Improved Outcomes in Colon and Rectal Surgery part 17 pps

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Medical legal issues
Charles F Gay Jr and Terry C Hicks
CHALLENGING CASE
A 60-year-old woman with a strongly positive family history of color-
ectal cancer undergoes a colonoscopy. She has a 1.5 cm pedunculated
polyp snared from the transverse colon. Five days after the proce-
dure, she presents to the emergency room with a lower GI bleed. She
is hemodynamically stable and you admit her for observation. She
remains stable and is discharged 2 days later with no further bleeding
episodes. The hospital risk manager calls you to discuss this case.
COMMENTS
When you meet with the risk manager, you inform her that you
had seen the patient in your office before the procedure. During
this office visit, you had discussed with the patient, her risk fac-
tors, indications for the procedure, details of the procedure,
and potential risks. This conversation was documented in your
office note and the patient signed a consent for the procedure.
The procedure was performed in the usual fashion. You feel that
you have a good relationship with the patient and the records are
well documented. Although any untoward outcome could lead to
litigation, the risk manager agrees that you have taken the appro-
priate actions to minimize your risk.
INTRODUCTION
As surgery enters the next millennium, it finds itself at the cross-
roads of a serious medical liability crisis. This chapter will briefly
review important aspects of the United States medical liability
situation and then addresses some risk-prevention techniques for
colorectal surgeons. This includes a general overview of the legal
process pertaining to medical malpractice issues and tips to help

prevent and defend such cases. It is intended to provide practical
information that can be used by medical care providers.
MAGNITUDE OF THE PROBLEM
A lack of affordable liability insurance is leading some doctors to
retire prematurely; relocate their practices to nonlitigious areas,
practice without insurance, or drop risky procedures. Some of the
specific examples are as follows:
Over the past decade, hundreds of emergency rooms have •
been forced to close their doors at least temporarily even
though the number of emergency visits have climbed over
20%.(1)
In many areas of the country, pregnant women are finding it
•
more difficult every year to get the care they need. A survey
by the American College of Obstetricians and Gynecologists
found that one in seven OBGYNs in the United States have
stopped practicing obstetrics because of the medical liability
crisis, and more than 12% of OBGYNs have decreased their
numbers of deliveries for similar reasons.
The American Hospital Association says that more than •
half of the hospitals are having difficulty recruiting doctors
because of the medical liability crisis.(2)
More than half of hospitals surveyed in “crisis” states said •
their local community lost doctors because of the medical
liability crisis.
71% of surveyed neurosurgeons said they no longer perform •
aneurism surgery, 23% no longer treat brain tumors, and
75% no longer operate on children.
At one point, in Palm Beach County, Florida, only four neuro- •
surgeons were available to handle emergency calls in the area’s

13 hospitals, leaving most emergency rooms with no coverage.
The evidence is clear that there exist a medical malpractice crisis
in the United States, and at present multiple grass route efforts
are being undertaken to address this on a local as well as on a
national level. The American Medical Association has continued
to add states to its liability crisis list, and more and more physi-
cians are finding that insurance premiums are becoming beyond
their reach. The most important fallout of this situation is that
access to care is being endangered especially in rural areas and
among low-income, inner-city populations.
By 2003, medical liability cost reached $26 billion—a 2000%
increase over 1975. Medical liability costs are rising far more rapidly
than the overall medical costs. From 1975 to 2000, medical costs
rose 449%, while medical liability costs rose by 1,642%. A study by
Blue Cross Blue Shield of “crisis” states found huge jury verdicts
where the primary driver for higher liability premiums.(3) Based
on comprehensive jury verdict research, there is little doubt that
soaring jury verdicts are serious-ongoing problems. At present, half
of the jury awards in medical liability cases exceed $1 million, and
the average award is $4.7 million.(4) The number of mega awards
has skyrocketed especially in states with no limits on noneconomic
damages. For the past several years, juries have awarded lottery-size
verdicts of $80, $90, or even $100 million.(5)
Many physicians feel the medical liability crisis is very straight-
forward. They note that medical liability costs are soaring faster
than the rate of overall healthcare costs and the rate of inflation,
leading directly to increasing insurance premiums for doctors.
In short, their position is that the litigation system generates too
many lottery-size verdicts, and encourages too many meritless
cases. As a result, insurance companies are fleeing the market,

making it more difficult for doctors to obtain liability coverage
at any price. The US Department of Health and Human Services
concluded: “The excess of a litigation system raises the cost of
healthcare for everyone, threatens Americans access to care, and
impedes efforts to improve the quality of care”.(6)
Other major impacts of the malpractice crisis are the practice
of defensive medicine and a negative impact on the young physi-
cians in training. In a recent AMA survey, 48% of the students
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medical legal issues
in their 3rd and 4th year of medical school indicated the liability
situation was a factor in their specialty choice.
It is of interest to note that overall 75% of medical liability
claims in 2004 were closed without payment to the plaintiff; and
of the 7% of the claims that went to a jury verdict, the defend-
ant won 83% of the time. Unfortunately, physicians that win at
trial still have large fees to pay for their defenses. The average cost
being $93,559 per case where the defendant prevailed at trial. In
all cases where the claim was dropped or dismissed, the cost of the
defendants averaged $18,774.(7)
Until medical liability issues are resolved, physicians will be
forced to continue to deal with the present medical legal climate,
and it is our hope that the following information will provide
some guidelines to lower their exposure to medical legal risks by
utilizing proactive risk management steps.
In today’s litigious society, physicians who practice good medi-
cine, exercise effective communications skills, establish rapport
with the patient, and accurately document care have the best
chance of averting malpractice claims. Even when physicians
do all of these, however, a bad outcome may still result in the

patient’s filing a claim for malpractice.(8) Research appears to
support the position that a patient who perceives the physician
as having good interpersonal skills and communication is less
likely to sue.(9) There are ways to conduct a medical practice that
deter patients from making claims and, even after one is made,
can enhance the chances of winning the case.
PHYSICIAN-PATIENT RELATIONSHIP
Medicine has changed dramatically in the last few decades
because of extraordinary technologic advances that have resulted
in specialization, such as colorectal surgery. This fragmentation
often decreases the opportunity to communicate effectively with
patients, who have also become much more demanding consum-
ers, increasingly aware of their “rights” through media and law-
yer advertising. Health insurers contribute to the problem, not
only by creating incentives that discourage referrals to a specialist
but also by placing restrictions on the specialist, once referral is
made, that can impede opportunities to establish rapport with
the patient. Under such circumstances, it is important to make
the most of each opportunity to listen to the patient, remember
and use the patient’s name, explain procedures in lay terms (avoid
medical terminology), and take the time necessary to answer any
and all questions. Remember that listening to a patient’s ques-
tions and complaints will be much less time consuming than
defending a malpractice claim.
Still one of the best books for improving communication and
relationships is Dale Carnegie’s How to Win Friends and Influence
People.(10) For a more practical guide with a medical orientation
one should read Malpractice Prevention and Liability Control for
Hospitals, by Orlikoff and Vanagunas.(11)
The frequency of medical malpractice claims has been on

the rise since the early 1970s.(12) As long as the contingency
fee system exists and there is not a loser pay provision, the rise
in suits against physicians will likely continue. Accordingly, it is
incumbent on the well-educated and well-trained specialist to be
aware of areas of treatment in colorectal disease that present an
increased risk of malpractice claims.
HIGH-RISK AREAS IN COLORECTAL TREATMENT
The following circumstances associated with increased risk for
malpractice claims in colorectal disease have been identified.(13)
Delay in diagnosis of colon and rectal cancer and appendicitis
Iatrogenic colon injury (e.g., colon perforation)
Iatrogenic medical complications during diagnosis or treatment
Sphincter injury with fecal incontinence resulting from ano-
rectal surgery
Lack of informed consent
The colorectal physician who is aware of these potential high-risk
conditions can use risk-prevention strategies to avoid litigation.
INFORMED CONSENT
Physicians should be mindful that consent and informed consent
are quite different concepts. Consent implies permission. Informed
consent is assent given based on information provided or knowledge
of the procedure and its inherent risks, benefits, and alternatives.
Courts have long recognized that “Every human being of adult
years and sound mind has a right to determine what shall be done
with his own body.”(14) The law of informed consent may vary
to some degree from state to state, but regardless of the law of the
state, each patient should be allowed an exchange of information
with the physician before a procedure is done. Informed consent
is not satisfied by merely having the patient sign a form. It is satis-
fied when consent was obtained after full disclosure of the risks,

benefits, and alternatives, of the procedure.
Many states use the “reasonable practitioner standard” to judge
whether informed consent was obtained. This standard focuses
on what a reasonable physician would disclose. The physician’s
duty is not to disclose all risks but primarily those that are sig-
nificant or material. A risk is material depending on its likelihood
of occurrence or the degree of harm it presents. The focus is on
whether a reasonable person in the patient’s position probably
would attach significance to the specific risk. This is the “reason-
able patient standard” that some state courts apply.
Moreover, to prevail on a claim for lack of informed consent, in
most states the patient must still prove causation (i.e., that he or
she would not have consented to the procedure if informed of the
risk. As a practical matter, it is difficult for a patient to persuade a
judge or jury that even though the surgery was needed to relieve
pain or disease, he or she would not have consented if told of the
risk of, for example, perforation of the colon. This is particularly
true when a patient is told of much more severe risks such as death
or paraplegia and agrees to the surgery. In that regard, the ques-
tion to be answered by the judge or jury on an issue of informed
consent is whether a reasonable patient in the plaintiff’s positions
would have consented to the treatment or procedure even if the
material information and risks were disclosed.
The following points should always be discussed with the patient:
The general nature of the proposed treatment or procedure •
The likely prospects for success of the treatment (but no •
guarantee)
The risks of failing to undergo the treatment •
The alternative methods of treatment, if any, and their inher- •
ent risks

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improved outcomes in colon and rectal surgery
Suffice it to say that good rapport with the patient coupled with
accurate and complete charting are the best tools to deter suits
based on informed consent and to provide a heavy shield in
defending them.
DOCUMENTATION
The importance of good communication and rapport with
patients (i.e., treating patients as you would like to be treated) can-
not be overemphasized in deterring lawsuits; however, complete
and accurate documentation of patient care is invaluable to a
defense of claims. In addition, good documentation may well nip
in the bud a potential claim when the plaintiff attorney consider-
ing filing suit reviews the record and care is fully documented.
Plaintiff attorneys are more likely to bring suit when the case is
poorly documented, because they can more easily argue that what
happened in the care of the patient was sinister and improper.
Where documentation is clear and accurate, the plaintiff attorney
may be deterred from filing suit because what happened is easily
proved from the record. Thus judgment becomes the issue when
documentation is accurate, and judgment used by physicians in
most cases is easier to successfully defend than a vague, evasive,
and poorly documented chart.
The following are some time-honored rules for charging that
help defend against malpractice claims.
Charting
A. Thorough and accurate charting is your primary shield to
liability.
B. If an event in which you are involved gives rise to litiga-
tion, chances are your testimony will not be taken for 1 or 2

years after the event. Accordingly, your chart will provide the
content and guidelines for your testimony.
C. Most important: If it is not charted, it was not done, nor
was it observed, administered, or reported. In Smith v. State
through Dept of HHR, (15) the court stated:
The experts concluded that decedent’s condition required
continued monitoring and that charting should have been
done on a regular basis. The experts also agreed that the
lack of documentation indicated that no one was properly
observing the decedent, based on the standard maximum
“not charted, not done.”
…The evidence indicates that the decedent was not ade-
quately monitored in this case. The nurses did not specifically
recall the patient, and thus the best evidence of their actions
would have been the documentation of the chart (emphasis
added).
D. General guidelines
1. If you are the treating or primary physician, make a daily
entry on the chart.
2. Chart at the earliest possible time.
3. If the situation prevents you from charting until later, state
why and that the recorded times are best estimates and not
fully accurate.
4. Always record the time (designate AM or PM) and the date
of every entry.
5. Chart all consultations.
6. Never black out or white out any entry on a chart. Should
you make a mistake in charting, place a single line through
the erroneous entry and label the entry “error in charting.”
However, if a hospital policy exists that governs errors in chart-

ing, follow it. An addendum is acceptable if placed properly
in sequence with the date and time it is made. An addendum
squeezed between progress notes is inappropriate.
7. Write legibly.
8. Spell correctly.
9. Chart professionally; do not impugn or insult the patient.
10. Never alter the medical records.
11. Do not insult, impugn, or criticize colleagues, co-workers, or
support staff.
12. Always designate the dose, site, route, and time of medication
13. Sign your entries on the chart.
14. Do not chart an incident report in your notes.
15. Chart objectively, not subjectively; do not use ambiguous
terms (examples below)
Subjective Objective
Patient doing well. Patient denies any complaints.
Awake, alert, and oriented.
Vital signs stable: BP, 100/70: P, 72; R, 18
Breath sounds within normal
limits (WNL)
Respirations regular and unlabored.
Breath sounds clear and equal bilaterally on
auscultation. No rales or rhonchi noted.
Circulation check WNL. Pedal pulses noted bilaterally. Nail beds
blanch quickly and toes warm to touch.
Patient denies any pain or tingling.
16. Document use of all restraints and safeguards, and patient
positioning (extremely important in surgery).
17. Document all patient noncompliance.
18. Document all patient education and discharge instructions,

and patient responses.
19. Always document patient status on transfer or discharge.
20. Record the patient’s name on each page of the medical chart.
21. Use accepted medical abbreviations.
22. Do not chart in advance.
E. Guidelines for charting in the ambulatory setting
1. Always chart the return visit date and the date that was pro-
vided to the patient.
2. Always chart all cancelled and missed appointments.
3. Document all telephone conservations and their content.
4. Chart all prescriptions and refills, as well as patient teaching
regarding prescriptions.
5. Chart all follow-up and discharge instructions. If possible,
have the patient or his or her representative cosign these
instructions.
ANATOMY OF A MALPRACTICE SUIT
Initial Phase
Once a patient initiates a claim for medical malpractice, the physi-
cian should immediately place a call to the risk manager or to the
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medical legal issues
malpractice insurance carrier. An attorney will usually be selected,
and the physician should insist that the appointed counsel be expe-
rienced and have a well-established reputation in the handling of
malpractice cases.
Physicians should work closely with the defense attorney to
review and analyze the allegations of the suit, with particular
focus on the strengths and weakness of the case. This team effort
can often substantially enhance the strength of the defense by
educating the attorney on the medical aspects of the case.

Pretrial Discovery
During this stage, each side will discover the facts and opinions
in the case. Written questions, or interrogatories, can usually be
propounded to obtain written responses. Depositions usually
follow the written discovery and are important to the overall out-
come of the case. Before testifying by deposition or otherwise, it is
advisable that the physician be thoroughly familiar with the facts,
including previous and subsequent medical care of the patient
and the allegations against the physician. This requires careful
review of medical records, other depositions, and all medical data
related to the case. A conference should be held with the attorney
before the physician’s deposition. They physician should allow
ample time to confer with the defense attorney before testifying.
Remember that the judicial system is adversarial, and the pur-
pose of the deposition is not to convince the plaintiff attorney
to understand that the case is frivolous. They physician is there
to answer the questions and defend the care administered, not to
educate the plaintiff attorney.
The deposition is simply the physician’s testimony, given under
oath, before a court reporter, in an informal setting. Attorneys for
both defendant and plaintiff are present. Any party to the lawsuit
may be present, but often the physician is the only party present.
The testimony is taken down in question-and-answer form.
Under the laws of discovery, the plaintiff attorney has the right
to ask the defendant physician proper questions. The physician
is present simply to discharge a legal obligation to answer proper
questions.
The physician’s deposition is most important. A good effort
is essential for an effective presentation. Close cooperation with
the defense attorney in preparation is fundamental. Above all, a

physician must be his or her own person.
Thorough preparation will assist physicians in giving a deposi-
tion with which they will be perfectly comfortable when they see
the printed transcript, that is, one that will be easily defended,
should any part of it later be challenged.
The following suggestions for giving testimony in depositions
can be helpful to the physician:
1. Tell the truth; you must testify accurately.
2. Do not guess or speculate. If you do not know the answer to
a question, say so.
3. If you are not certain of what the attorney is asking, ask that
the questions be clarified or repeated. Do not attempt to
rephrase the question for the interrogator (e.g., “If you mean
such and such,”).
4. Keep your answers short and concise. Do not volunteer
information. Answer only the question posed.
5. Be courteous. Avoid jokes and sarcasm.
6. Think about each question that is posed. Listen to each word.
Formulate an answer, then give the answer. Do not permit
yourself to become hurried.
7. Do not argue with opposing counsel. If an argument is
necessary, your attorney will do it for you.
8. If you realize that you have given an incorrect answer to a
previous question, stop at that moment and say so; then
correct your answer.
9. Be aware of questions that involve distances and time. If you
make an estimate, make sure everyone knows it is an estimate.
10. Do not lose your temper, no matter how hard pressed. This
may be a deliberate ploy; do not fall for it.
11. Do not anticipate questions. Be sure to let the attorney

completely finish the question before you begin to respond.
12. Do not exaggerate or brag.
Testing Your Memory of the Case
You have the right to refer to the chart or hospital records when-
ever you wish. Your memory is usually a composite of events you
recall as jogged by your records. Watch for generalities, ploys, and
tricky questions by the plaintiff attorney during the deposition.
Generalities. Often the plaintiff’s attorney will begin with gen-
eral questions, such as, “Doctor, how do you treat a patient when
you suspect he has X disease?” In all likelihood, the lawsuit to
which you are a party involves X disease or involves the plaintiff’s
attorney trying to make it X disease. You really cannot answer
this question, and you should say just that. X disease probably
occurs in various forms, and you have been given no particular
information—no patient complaints, no patient history, no find-
ings on physical examination, no results of laboratory studies, no
clinical impression—all factors you must know to diagnose and
treat intelligently. The question is simply too general.
A similar question might be “Doctor, what are the standards for
making a diagnosis of X disease?” Again, you should advise that
this question is too broad and defies rational response because no
details have been given. You, as a physician, do not immediately
diagnose X disease or any other diagnose X disease or any other
disease. You evaluate all the data in light of your formal train-
ing and clinical experience in considering or making a diagno-
sis. Patient signs and symptoms are innumerable. You must have
specifics. For example, in one doubtful clinical presentation, you
may have to order a particular set of laboratory studies; in another,
the evidence of a certain disease process may be more definitive
and clear-cut from the history and clinical examination.

A proper question is, “Doctor, what are the characteristics of X dis-
ease?” Particularly if your case involves X disease, you should know
its characteristics, but you should also point out that they are general
characteristics and most certainly will vary in specific instances.
The point is, you must avoid generalities. You must demand
specifics. Try to make the questioner stick to the specific case.
Ploys
Question: “Doctor, you have no memory of events independent
of your records, do you?”
Appropriate response: “I have an excellent recall of the events when
I refer to the records.”
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improved outcomes in colon and rectal surgery
Ploy: “Doctor, if an event is not noted in your records or in the
hospital records, is it fair to say that event did not occur?”
Appropriate response: “That is incorrect. It is impossible for a
physician to note everything that occurs. My records are for my
own use, to jog my memory. Thus I note pertinent highlights,
which when later reviewed give me the complete picture at the time
in question.”
Remember that physicians treat patients, not charts. You may
properly testify to the following:
1. What you actually recall
2. What you recall with the assistance of your records
3. What is recorded
4. What your routine or standard procedure is, even when such
is not recalled and not recorded
Tricky questions. Many plaintiff attorneys will use questions
cleverly phrased to evoke a response that can later be used against
the physician.

Possibilities. Questions phrased in terms of possibility invite
speculation and are improper. The criterion is reasonable medical
probability.
Question: “Doctor, isn’t such and such possible?” or “Couldn’t
such and such have happened?”
Appropriate response: “Most improbable.”
Doing things differently. Almost all malpractice cases involve
the “retrospectroscope” or Monday morning quarterbacking to
suggest the physician knew things beforehand that were only
learned later or that the physician has 100% control over the
healing process.
Question: “Doctor, is there anything you would do differently
now if you had Mrs. White’s case to treat again?”
Appropriate response: “My recommendations to Mrs. White
were based on her complaints, her history, and findings at the
time and on my clinical impression at that time. The course
I recommended was appropriate on the basis of those factors.
Question: “Doctor, you did not intend for Mrs. White to have
this complication, did you?”
Appropriate response: “Of course, no harm to Mrs. White was
intended. At the time of my recommendations, there were good
prospects for a good result. The procedure (or regimen) does have
known complications, and that is why the risks were explained to
her beforehand.”
Many other factors are involved in preparing for and suc cessfully
testifying by deposition or at trial.(16) Suffice it to say that effec-
tive and sincere testimony is critical to a successful defense in
malpractice cases. Ineffective testimony can render a defensi-
ble case indefensible. Many tricks and ploys may be used by the
plaintiff attorney, and the physician who is prepared with a basic

understanding of how to answer such questions can substantially
enhance the defense.
Trial
After pretrial discovery, the physician should have a clear under-
standing of the evidence and witnesses, the experts in particular,
to be use against him or her at trial. Working with the defense
attorney to rebut this evidence and to assist with selection or
expert witnesses to testify for the defense is strongly advised and
helps the physician to prepare the defense.
At the trial, the physician is carefully observed at all times
by the judge and jury, and the physician’s trial testimony,
mannerisms, and behavior are critical to a favorable verdict.
A well-trained and educated physician who portrays a sincere,
conscientious, and caring attitude about the patient’s well-
being greatly increases the chances of a favorable jury verdict,
even where severe complications have occurred and there may
be questions of the appropriateness of the course of treatment
chosen.
CONCLUSION
The defense of medical malpractice claims is similar to the
defense of criminal cases. The physician stands accused and rep-
utation is usually an issue of great importance. The emotional
costs to the physician are sometimes staggering. The physician
should recognize that until some meaningful tort reform is
enacted, these cases will likely continue to increase and should
be dealt with as a regrettable aspect of practice.(17) Under these
circumstances, it is best to accept the reality of the medicolegal
arena and use the best means available to aggressively defend and
win the malpractice case.(18)
REFERENCES

1. The American College of Emergency Room Physician; cited
in Federal Medical Liability Reform. Alliance of Specialty
Medicine; 2005.
2. The American Hospital Association. Professional Liability
Insurance: A Growing Crisis; 2003.
3. Blue Cross Blue Shield Assoc. The Medical Malpractice
Insurance Crisis: The Impact of healthcare and access; 2003.
4. Manhattan Institute. Malpractice maladies: Doctors continue
to flee states without – of – control medical – injury- verdicts;
2005.
5. U.S. Dept. of Health and Human Services. Addressing the
new healthcare crisis: Reforming the medical litigation
system to improve the quality of healthcare; 2003.
6. U.S. Dept. of Health and Human Services. Addressing the
new healthcare crisis; Reforming the medical litigation
system, improve the quality of healthcare; 2003.
7. The American Medical Association. Medical liability reform;
2006.
8. Entman SS, Glass CA, Hickson GB et al. The relationship
between malpractice claims history and subsequent obstetric
care. JAMA 1994; 272: 1588–91.
9. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that
prompted families to file medical malpractice claims follow-
ing perinatal injuries. JAMA 1992; 267: 1359–63.
10. Carnegie D. How to Win Friends and Influence People. New
York: Simon & Schuster; 1936.
11. Orlikoff J. Vanagunas A. Malpractice Prevention and
Liability Control for Hospitals. Chicago: American Hospital
Association; 1988.
12. Danzon PM. The frequency and severity of medical mal-

practice claims: New evidence. Law Contemp Probl 1986; 49:
57–84.
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medical legal issues
13. Kern K. Medical malpractice involving colon and rectal dis-
ease: a 20-year review of United States civil court litigation.
Dis Colon Rectum 1993; 36: 531–9.
14. Schloendorff v. Society of New York Hospital, 211 NY 125,
105 NE 92,93; 1914.
15. Smith v. State, through Dept of HHR, 517 SO2d 1072. La
App 3d Cir; 1987.
16. Taraska JM. The physician as witness. In Legal Guide for
Physicians. New York: Matthew Bender, 1994: 1–56.
17. Taraska JM. Tort reform. In Legal Guide for Physicians. New
York: Matthew Bender, 1994: 1–64.
18. Gay CE. Medicolegal issues. In Hicks TC, Beck DE, Opelka
FG, Timmcke AE. eds, Complications of Colon and Rectal
Surgery. Baltimore: Williams & Wilkins, 1996: 468–77.


Miscellanous conditions
M Benjamin Hopkins and Alan E Timmcke
CHALLENGING CASE
A 26-year-old man has a 2 month history of perianal itching. He
has variable bowel movements and no family history of colorectal
cancer. Physical exam demonstrates thickened perianal skin with
ridges in a circum anal pattern. The sphincter tone is normal and
no masses or tenderness is appreciated.
CASE MANAGEMENT
A diagnosis of pruritis ani is made and the patient was placed on

additional dietary fiber and instructed on anal hygiene (keeping
his perianal area clean and dry). In addition to the management
of conditions already discussed, a number of others merit discus-
sion, including pruritis ani, condyloma acuminatum, Human
Immunodeficiency Virus, and other sexually transmitted diseases.
PRURITUS ANI
An itching and burning sensation about the anus is referred to
as pruritus ani. Frequently mistaken by patients for symptoms
of hemorrhoids, the symptoms can be very discouraging and
frequently wax and wane. Despite its ubiquity, pruritus ani is an
under-diagnosed condition. The majority of patients choose to
self medicate and do not seek medical care.(1) It affects males
more frequently than females by 4:1.(2) Most patients complain
of itching and burning made worse during hot, humid weather
or after exercise. The itching sensation can advance to the point
of distress, driving some to suicide. On physical exam, the affected
area can vary from mild erythema and excoriations to marked skin
thickening, cracking, and lichenification (Figure 15.1). Excessive
scratching or vigorous cleansing of the afflicted area can exacer-
bate the condition.
The etiology of pruritus ani, like other dermatitides, can range
from poor hygiene, poorly absorbent or ventilated clothing, exces-
sive or improper cleansing, and dietary intolerances. Fecal soilage
can be a strong irritant to the perianal area leading to skin irritation.
Causes of soilage can include incomplete wiping due to skin tags or
other anatomic imperfections, loose or tenacious stool consistency,
and poor anal sensation or sphincter tone. A small study of 39 males
(23 of whom had pruritus ani) demonstrated a greater rise in rectal
pressure associated with decreased anal pressure, and longer dura-
tion of internal anal sphincter relaxation.(3) Clothing choice has

also been associated with idiopathic pruritus ani with tight fitting,
nonaerating fabrics exacerbating the problem. Additionally, hirsute
patients are more prone to episodes of pruritus ani. Foods such as
caffeinated beverages, chocolate, tomatoes, and citrus fruits have
been shown to cause pruritus ani.(4–6) Coffee in particular has
been associated with pruritus ani, with increased amounts of cof-
fee intake being associated with worsening symptoms. One pos-
sible etiology for this is a decreased internal anal sphincter tone,
similar to that seen in relaxation of the lower esophageal sphincter
with gastroesophageal reflux disease.
Contact dermatitis should be ruled out as a possible etiology.
Clues to this diagnosis include recent use of new creams, toiletry
items, or new laundry detergent. After the initial irritation from
these agents, itching and pain can be exacerbated by continued
scratching and abrasion. Occasionally, home remedies can worsen
the condition as well.
Often, simple reassurance can be the best treatment for idi-
opathic pruritus ani. Knowing that there is no underlying disease,
such as cancer, can provide just as much benefit as lifestyle changes.
Lifestyle changes should include improved cleanliness, changes in
clothing, as well as dietary changes. Patients should cleanse them-
selves several times a day avoiding excessive scrubbing of the
affected area. If available, showering after bowel movements can
Figure 15.1 Priritis ani.

miscellanous conditions
be very effective. Patients should be instructed to dry the area with
a hair dryer or with a blotting technique to avoid trauma to the
anal area. Dampened toilet paper may assist in gentle cleansing,
but Baby wipes or Tucks should be avoided as they may excessively

traumatize the perianal area after defecation. Choice of clothing
can exacerbate the condition, with loose fitting, soft cotton clothing
providing some relief. Dietary changes involve excluding possible
causative foods for 2 weeks to see if the condition improves. If the
symptoms resolve or improve, suspected foods may be reintro-
duced to ascertain which cause recurrence or worsening of the
itching or burning sensation.
Occasionally, hydrocortisone cream may be used to overcome
severe problems. The cream decreases inflammation and irrita-
tion, thus promoting healing. However, prolonged use of a steroid
cream may lead to atrophy of the skin with further breakdown and
worsening conditions. Due to this concern, hydrocortisone cream
should not be used for more than 2 weeks. Other skin protective
creams may be used in the initial stages and then transitioned to
dry powders for long-term relief.
More extreme measures at treating pruritus ani have been
attempted. These include injections with alcohol, oil soluble anes-
thetics, and methylene blue into the perianal skin.(7, 8) While
providing some temporary relief, abscess formation, skin break-
down, and skin sloughing can occur. While these outcomes can
be treated with local drainage and antibiotics, the morbidity and
poor success rate prevents them from being effective treatments.
Surgical undercutting of the perianal skin has also been described.
(9) While the skin can be made insensate, recurrence of the der-
matitis occurs. Additional problems with abscess formation and
sepsis have been described. As with injections, the risks of surgical
undercutting outweigh the benefits.
Other causes of pruritus ani need to be excluded during the
workup. Hemorrhoids, anal fissures, psoriasis, rectal and anal can-
cer, as well as colon cancer have all presented with an itching or

burning sensation of the anus.(10) While the relation of cancer
to pruritus ani is unknown, patients presenting with itching in
their presenting complaints had longer duration of itching than
those with benign causes.(10) Additional medical problems such
as diabetes, antibiotic use, fungal and parasite infections, and anal
intercourse need to be investigated as well.
CONDYLOMA ACUMINATUM
Human papillomavirus (HPV) is the causative pathogen in con-
dyloma acuminatum. The condition affects nearly 20 million
sexually active adults, with 5.5 million new cases occurring each
year.(11) The virus is spread via close contact with an infected
individual and autoinoculation to other body surfaces is possi-
ble. Anogenital warts from HPV is considered the most common
anorectal infection among homosexual men. Anorectal warts
are more common than penile warts owing to the moist, warm
environment thought to be favorable to their growth. In addi-
tion to perianal lesions, intraanal lesions are common among
homosexual men.(12) Therefore, in order to successful treat
these patients, internal as well as external therapies need to be
utilized to prevent reinfection. Additionally, the patient and all
sexual partners should be treated to prevent repeat inoculation.
Treatment options for patients include excision and destruction.
Excision of the condyloma generates a tissue diagnosis as well
as typing of the causative papillomavirus.(13) Due to the risk
of malignant transformation, histopathologic examination is
recommended for all patients undergoing treatment. The tech-
nique used involves elevating the lesion with local lidocaine/
epinephrine injection, and excising the lesion; taking great care
that the underlying musculature is left intact. One must also be
careful to leave as much of the normal skin and mucosa as pos-

sible. Complications of intraanal excision can include strictures
of the anal canal. Sitz baths are helpful during convalescence to
assist in wound healing. Unfortunately, surgical excision has a
high recurrence rate ranging from 9% to 46% depending on the
study.(14, 15)
Destructive techniques used in the treatment of condyloma
include electrocautery, cryotherapy, laser therapy, immunotherapy,
and various topical agents. Fulguration of the condyloma using
electrocautery and curettage of the destroyed tissue is an effec-
tive tool in treating condyloma. Care must be taken to prevent
deep burns which can damage the surrounding skin and lead to
deep wounds and severe scarring. This method can be of par-
ticular use within the anal canal if appropriate precautions are
taken. Cryotherapy is similar to electrocautery in that the wart
and underlying tissues are destroyed, leading to sloughing of the
condyloma. Cryotherapy has been reported to lead to a foul smell-
ing and damp slough thought to result in a higher recurrence
rate. Again, great care must be taken to ensure that surrounding
healthy tissue is not damaged. Laser therapy is another destructive
technique to eliminate condyloma. Similar to other destructive
techniques, complications include loss of tissue, fibrosis, and anal
stenosis.(16) Additionally, aerosolized viral particles generated
during laser therapy can inoculate the medical provider and result
in respiratory papillomas.(17)
Several topical agents are available for treating anal condyloma.
They can be applied in the office setting by medical personnel
as well at home by the patient. Trichloroacetic acid, podophyl-
lin, and imiquimod are currently available. Trichloroacetic acid
is a caustic agent used to chemically burn the anal wart. The
acid must be applied to the anal wart after cleansing the peri-

anal area. Liberal application of trichloroacetic acid will lead
to burning and necrosis of normal skin and should be avoided.
The acid should be applied to the wart only. After application,
the wart should have a frosty white appearance. Treatment
of anal canal lesions should include blotting the lesion with a
swab before removing the anoscope. This prevents burning of
the adjacent mucosa. The caustic effects of trichloroacetic acid
include skin necrosis, fistula in ano, and anal stenosis. Patients
should return to the office every 7–10 days for reapplication.
Swerdlow and Salvati reported a recurrence rate of 25% using
this technique.(18)
Podophyllin is a topical agent which can be applied in the
office setting or by the patient at home. Podophyllin is applied to
the warts themselves, taking care to not apply to uninvolved skin.
Podophyllin is a destructive agent which leads to necrosis of the
treated areas. Complications of podophyllin treatment can run the
gamut of local skin irritation to systemic toxicity. Complications
including fistula in ano, anal stenosis, and skin necrosis have been
reported.(19) If large doses are applied to the skin, hepatic, renal,

improved outcomes in colon and rectal surgery
gastrointestinal, and neurologic complications have occurred.
Pregnancy is an absolute contraindication for the use of topical
podophyllin. Treatment with podophyllin has a clearance rate of
about 50%, but the recurrence can be as high as 90%. This high
recurrence rate necessitates repeat treatments.
Imiquimod is a newer agent in the arsenal against anal condy-
loma. It can be applied in the office setting as well as at home and
has been shown to have similar efficacy to podophyllin and other
fulguration techniques.(11) As opposed to destructive applica-

tion creams, imiquimod stimulates the innate and cell mediated
immune response to clear papillomavirus infected cells. The
cream is applied to the wart and left in place for 8 hours, and then
the washed off. Imiquimod is applied 3 times a week for up to
16 weeks of therapy. As imiquimod is not cytodestructive, con-
cerns of skin necrosis and fistula formation seen with other abla-
tive therapies are not realized. Langley and colleagues reviewed the
cost-effectiveness of imiquimod therapy and found a combination
initial imiquimod treatment followed by second-line therapy for
recurrence gave the highest success rate and the lowest total cost of
therapy.(20) Second-line therapy included fulguration techniques
used in the office.
It should be noted that all topical agents have lower success
rates when used to treat highly keratinized warts. Due to this
limitation, intraoperative techniques may better treat these
chronic lesions. If other lesions recur, subsequent treatment with
topical agents can be considered.
Immunotherapy as described by Abcarian et al. has been shown
to effect regression of the condyloma lesions.(21) The therapy
consisted of an autologous vaccine created from the patient’s wart
tissue. Intramuscular injections were given once the vaccine was
created. Difficulty and expense in creating this immunotherapy
have curtailed its widespread use.
Due to the increased risk of papillomavirus lesions leading to
anal squamous intraepithelial lesions and an increased risk of
cancer, many are advocating screening techniques similar to rou-
tine papanicolaou screening in women. Screening should include
identifying risk factors such as human immunodeficiency virus
(HIV) status, history of anal warts, and history of anal pain and
bleeding. Pap testing using a liquid medium allows for the collec-

tion of epithelial cells for analysis.(22) The increased incidence
of squamous cell carcinoma transformation in the HIV posi-
tive population should lead the clinician to screen these patients
yearly.
HUMAN IMMUNODEFICIENCY VIRUS
Due the depressed immune system, HIV positive individuals are
at increased risk of wound complications following surgery. Of
those affected, more severe HIV disease leads to higher morbidity
and mortality from minor surgical procedures including hemor-
rhoidectomy, lateral internal anal sphincterotomy, and transrectal
biopsies. Due to the high complication rates, surgical treatment of
benign anorectal diseases should be approached carefully. Before
surgical intervention, viral load, and immunosuppression should
be carefully evaluated.(23)
Treatment of anal ulcers involves identification of the causative
agent and appropriate medical management. Etiologies of anal
ulcer in the HIV patient include herpes virus, syphilis, cytomega-
lovirus, and cryptococcus.(24, 25) Surgical management is reserved
for chronic, nonhealing ulcers and includes local debridement,
unroofing of ulcerative cavities, and steroid injection into the cav-
ity. Complications of surgery include prolonged drainage, poor
wound healing, incontinence, and superinfections.
Treatment for fistula in ano and perianal abscesses in an HIV-
infected patient remains the same as HIV negative patients.
However, abscesses and fistula appear more frequently in the more
advanced stages of HIV infections. Surgical therapy is warranted
for source control of the affected area, but the complication rate is
high. Patients should be advised of the increased risk of nonheal-
ing wounds, recurrence, and sepsis. Surgical management should
include conservative strategies used in the treatment of anorec-

tal disorders seen in Crohn’s disease. Draining setons and drain-
age catheters (Malecot and Pezzar drains) should be the initial
treatment in those with severe immunodeficiency. Fibrin glue as
well as collagen plugs could also prove useful in the treatment of
perianal fistula.
Kaposi’s sarcoma can lead to abdominal pain, lower and upper
gastrointestinal bleeding, malabsorption, obstruction, and perfo-
ration.(26, 27) The clinician must understand that gastrointestinal
disease can occur in the absence of skin manifestations. Surgical
treatment for gastrointestinal disease is reserved for bleeding,
obstruction, and perforation. Chemotherapy is used to treat the
manifestations of Kaposi’s sarcoma. Complications of medical
management include paralytic ileus and necrosis or perforation
of the bowel.
As stated previously, the depressed immune system in HIV posi-
tive patients yields higher complication rates with surgery. Therefore,
any abdominal colorectal procedure will carry higher rates of wound
infections, dehiscence, anastomotic leak, bowel obstruction, and fis-
tula formation. If colorectal resections are required, creation of a
diversion with stoma formation has been shown to decrease the rate
and severity of subsequent complications.(28–30)
Colitis secondary to cytomegalovirus (CMV) infection has an
increased rate among the HIV population. Autopsies of those
infected with HIV have demonstrated CMV coinfections to be
present in almost 90% of those studied.(31, 32) All areas of the
gastrointestinal tract can be involved; however, colonic involve-
ment predominates. Lower gastrointestinal bleeding and ulcer per-
foration are common causes for surgical intervention. Ileocolitis
and proctocolitis can be indications for partial or total colectomy.
It should be noted that any indicated colorectal surgery should be

approached cautiously and that the most conservative manage-
ment possible should be pursued. Previously mentioned surgical
complications among the immune compromised patients should
guide the surgeon’s interventions in treating these patients with
the most conservative care.(24, 28)
COMMON ANORECTAL SEXUALLY
TRANSMITTED DISEASES
Herpes simplex virus (HSV) is transmitted via direct skin con-
tact and results in small, painful vesicles about the perianal skin.
Lesions typically last for 2 weeks and remain contagious even in
the asymptomatic stage. Vesicles can become secondarily infected

miscellanous conditions
and are noted to have erythematous edges. Proctitis can occur
and is diagnosed with endoscopic evaluation demonstrating an
inflamed and friable mucosa. Swabs taken from the ulcerations
are sent for viral culture and polymerase chain reaction (PCR).
Treatment involves medical management and local debride-
ment for superimposed infections. Of note, Elsberg syndrome
can develop on this patient population. The syndrome describes
a sacral radiculitis which includes symptoms of constipation,
urinary retention, lower extremity weakness, and parasthesias.
Magnetic resonance imaging and polymerase chain reaction
testing of the cerebrospinal fluid (CSF) can aid in the diagno-
sis. Management includes local analgesic creams for sympto-
matic relief and good hygiene to prevent secondary infections of
the affected area. Antiviral medications are available which can
decrease the severity and length of viral recurrences, but does
not cure the disease. Patients must be counseled that viral shed-
ding can occur at any stage in the disease progression, even when

the patient is asymptomatic.
Chlamydia trachomatis infections can lead to proctitis, with
symptoms of rectal urgency, bleeding, and pain. If the infection
progresses proximally, bloody diarrhea can occur. Endoscopic eval-
uation demonstrates diffuse inflammation and ulcerations. PCR
and cultures reveal the diagnosis. Treatment includes antibiotics
such as doxycycline and azithromycin.
Neisseria gonorrhea is a gram-negative diplococcus which infects
the mucous membranes via direct contact. This infection can lead
to proctitis, urethritis, cervicitis, pharyngitis, and conjunctivitis. In
men, transmission occurs via anal receptive intercourse. Women
may become infected by similar means or from autoinoculation
secondary to a vaginal infection. After an incubation period rang-
ing 3 days to 2 weeks, proctitis or cryptitis may occur. Symptoms
can include pruritus ani, bloody discharge, and pain. Disseminated
gonorrhea occurs if the disease is not treated; pericarditis, meningi-
tis, and arthritis are manifestations of disseminated disease. A thick,
purulent discharge can be expresses from the anal crypts and is highly
suspicious for gonoccal proctitis. This discharge should be collected
on Thayer-Martin plates for identification via culture. Management
includes systemic antibiotics with ceftriaxone, cefixime, flouroqui-
nolones, or azithromycin. Current treatment of gonorrhea also
includes treatment of a presumed Chlamydia infection.
Another common sexually transmitted disease is syphilis,
caused by the spirochete, Treponema pallidum. Anorectal disease
presents much like other sites of inoculation: a chancre repre-
sents the first stage of the disease. These ulcerative lesions may
be associated with pain and inguinal adenopathy. Rectal symp-
toms may include discharge or bleeding. If untreated, the first
stage of syphilis resolves within 2–4 weeks with subsequent pro-

gression to secondary syphilis. A macular rash on the torso and
extremities denotes secondary syphilis. Condyloma lata may be
present during this time as well as mucosal ulcerations. Without
treatment, this condition will spontaneously resolve within a few
weeks. Tertiary syphilis with its neurologic and vascular seque-
lae will eventually develop if left untreated. Serologic testing with
Venereal Disease Research Laboratory (VRDL) and rapid plasma
regain (RPR) will provide the diagnosis. The treatment of choice
remains penicillin G and doxycycline.
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