In perianal Crohn’s disease (PCD), symptoms and inflammation are centralized around the anus. It’s associated with skin tags, ulcers, fissures, fistulas, and abscesses in or around the perianal area.
It may also result in anal stenosis, a narrowing of the anal canal that can make passing stool difficult. About 18% to 44% of people with Crohn’s have this severe manifestation of the condition.
People living with PCD can have mild to severe symptoms, which can negatively impact day-to-day life. Management of the disease benefits from a multidisciplinary approach and utilizing both medical and surgical treatment options.
This article will discuss the symptoms, causes, diagnosis, and treatment of PCD.
Perianal Crohn’s Disease Symptoms
As a result of the anal lesions associated with PCD, the symptoms in the perianal area of the body include:
ItchingPainAnal bleedingPus dischargeStool incontinence
Causes
The exact cause of Crohn’s disease is not entirely known.
There are some genetic factors related to the condition. The major genes associated with Crohn’s influence the functions of the immune system. Researchers have identified more than 200 genetic variants related to the risk for Crohn’s.
Environmental and lifestyle factors, such as smoking, dietary intake, and living in an urban setting, have also been noted as risk factors for Crohn’s disease.
For perianal Crohn’s disease in particular, factors involving genes, immune functioning, and microbiology in the anal area of the body have been implicated, though the cause remains unclear.
Diagnosis
The following steps are taken to diagnose a person with perianal Crohn’s disease:
Medical history and a physical exam: A healthcare provider will take a thorough medical history, asking about any history of pain, pus discharge, or bleeding in the anal area. They will also ask about experiences with incontinence or urinary tract infections. Exam under anesthesia (EUA): This procedure may involve draining abscesses, identifying the opening(s) of any fistula present, and placing setons (a nylon string inserted into the fistula to allow for draining and healing). EUAs have a diagnosis accuracy rate of 90%. Endoscopy: With the use of a small scope, a surgeon can view inside the intestines to look for inflammation and any internal fistula openings. Endoanal ultrasound (EUS): This diagnostic strategy may be used to produce two- and three-dimensional images of the anal sphincters. With the use of hydrogen peroxide, the EUS may also be able to detect fistula tracts (tunnels). Pelvic magnetic resonance imaging (MRI): This is often used to assess perianal fistulas and identify abscesses and inflammation that may not have been otherwise detected.
Treatment
The primary treatment options for PCD are medication and surgery, though sometimes a combination of methods are used. The use of any type of treatment will depend on the severity of symptoms and the success of previously utilized methods.
Medications
Some medications used to treat PCD include:
Antibiotics, such as metronidazole and ciprofloxacin, are often used as the first line of treatment for those diagnosed with PCD. They may also be used in conjunction with other medical therapies. Immunomodulators, used to suppress the immune system’s response and reduce inflammation, may be taken in a pill or by injection. Tissue necrosis factor (TNF) inhibitors, a type of biologic agent that blocks the action of the TNF molecule that contributes to inflammation, may also be used.
Surgery
Surgery options aim to reduce the risk of sepsis, drain abscesses, heal fistulas, and mitigate incontinence as a result of the procedure. Surgeries may be paired with medicines to improve the treatment response and reduce symptom recurrence.
For simple fistulas, clearing and closing a fistula through fistulotomy is a preferred procedure. Seton placement to drain a fistula, or clearing and then filling or covering the fistula with healthy tissue or special glue called fibrin, may be utilized for more complex fistulas.
More invasive approaches may be indicated for people whose symptoms have not been addressed by other surgical or medical treatments. In these cases, surgeons may perform an ileostomy to create another way for stool to exit the body, or a proctectomy to remove the anus and rectum.
Prognosis
Though advancements have been made in the treatment of PCD, management remains challenging for healthcare providers and those living with the condition.
Long periods of pus drainage from fistulas and recurrences of anal lesions are common. Even after 18 months of remission, research has found that 44% of patients experience recurrence of symptoms.
As few as one in three people will experience long-term healing for those who have anal fistulas with Crohn’s disease. While there is some amount of successful lesion with the use of medications, several do not have success as long-term treatments.
Incontinence because of certain surgical procedures is also possible for some patients.
Because of these challenges and outcomes, involvement of both a gastroenterologist and colorectal surgeon can inform a multidisciplinary approach to assessing symptoms, identifying the least invasive treatments, and improving quality of life.
Coping
People living with PCD describe the combination of symptoms, treatments, and daily life—including the physical, emotional, sexual, and social factors—as very challenging.
Seeking out additional information about PCD, as well as reaching out for support from family, friends, and others with a similar diagnosis via online support groups, are potential strategies.
Discussing any accommodations at work may also help those with PCD identify useful modifications to their work environment.
A Word From Verywell
Perianal Crohn’s disease is a more severe manifestation of Crohn’s and is associated with significant impacts on quality of life. Available treatments may be more successful for some living with PCD than others, and it can depend on the severity of a person’s individual case.
For those with PCD, working with a team of multidisciplinary healthcare providers will help inform which treatments may provide the most relief and quality-of-life improvements. Seeking out support from family and other patients can also be a key coping tool.
