Anorectal symptoms are very common among the general population, and often attributed to non-specific causes, such as “hemorrhoids.” For patients at risk of, or who already have, HPV-related dysplasia, it’s crucial to understand what symptoms to be concerned about, and how to properly investigate these clinical concerns.
Bleeding
It’s important to clarify the nature, frequency, and quantity of any anal bleeding. Occasional specks of blood on toilet paper when wiping is fairly common, and usually associated with mechanical issues, such as an acute anal fissure. Sudden larger volumes of fresh blood without pain that resolve spontaneously may be related to an internal hemorrhoidal bleed. Ongoing bleeding is more concerning, especially if there are other symptoms present.
- As with any patient, always make sure you have ruled out colonic reasons for bleeding, i.e. colon cancer, IBD, etc. Referral for endoscopy should be strongly considered, especially in patients over 40.
- Ensure that you have performed a thorough visual inspection of the anal verge and perianal skin – fissures are commonly seen and treatment may help resolve bleeding and discomfort.
- Ensure that you have performed a thorough DARE to rule out anal induration/mass that could signify an anal cancer.
Itching
Pruritus ani is a non-specific phenomenon that can be caused by multiple factors. Perianal dysplasia may indeed cause some itching, although it is often asymptomatic.
- As with any anorectal concern, please make sure you perform a thorough inspection of the perianal skin and a DARE.
- Erythema of the perianal skin is non-specific. Consider causes such as psoriasis (sharply-marginated, usually coexists with typical psoriatic plaques elsewhere on the body) and bacterial infection (group B strep can cause a chronic perianal rash, often with fissuring).
- Is there any evidence of another sexually-transmitted infection, such as herpetic vesicles/ulcers, or condylomata lata?
- If there’s no clear explanation for itching, please refer patients to my handout on pruritus ani for behavioural tips and other over the counter solutions.
Lumps/masses
It’s important to be able to distinguish benign from malignant anal/perianal masses.
- Anal/perianal warts are usually easy to recognize – they are fleshy, skin-coloured, verrucous papules often clustered in groups. If you look closely, you may be able to appreciate hairpin blood vessels in each individual frond. Internal anal canal warts usually feel soft and mobile on DARE. Because they are not as keratinized as perianal warts, they tend to be quite fragile and bleed easily with manipulation. Warts should not be painful to palpate!
- External hemorrhoids usually present when they are acutely thrombosed. These are easily recognizable as a bluish/purplish firm mass at the anal verge that has a rapid onset and resolves spontaneously within a few weeks. Importantly, there are usually no surface changes to the texture of the skin with hemorrhoids.
- Any persistent firm/indurated perianal mass needs to be biopsied (full-thickness), unless you have a clear alternate explanation for what it is.
- Anal canal cancers are also usually firm and fixed, though in some cases they may feel more warty. They will occasionally be tender to palpate if they are deeply invasive. If you are at all unsure about an anal mass, please refer.
Pain
Pain is an important warning sign that something is amiss in the area. While there are often easily-identifiable causes for pain, such as an acute anal fissure or a thrombosed hemorrhoid, other times there may be causes for pain that need further investigation.
- In patients who are at risk of anorectal sexually-transmitted infections, you must rule these out! Ensure that you perform an anorectal swab for chlamydia/gonorrhea, swab any lesions suspicious for HSV, and obtain syphilis serology. Do not skip this step! Anal STIs are common in the at-risk population and are common causes of symptoms.
- Painful visible/palpable lesions that cannot be attributed to traditional STIs, or that do not respond to treatment, may represent an invasive cancer. These need to be biopsied.