Anal problems in children

Essentials

  • Visual inspection of the anal area is easy and should be carried out routinely when examining a child with abdominal or perianal complaints.
  • A digital rectal examination should not be performed if an acute fissure or abscess is suspected as this would cause great pain to the child.

Anal redness

  • A common symptom, usually irritation caused by faeces
  • Perianal streptococcal dermatitis (picture (Perianal streptococcal dermatitis)) is usually easy to identify clinically: severe redness suggestive of acute inflammation, often with accompanying watery anal discharge.
    • Perianal streptococcal dermatitis is treated with oral antibiotics, but it should be borne in mind that the condition is almost always associated with untreated constipation.
  • Severe perianal redness and oedema are suggestive of chronic enteritis.

Anal fissure, fresh blood on the stool

  • The main symptom is pain on defecation and fresh blood on the stool and WC paper.
  • On perianal inspection, a fissure is visible on the mucocutaneous junction of the anus. The buttocks should be spread apart in order to see the fissure. A digital rectal examination is painful and not necessary for diagnosis. Unlike with adults, a fissure in a child may be situated anywhere along the anal perimeter.
  • Pain on defecation may lead to constipation which might further prolong the healing of the fissure as the large stool will repeatedly tear the fissure open.
  • Almost all fissures improve with conservative treatment, which consists of laxatives (e.g. lactulose) and creams to protect the anal area (e.g. petroleum jelly). Creams indicated for haemorrhoids and fissures in adults should not be used in children.
  • Very rarely (< 5% of cases) a child’s fissure becomes chronic and surgical treatment might be indicated.
  • The possibility of sexual abuse should be kept in mind in cases with findings that deviate from the usual.

Perianal abscess and fistula

  • Occurs most commonly in boys aged less than 12 months or in adolescents
  • Pain on defecation or when sitting down, occasionally pain associated with urination
  • Digital rectal examination is very painful and should therefore not be performed routinely
  • An abscess must be incised and drained when it is "ripe". The drainage needs occasionally to be carried out in the operating room, and some cases will heal without surgical intervention.
    • Should low-grade fever develop after the drainage, oral antibiotics should be prescribed.
    • Frequent baths or showering postoperatively
  • An external opening with purulent discharge is suggestive of a fistula.
    • A fistula is usually not painful.
    • Fistulae in infants often heal spontaneously.
    • Fistulae in adolescents are treated in the same way as those in adults.
  • Perianal abscesses and fistulae in older children may suggest a chronic inflammatory bowel disease. The threshold to refer a paediatric patient to specialist assessment should be low.

Haemorrhoids

  • Very rare in children
  • A bleeding haemorrhoid is very rare and hardly ever the aetiology behind blood on the stool
  • Haemorrhoids in a child require specialist intervention.

Rectal prolapse

  • Most common at the age of 1–2 years
  • The rectum can usually be easily pushed back in situ manually, but in most cases it retracts spontaneously.
  • If the prolapse recurs, laparoscopic surgery may be considered in older children.

Anal skin tags

  • A single non-inflamed tag is common in the 6 o’clock position (dorsal part of the anus), sometimes in the 12 o’clock position, particularly in girls.
  • Cauliflower-like tags are a manifestation of Crohn’s disease.

Anal itching (pruritus ani)

  • Intermittent itching is common, usually related to irritation caused by faeces.
  • Pinworms (threadworms) (Pinworm (enterobiasis)) may cause pruritic dermatitis.

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