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The necessity for routine histopathologic evaluation of hemorrhoidectomy specimens considered free of suspicious areas after careful visual and manual inspection remains controversial.The purpose of this work was to prospectively study the prevalence of anal intraepithelial neoplasia in macroscopically normal operative specimens.From October 2005 to September 2010, all hemorrhoidectomy and fissurectomy specimens were sent for routine histopathologic analysis.This study was conducted at a tertiary referral center.The primary outcome measured was the histopathologic examination of surgical samples.Among the specimens from 2997 procedures, routine histopathologic evaluation found anal intraepithelial neoplasia in 97 patients (3.2%), despite the fact that visual and manual inspection had determined that the specimens were free of any suspected anal intraepithelial neoplasia or human papillomavirus-related lesion. The pathological diagnoses for these macroscopically normal specimens were AIN1 in 22 (23%) patients, AIN2 in 48 (49%) patients and AIN3 in 27 (28%) patients, making the prevalence of high-grade and low-grade disease 2.5% (anal intraepithelial neoplasia 2/3) and 0.7% (anal intraepithelial neoplasia 1).This study was limited by being a single-center study.This prospective single-center study demonstrated that the prevalence of infraclinical anal intraepithelial neoplasia in macroscopically normal hemorrhoidectomy and fissurectomy specimens is not negligible (3.2% with 2.5% high-grade disease).

Recto-urethral fistulas in Crohn's disease are rare, and managing them is difficult. The various surgical techniques are not reliably effective and are associated with a significant risk of morbidity. The rectal mucosal transposition flap technique, which is used most frequently, requires the rectal mucosa to be in a healthy condition. We report here on a case where treatment was by injecting fibrin glue into a complex fistula with a single anorectal point of origin but combining a median recto-urethrocutaneous tract with two deep lateral rectoperineal tracts. The patient had presented with active rectal Crohn's disease. This treatment produced complete closure, verified by MRI, of all the fistula tracts, which was still maintained after three years, and with normal anal continence. When confronted with this type of fistula, and particularly when the condition of the rectal mucosa is poor, the specialist should be encouraged by this good result to consider the injection of fibrin glue, a technique without risk of morbidity, as a first course of action.

The incidence of radiation-induced chronic hemorrhagic proctitis is less than 10 to 20%. The onset of this proctitis is delayed relative to the radiation therapy and generally develops from 6 to 24 months later. There are numerous predisposing factors, the most important of which is the radiation therapy dose: risk increases exponentially above 40-45 Gy. Its pathophysiology involves progressive obliterating endarteritis and transmural interstitial fibrosis, which induce chronic ischemia that is irreversible and progressive during the years after radiation therapy. Its diagnosis depends most often on the combination of clinical history and typical endoscopic appearance (congestive mucosa and/or telangiectases). Topical administrative of sucralfate or corticosteroids as well as argon plasma coagulation, with formalin treatment if necessary, provides relief for most patients.

Anal epidermoid carcinoma is a rare malignant tumor, comprising less than 5% of all carcinomas of the colon, rectum, and anus. The primary therapy now includes radiotherapy, often in combination with chemotherapy. Radical surgery is now rarely indicated. Therapeutic indications are based on locoregional staging, the presence of visceral metastases and an evaluation of the medical history. Anorectal endosonography is helpful in evaluating locoregional extension. In addition, magnetic resonance imaging, positron emission tomography scanning and inguinal sentinel lymph node procedure should play a role in a more selective approach in patients with anal carcinoma.

Summary Introduction Primary anal actinomycosis of cryptoglandular origin, mainly due to Actinomyces israelii , a specific and rare cause of anal suppurative disease, needs to be recognized because it can be cured using specific treatments. Method Data were reviewed from 6 patients with actinomycotic anal abscesses of obvious cryptoglandular origin observed in a single proctology unit between 1983 and 2000. Therapeutic management included conventional surgical treatment of anal sepsis followed by a specific oral antibiotic therapy maintained until the surgical wound had completely healed. Results All but one of the patients were men (median age, 53 years). All abscesses, except one, were indolent. No patient presented macroscopic ″sulphur granules″ in the pus, but one presented ″watery pus″. The diagnosis was established by histological study of the surgically excised tissue or by anaerobic culture of the pus. In the one HIV-positive patient, an uncommon organism was isolated: Actinomyces meyeri . Two cases of recurrence were observed without evidence of Actinomyces infection. Conclusion Actinomycosis should be suspected particularly in indolent anal suppuration. The absence of macroscopic ″sulphur granules″ does not mean this diagnosis can be ruled out. Careful histological examination of the excised tissue and appropriate anaerobic cultures of pus should be carried out to achieve complete eradication of this rare, but easily curable disease.

Une fistule anale d'origine cryptoglandulaire peut-elle etre d'origine sarcoidosique? Si oui, en raison de leur parente sur le plan histologique, quels sont les elements discriminants avec les fistules anales dela maladie de Crohn?

This prospective study was designed to describe a typical attack of proctalgia fugax. Patients were recruited from May 2003 to June 2004. Whatever the reason for consultation, they were systematically asked: “Do you ever suffer intermittent and recurring anorectal pain lasting for at least three seconds?” If the answer was yes, they were interviewed with a questionnaire and had a proctologic examination. The criterion for proctalgia fugax was a positive answer with a negative examination. The study included 1,809 patients. Fifty-four of these patients (3 percent) had proctalgia fugax and 83 percent of them had never sought medical advice for this problem. The mean age was 51 (range, 18–87) years. Thirty-seven patients were females (69 percent). The onset of pain was sudden and without a trigger factor in 85 percent of cases. Attacks occurred in the daytime (33 percent) as well as at night (35 percent). The pain was described as cramping, spasm-like, or stabbing in 76 percent of cases. It did not radiate in 93 percent of cases. There were no concomitant symptoms in 81 percent of cases. Attacks stopped spontaneously in 67 percent of cases. The average duration was 15 minutes (range, 5 seconds to 90 minutes). The average annual number of attacks was 13 (range, 1–180). Proctalgia fugax affects twice as many females as males at approximately aged 50 years. Commonly the roughly once-monthly attack occurs as a sudden pain with no trigger factor, diurnally as often as nocturnally. The nonradiating cramp, spasm, or stabbing pain, without concomitant symptoms, is most severe on average after 15 minutes and declines spontaneously.

Studying anal cytology to detect intraepithelial neoplasia has been demonstrated to be useful in highly selected populations. This study was designed to determine the frequency of abnormal smears in a wide sample of patients consulting for anorectal symptoms. An anal smear was proposed during each consultation during a three-month period. A total of 205 patients (112 females) were included. After the consultation, visible condylomas were detected in 12 (6 percent) of the cases. Two hundred three (99 percent) smears were able to be analyzed. No case of high-grade squamous intraepithelial lesion was found. Four cases of low-grade squamous intraepithelial lesion were found, all in HIV patients with a history of condylomatous lesions. Forty smears were interpreted as atypical squamous cells of undetermined significance and 159 were normal. The prevalence in this population of low-grade squamous intraepithelial lesion was 19 percent (4/21) in HIV seropositive males, and 15 percent (4/26) in the case of a past history of condyloma. The factors associated with an abnormal smear (low-grade squamous intraepithelial lesion or atypical squamous cells of undetermined significance) were a history of anal condylomatous lesions (odd ratio, 4.9; range, 2.1–11.5), HIV seropositivity (odd ratio, 4; range, 1.6–9.9), and smoking (odd ratio, 2.1; range, 1.1–11.5). This work confirms that the frequency of low-grade squamous intraepithelial lesion is raised in HIV-seropositive males and also where there is a history of condyloma, which corroborates the necessity for regular monitoring and screening of these patients at risk. This study also suggests that the use of tobacco is associated with anal cytologic abnormalities.

This prospective study evaluated the efficacy and safety of local formalin application in chronic refractory radiation-induced hemorrhagic proctitis. All patients were treated under anesthesia by direct application of 4 percent formalin to the affected rectal areas. The study included 33 patients (17 women) and was conducted between January 1994 and December 2001. There were 11 anal cancers (33 percent), 11 prostate cancers, 9 cervical or endometrial cancers, 1 bladder cancer, and 1 rectal cancer. The mean number of daily rectal bleeds was 2.7 (range, 0.5–15). Nineteen patients (58 percent) were blood transfusion dependent. Twenty-three patients had only one formalin application and 10 patients required a second application because of the persistent bleeding. The treatment was effective in 23 cases (70 percent): 13 patients had complete cessation of bleeding and 10 patients had only minor bleeding. Six anal or rectal strictures occurred: 4 patients had been treated for anal cancer (36 percent) and 2 patients had been treated for other cancers (9 percent). None of the strictures was malignant. Anal incontinence worsened in 5 patients of the 11 who had been treated for anal cancer (45 percent) and occurred in 4 of the 22 other patients (18 percent). Formalin application is an effective treatment for chronic radiation-induced hemorrhagic proctitis. However, local morbidity is not negligible. This result may be related to the high proportion of anal cancers in the series. In our opinion, therefore, formalin application should be reserved for severe hemorrhagic proctitis refractory to medical treatment and should be thoroughly discussed in cases of anorectal radiation-induced stricture, prior anal incontinence, or treated anal cancer.

Purpose Anoperineal tuberculosis is a rare extrapulmonary form of the disease that we must learn to recognize because it requires specific treatment. Methods Data from seven patients with anoperineal tuberculosis observed in a Parisian proctology unit between 1982 and 1999 were reviewed. Results All the patients were male (median age, 55 years); five were born in underdeveloped countries, and two were still living there. The average length of time between first manifestation of the disease and diagnosis was three years (range, 3 months to 9 years); all patients had undergone surgery previously. There were six recurring anal fistulas (complex in 5 cases) and one recurring abscess. In every case, the diagnosis had been suspected or confirmed by systematic histologic study of the surgically excised tissue. An association with pulmonary tuberculosis was found in each case. Treatment included two parts: conventional surgical treatment of anal sepsis and specific medical antituberculosis treatment. Evolution was favorable in all cases, with no recurrence of disease. Human immunodeficiency virus infection did not increase the incidence of anoperineal tuberculosis. Conclusion Tuberculosis should be suspected in all recurrent fistulas. Histologic examination of the excised tissue and a lung x-ray should be performed to avoid delay in diagnosing an easily curable disease.

We report an anal metastasis from a lung cancer which was diagnosed on symptoms mimicking an acute anal abcess. The diagnosis was based on specific immunohistochemistry.