Evaluation of anorectal symptoms in men who have sex with men
- C Mel Wilcox, MD
C Mel Wilcox, MD
- Professor of Medicine
- University of Alabama at Birmingham
Anorectal symptoms in men who have sex with men (MSM) may be caused by conditions related to infections for which they are at increased risk (eg, proctitis, perianal abscess/anal fistula, anal warts/dysplasia, human papillomavirus [HPV]-associated anal cancer) or conditions seen in the general population (eg, anal fissure, hemorrhoids, pruritus ani) [1-5].
The evaluation of anorectal symptoms in MSM will be addressed in this topic. The management of common anal problems in the general patient population, with the exception of proctitis, which is covered here, are discussed separately. (See "Perianal and perirectal abscess", section on 'Management' and "Anorectal fistula: Clinical manifestations, diagnosis, and management principles" and "Condylomata acuminata (anogenital warts): Management of external condylomata acuminata in men" and "Clinical features, staging, and treatment of anal cancer" and "Anal fissure: Medical management" and "Anal fissure: Surgical management" and "Home and office treatment of symptomatic hemorrhoids" and "Surgical treatment of hemorrhoidal disease" and "Approach to the patient with anal pruritus", section on 'Management'.)
The anal canal, which is surrounded by internal (involuntary) and external (voluntary) sphincter muscles, extends 2.5 to 3.5 cm to the anal verge (visible lower edge of sphincter) inferiorly. In the mid-point of the anal canal is the dentate line, which is the demarcation between columnar epithelium superiorly and squamous epithelium inferiorly (figure 1). Along the dentate line lie crypts, which have small glands at their base. The squamous epithelium between the dentate line and anal verge is called “anoderm,” which is similar to normal skin but highly sensitive, and the squamous epithelium outside the anal verge is the perianal skin.
General approach — The cause of anorectal symptoms in men who have sex with men (MSM) is often suggested by history and physical examination findings (table 1). Patients should be evaluated by obtaining a detailed history, performing an external rectal exam for visible abnormalities (eg, anal warts, hemorrhoids) and performing a digital rectal exam for palpable abnormalities (eg, perianal abscess, rectal mass). In addition, anoscopy is recommended for patients with rectal pain, bleeding, and/or bloody or purulent discharge and in patients with a palpable abnormality on digital rectal exam (See 'History' below and 'Physical examination' below and 'Anoscopy' below.)
If digital rectal exam reveals a palpable abnormality that cannot be visualized on anoscopy, the patient should be referred for transrectal ultrasound or pelvic magnetic resonance imaging (MRI) scan (with and without contrast) to determine if the finding represents a cystic or solid lesion. The former would be suggestive of a perianal abscess, while the latter would raise concern for anal cancer.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- DIAGNOSTIC EVALUATION
- General approach
- - History
- - Physical examination
- - Laboratory studies
- - Anal Pap test
- - Anoscopy
- - Imaging
- When to refer
- - Clinical manifestations and diagnosis
- - Management
- Perianal abscess/anal fistula
- Anal warts/dysplasia
- Anal cancer
- Anal fissure
- Pruritus ani
- SUMMARY AND RECOMMENDATIONS