Anal sinusitis and anal papillitis

　　Etiology

　　1. Infection and injury:The anal sinus is bag-like, with the sinus base below and the opening upward, leading to poor drainage and easy to store feces, causing infection and injury. The edges of the anal sinus also have free semilunar-shaped anal valves, which are easily scratched or torn during defecation. An increase in defecation frequency or the presence of intestinal inflammation, dysentery, diarrhea, constipation, and other conditions frequently stimulate the anal sinus and anal valves. A decrease in body and local resistance, or systemic chronic consumptive diseases, can lead to the accumulation of feces and foreign bodies in the anal sinus, blocking the sinus ducts. This causes the anal glands to secrete anal fluid that does not drain properly, combined with feces decomposition and bacterial proliferation, leading to inflammation and swelling of the anal sinus. Common pathogenic bacteria include Escherichia coli, Staphylococcus, Proteus, gas-producing bacteria, Streptococcus, Mycobacterium tuberculosis, and Pseudomonas aeruginosa, with Escherichia coli accounting for 60% to 70%.

　　2. The influence of sex hormones:Gao Yuejin et al. (1985) pointed out that, like sebaceous glands, the development and function of anal glands are mainly regulated by human sex hormones. The level of sex hormones directly affects the proliferation and atrophy of anal glands, and therefore, the level of sex hormones is closely related to the occurrence of anal sinusitis. Among sex hormones, androgens have the greatest impact. Newborns have a higher level of androgens brought by the mother, so there are more perianal infections. After passing through the growth and development period, with the decrease in androgen levels, some perianal infections can heal spontaneously. The level of androgens in males and young adults is higher, so there are more anal gland infections, and perianal abscesses often occur in young adults. The level of sex hormones in the elderly is significantly reduced, and the anal glands atrophy accordingly, so anal sinusitis and perianal infections are rare in the elderly.

　　3. Influence of embryonic development:It is believed that during the 7th week of embryonic development, the cloacal membrane and anal membrane rupture and fuse with the hindgut. At this time, the dorsal part of the cloacal membrane differentiates into the anal canal, the lower part of the anal vermillion border, and the anal columns. If for some reason, the anal membrane and hindgut fuse abnormally, it cannot form a normal anal vermillion border and crypts, resulting in irregular anal vermillion borders and excessively deep crypts. After birth, they are prone to bacterial infection and injury, leading to anal sinusitis, perianal abscess, and anal fistula. Clinical observations have confirmed that the anal crypts of patients with perianal abscess and anal fistula are often abnormally deep, reaching 3-10mm, and the number can increase to 3-13. The theory that embryonic development affects anal sinuses has been widely recognized by experts.

　　Severe constipation can cause acute intestinal obstruction in patients, manifesting as abdominal pain, vomiting, bloating, and the cessation of anal gas and fecal evacuation. An abdominal erect and supine film examination can diagnose the disease if there is a step-like change in the liquid-gas plane. Other complications include anal papillitis, mainly manifested as anal discomfort, prolapse of anal papillae, bleeding and pain, impaction, anal itching, and moisture, etc.

　　1. Anal sinusitis:During the chronic stage, there are no obvious symptoms, but there are often mild anal pain,坠胀or discomfort, or decreased anal gland secretion, dry anal canal, and difficulty in defecation. During the acute onset, there may be pain during defecation, increased secretions, occasional contamination of toilet paper with pus and blood, burning discomfort, anal distension, etc. If the anal sphincter is stimulated by inflammation, it can cause mild or moderate spasmodic contractions of the sphincter, with frequent short-term paroxysmal dull pain, or pain that persists for several hours. In severe cases, pain can radiate through the pudendal nerve, sacral nerve, and perineal nerve, resulting in referred pain.

　　2. Anal papillitis:Generally, there are no obvious symptoms. When the anal papillae become enlarged and prolapse from the anal opening, visible prolapsed substances of varying sizes can be seen, covered with skin. During the acute stage or when they are impacted, swelling, congestion, necrosis, and ulceration may be observed.

　　1. Avoid eating刺激性 foods, such as chili.

　　2. Correct bad living habits, such as drinking alcohol and prolonged sitting, which can stimulate.

　　3. Maintain anal hygiene, change underwear frequently, and persist in washing the anal area after each bowel movement, which has a positive effect on preventing infection.

　　4. Regular physical exercise enhances physical fitness, improves blood circulation, strengthens local disease resistance, and prevents infection.

　　5. Timely treatment can avoid systemic diseases that can cause perianal abscess, such as ulcerative colitis and intestinal tuberculosis.

　　6. Do not sit on damp ground for a long time, so as not to cause anal part to be cooled and wet, causing infection.

　　7. Actively prevent and treat other anal diseases, such as anal cryptitis and anal papilloma hypertrophy, to avoid the occurrence of perianal abscess and anal fistula.

　　8. Prevent constipation and diarrhea, which is of great significance for preventing the formation of perianal abscess and anal fistula.

　　9. Once anal rectal perianal abscess occurs, early treatment should be carried out to prevent spread and diffusion.

　　Anorectal scope examination:Anal sinusitis can be seen with deepening crypts, congestion, edema, and in the acute attack phase, there can be more secretion in crypts, or pus and blood, with significant tenderness. Anal papillitis can be seen with triangular, bow-shaped, papillary hyperplastic lesions, covered with skin. During acute attacks, anal secretion increases,呈脓液性或脓血性，with redness and swelling of the anal valves and papillae.

　　1. What foods are good for anal sinusitis and anal papillitis

　　1. Eat more light and vitamin-rich foods such as mung beans, radishes, winter melon, and fresh vegetables and fruits. For long-standing anal fistula, most are deficiency syndrome, and more protein-rich foods should be eaten in diet, such as lean meat, beef, mushrooms, etc.

　　2. Eat more fibrous foods such as bananas, coarse grains, etc., to prevent constipation.

　　3. Eat more foods rich in protein such as lean meat, mushrooms, jujube, eggplant, yam, etc.

　　2. What foods should be avoided for anal sinusitis and anal papillitis

　　1. Avoid greasy foods, and eat less food with internal damp-heat.

　　2. Avoid smoking, drinking and strong tea.

　　1. Conservative treatment

　　1. Traditional Chinese Medicine

　　(1) Differential diagnosis and treatment: A. Damp-heat type: Anal burning pain or pain and itching, anal sinus redness, papillary edema. Accompanied by irritability, bitter mouth, reddish urine and yellowish stool, dry stool. Tongue red, tongue fur yellow greasy, pulse slippery and rapid.宜清热利湿，方用龙胆泻肝汤。B. Heat-toxin type: Irritability, thirst, constipation, short and reddish urine, anal burning pain, anal sinus redness, papilla hypertrophy and redness, bleeding or purulent discharge, tongue red, tongue fur yellow, pulse wiry and rapid.宜清热解毒，方用内疏黄连汤加减。C. Damp turbidity type: Anal sinus and papillary edema, skin erosion, anal dampness and itching. Can be accompanied by abdominal distension, anorexia, heavy and tired body. Tongue pale red, tongue fur white greasy, pulse slippery.宜利湿化浊，方用萆粟渗湿汤加减。D. Deficiency fire type: Slight anal pain and prolapse, anal sinus or papilla dark red, accompanied by dry stool, dry mouth and thirst. Tongue red with little juice, pulse wiry and thready rapid.宜养阴清热润便，方用增液汤加减。

　　(2) Experience formula: Often used Shaoyao Huaijiao Wan and modified prescription: 15g Diyu, 10g Huaijiao, 10g Huangqin, 10g Yehuanghua, 10g Jinyinhua, 10g Danggui, 10g Shengdi, 10g Chishao, 6g Chuangxiong, 40g Chixiao, 6g Gancao, 10g Tufuling.

　　Usage: Decocted for oral administration, 2 times per day. On the third day, decoct the soup for sitz bath. It has the effects of pain relief, swelling reduction, softening stool, and pus removal. For mild cases, it can control the attacks. For severe cases, it can be taken after surgery to clear heat, moisten intestines, and stabilize the effect.

　　(3) External Treatment: A. Steaming and washing method: 15g of Phellodendron amurense, 15g of rhubarb, 15g of mugwort, 15g of Sanguisorba officinalis, decocted to 1500ml, first steamed, then sit in a bath for 10-20 minutes, twice a day. B. Ointment application: Apply the ointment of Coptis, Phellodendron, and rhubarb to the anal cavity. C. Suppository insertion: Hemorrhoid宁 suppositories, Chrysanthemum mongolicum suppositories, analgesic and anti-inflammatory suppositories, etc. can be chosen. E. Enema: 10g of Coptis, Sanguisorba officinalis, and rhubarb each, decocted to 50ml, once a day at night.

　　2. Western Medicine

　　(1) Antibiotics: Metronidazole is the first choice, followed by gentamicin, ceftriaxone, amoxicillin, norfloxacin (氟哌酸) and others. Administration through the anus is more effective and faster.

　　(2) Anal Suppositories: Indomethacin (消炎痛) suppositories have a significant anti-inflammatory, anti-exudative, and analgesic effect on patients in the acute attack phase; chlorhexidine (洗必泰) suppositories can be used during the chronic phase.

　　Secondly, surgical treatment:Surgery is the root treatment for this disease, and the appropriate surgical method should be selected according to the lesion.

　　1. Anal Sinus Incision and Excision:Firstly, use a hook-shaped probe to probe the deep anal crypts, then incise the anal crypts along the probe to the internal sphincter, cut part of the internal sphincter, excise the diseased sinus and nodules, make a diamond-shaped incision to the skin, and trim the wound surface to ensure good drainage. One suture can be made above the incision to stop bleeding. Attention should be paid to not excising too deeply to prevent postoperative bleeding, and this surgical method can completely cure anal sinusitis.

　　2. Anal Papillae Ligation and Excision:The patient takes a lateral position, the perianal skin is prepared, the anus and perianal area are conventionally disinfected, covered with a disinfected gauze drape, and locally infiltrated anesthetized with 0.5% lidocaine solution of 1-5ml, then a transfixing ligation is performed at the base of the anal papillae, the top is excised, one indomethacin suppository is inserted, and the wound is bandaged with disinfected gauze. 1-3 large anal papillae can be ligated each time, do not defecate on the day of surgery, sit in a bath after defecation the next day, do not remove the suture, and wait for about 7 days for spontaneous detachment. For those with large basal papillae, the skin at the base should be cut open to near the dentate line, while ligating, the hemostat is released and the thread is tightened, and the knot is tied at the dentate line, which can reduce postoperative pain and shorten the course of treatment. This method is simple to operate and has a reliable curative effect.

　　3. Electrocautery:For small triangular papillae, electrocautery or electrocoagulation can be used to burn to the base, and indomethacin suppositories are inserted postoperatively, followed by sitting in a bath after defecation.