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!
(axx002) (axx009) (axx010)
Local hygiene with normal soap.
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.
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.
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...
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:
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:
axx008chancre+hemorrhoid+herpes) //axx043 //
Treat as a chancre on the penis. See "15-Genital Area"
- Worms? It is never dangerous to give mebendazole 1tab 6x/day or 1tab 2x/day for 3 days
//axx039 // axx043-44 // Gonorrhea/chlamydia? (Especially if patient has a "large sphincter") //axx040 //...doxycyline 100mg 2x/day for 10 days (also covers syphilis which is often associated but not always visible)
See "15-Genital Area"
Deep painful wounds. No history of abscess. Too big to be simply chancroid and not responding to ciprofloxacin....
A German doctor specialized in tropical diseases made a visual diagnose: chlamydia!?! ... The lesion was recovering (slowly) with doxycycline!!! (See evolution on photos)
For chlamydia "normal" disease, see 15-Genital Discharge
Other "normal diseases"...