a proctological clinical examination should be performed by a pathology specialist. An anorectal physiological assessment and an endo-and/or perineal ultrasound (ultrasound) will then be decided if necessary. A magnetic resonance imaging (MRI) assessment of the pelvis and spine looks for possible nerve compressions. An undercover diagnostic test may be offered depending on the suspected diagnosis.

What therapeutic solutions can be offered?

A multidisciplinary approach through symptomatic treatments (drug, osteopathy, physiotherapy) can solve the problem in 80% of cases.
Surgery should only be considered as a last resort. It gives results in more than 60% of neurological compressions of the pudendal nerve. In all cases, it must be associated with multidisciplinary care.
 

Sexually transmitted infection (STI)

A sexually transmitted infection (STI) is an infection that is transmitted between partners during different forms of genitinal, oral or sex .

All sexual practices that involve contact with another person (without protection), are potentially at risk of transmitting an STI. The risk varies depending on the practices and the infectious agent involved.

The following diseases are mainly sexually transmitted :

Bacterial origin:

• gonorrheo (Nesseria gonorrheo)
• Chlamydia (Chlamydia trachomatis)
• lymphogranuloma venereum (Chlamydia trachomatis)
• Chancroid (Haemophilus ducreyi)
• syphilis (Treponema palidum)

Parasitic origin:

• trichomoniasis

Viral origin:

• herpes (HSV)
• genital warts or genital warts (HPV)
• cancer of the cervix, anus, vagina and orophringeal zone (HPV)
• hepatitis B, C (HBV, HCV)
• HIV responsible for AIDS

These diseases can result in various symptoms, they can go unnoticed. Their description is beyond the scope of this site. But let's remember that risky behaviour requires frequent screening.

In Switzerland there are anonymous reporting procedures for syphilis, gonorrheo and lymphogranuloma venereum, which allow epidemiological monitoring.

Treatment:

Bacterial and parasitic infections respond to antibiotic treatment. This is usually quickly effective. Resistance is beginning to be observed. The treatment of viral infections makes it possible to control the disease without the eradication of the virus itself being expected (HPV, HIV, HBV, HCV, HSV). Only papillomavirus (HPV)-related lesions may require surgery.

Prevention:

The best prevention remains the systematic use of condoms. sex is particularly at high risk of transmission and its practice without protection should be strictly reserved for safe partners.

Para-abscesses

What is a para-anal abscess?

A para-anal abscess is an infection in the form of a collection of pus in the area of the anus. This infected pouch is the site of a proliferation of digestive-type bacteria that put this cavity under strong pressure. The abscess initially of a few millimeters then extends into the tissues of least resistance around its perimeter and increases in size. It diffuses through the layers of the musculature of the anus (called sphincter) and willingly fuses into the fat of the buttock. It then forces the skin and tends to drain spontaneously in the form of a discharge of pus near the anus.

How does a para-anal abscess present itself?

The para-anal abscess usually presents as a hard, red, painful and hot "ball " located up to 10 cm around the anus. Pain is characteristic. Well localized, it is willingly pulsatile (" I have my heart in the back ") and very intense, making it difficult to sleep. The painful pressure of the abscess increases for 48 to 72 hours until spontaneous discharge, which usually relieves the patient. Fever is uncommon and when present signals a deeper (high) location of the abscess.

Where do paraanal abscesses come from?

More than 90% of para-abscesses are due to the occlusion of one of the lubrication glands of the anus (Hermann and Desfosses glands). These are located between the two cylinders of internal and external sphincter muscles. For a small number, the abscess may be related to a pre-existing condition. The abscess is then a complication of the underlying disease, which must be diagnosed correctly to control the infection (anal canal lesions, cracks, sexually transmitted diseases, inflammatory bowel diseases such as Crohn's disease, tumors).

Is this dangerous?

The infection can spread into the blood or fatty tissue of the perineum (Fournier's gangrene). This fortunately rare but serious situation can be deadly.

Release of the abscessed pocket should be carried out quickly.

What needs to be done?

Treatment with antibiotics is not enough to treat the abscess. An incision of the skin to the abscess pocket should be made away from the sphincter muscles. This can be done under local anesthesia and on an outpatient basis.   It can sometimes require general anesthesia and hospitalization for a few days. The placement of rubberized drain in the wound is sometimes necessary (horseshoe abscess).

How has it evolved?

The closure of the incision is expected within 3 to 4 weeks and usually allows a return to work within 15 days. In more than half of the cases, however, the progression will be towards a recurrence of the infection along the same path, thus constituting a fistula.

Chronic constipation

Constipation is a common condition that affects people of all ages. This may mean that you don't pass bowel movements (poop) regularly, or you are unable to empty your bowels completely.

Constipation can also cause stools to be hard or pass as small pebbles or large painful pieces.

The severity of constipation varies from person to person. Many people do suffer from constipation for a short time, but for others, constipation can be a chronic (long-term) condition that causes pain and discomfort and affects quality of life.

What causes constipation?

It is often difficult to identify the cause. However, there are a number of things that increase the risk of constipation, including:

1. not eating enough fiber, such as fruits, vegetables and grains
   
2. a change in your lifestyle or routine, such as a change in your eating habits
   
3. Ignoring the urge to defecate
4. side effects of certain medications
5. not drinking enough fluids
6. anxiety or depression

In children, poor diet, fear over toilet use, and poor toilet formation can all be responsible.

The definition of constipation include the following:

1. Infrequent bowel movements (usually less than three times a week and compact, dry, hard and small.)
2. difficulty passing stool. (tensioned for more than 25% of bowel movements or a subjective feeling of hard stools)
3. the feeling of incomplete evacuation of the colon.
   

Chronic constipation is the presence of constipation symptoms that last more than 6 months.

fissure

What is an fissure?

The anal fissure is a sore of the skin of the anus at the level of the anal canal, like a crevasse.

The origin of the fissure?

Most often, it is caused by hard stools (constipation), but can also appear after diarrhea, after childbirth or in association with other diseases. In many patients the cause is not found.

What are the symptoms of fissure?

The most common symptom of a crack is severe burning pain   during and after passing stool. This pain can last from a few minutes to an hour or several hours. Bright red bleeding can sometimes occur. Itching (anal pruritus) may be associated with it. 

How to make the diagnosis?

The diagnosis of an fissure is made by a simple visual examination of the anus. In general, there is no need for further more complex investigations.

How are fissures treated?

Many cracks heal with simple measures, such as laxatives, creams, and painkillers. A proper diet is necessary. It helps soften the stool and prevent recurrence.

Some cracks do not heal and become chronic.

When should surgery be used?

When symptoms do not resolve or the crack becomes chronic, surgery is sometimes necessary.

It consists of removal of fibrous tissue and / or relaxation of the sphincter allowing the disappearance of pain.

A large part of these procedures can be performed under local anesthesia on an outpatient basis.

Hemorrhoidal disease

What is hemorrhoidal disease?

Haemorrhoid disease is a common pathology since it motivates 1,200 consultations per 100,000 inhabitants per year. Women and men are affected equally, peaking between the fourth and fifth decades.

Causes of the disease

Constipation, flare-up efforts during defecation and pregnancy are the most frequently cited causes.

How does it manifest itself?

The symptoms are primarily bleeding, see pain or itching. This disease may be complicated by a thrombosis (blood clot) of one or more hemorrhoidal nuclei requiring emergency treatment.

How to make the diagnosis ?

Evaluation of hemorrhoidal disease requires only a proctological assessment, above all an anoscopy. This examination makes it possible to specify the stage of the disease.

What treatment to offer ?

At all stages, a diet rich in fiber or mucilage transit regulators are indicated. They improve the quality of stool which decreases hemorrhoidal congestion and bleeding.

Depending on the stage of the disease, it is sometimes necessary to resort to a minimal instrumental treatment such as :

Infrared photocoagulation

This technique needs to be repeated.

Band ligation according to Barron:

Through an anuscope the base of the hemorrhoidal package is sucked out, and the ligation is applied. The hemorrhoid will have been mechanically retracted and fixed in depth. Such a ligature can be repeated several times. This technique has an excellent complications / results ratio.

When surgery is needed

At a more advanced stage of the disease

Selective pedicle ligation under Doppler control (THD, HAL):

It consists in selectively binding under Doppler control each hemorrhoidal arterial pedicle and replaces the hemorrhoids that will decrease in volume, in the anal canal. There is no wound and the pain is minor and the return to normal activities is rapid. The operation can be done on an outpatient basis. Results should be evaluated after 6 weeks. Stage II, III and (IV) hemorrhoids are the best indications.

Circular muccosectomy by agraffage (Longo):

This technique performs a circular stapling of the suprahemorrhoidal mucosa. It reduces the volume of hemorrhoids that will be replaced inside the anal canal. Stage III is the ideal indication. Postoperative pain is not significant, and a quick return to  normal activities and rule. This treatment requires short-term hospitalization. The long-term results (recurrence) are less good than for the conventional technique. 

Classical surgery (Ferguson, Milligan-Morgan etc...):

It removes symptomatic hemorrhoids. This technique induces relatively significant post-operative pain (margin wounds) and requires a long healing time. The long-term results are excellent. Stage III and IV hemorrhoids are the best indications.