Improved Outcomes in Colon and Rectal Surgery part 17 pps

  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 colorectal cancer undergoes a colonoscopy. She has a 1.5 cm pedunculated polyp snared from the transverse colon. Five days after the procedure, 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 factors, 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 appropriate 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 physicians 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 physicians in training. In a recent AMA survey, 48% of the students  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 defendant 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 medicine, 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 questions 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 anorectal 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 satisfied 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 “reasonable 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 question 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  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) cannot 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 considering 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 litigation, 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 charting, 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 provided 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 physician should immediately place a call to the risk manager or to the  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 outcome 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 deposition 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 general 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 findings 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 training and clinical experience in considering or making a diagnosis. 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 disease?” 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.”  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 effective 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 understanding 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 reputation 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 following 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 malpractice claims: New evidence. Law Contemp Probl 1986; 49: 57–84.  medical legal issues 13. Kern K. Medical malpractice involving colon and rectal disease: 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 exacerbate the condition. The etiology of pruritus ani, like other dermatitides, can range from poor hygiene, poorly absorbent or ventilated clothing, excessive 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 duration 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 coffee intake being associated with worsening symptoms. One possible 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 idiopathic 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 themselves 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 irritation, 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 breakdown, 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 dermatitis 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 cancer, 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 condyloma 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 possible. 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 addition 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 technique 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 possible. 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 effective 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 particular 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, podophyllin, 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 perianal 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 condyloma. 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 application 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, concerns 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 routine 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 positive 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, cytomegalovirus, 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 nonhealing wounds, recurrence, and sepsis. Surgical management should include conservative strategies used in the treatment of anorectal disorders seen in Crohn’s disease. Draining setons and drainage 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 perforation.(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 positive 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 fistula 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 perforation 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 management 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 contact 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 debridement 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 diagnosis. 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 evaluation 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 ranging 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 symptoms may include discharge or bleeding. If untreated, the first stage of syphilis resolves within 2–4 weeks with subsequent progression 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. REFERENCES 1. Nelson RL, Abcarian H, Davids FG, Persky V. Prevalence of benign anorectal disease in randomly selected a population. Dis Colon Rectum 1994; 88: 341. 2. Wexner SD, Dailey TH. Pruritis ani: diagnosis and management. Curr Concepts Skin Disorders 1986; 7: 5–7. 3. Farouk R, Duthie GS, Pryde A, Bartolo DC. Abnormal tran- sient internal sphincter relaxation in idiopathic pruritus ani: physiologic evidence from ambulatory monitoring. Br J Surg 1994; 81: 603. 4. Kranke B, Trummer M, Brabek E et al. Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients. Wien Klin Wochenschr 2006; 118: 90. 5. Friend WG. The cause and treatment of idiopathic pruritus ani. Dis Colon Rectum 1977; 20: 40–2. 6. Daniels GL, Longo WE, Vernava AM. Pruritus ani: causes and concerns. Dis Colon Rectum 1994; 37: 670–4. 7. Stone HB. Pruritus ani. Treatment by alcohol injection. Surg Gynecol Obstet 1926; 42: 565–6. 8. Turell R. Tattooing with mercury sulfide for intractable anal pruritis. Surgery 1948; 23: 63. 9. Lockhart-Mummery JP. Diseases of the Rectum and Colon. London: Baillere; 1934. 10. Daniel GL, Longo WE, Vernava AM 3rd. Pruritus ani. Causes and concerns. Dis Colon Rectum 1994; 37: 670. 11. Sauder DN, Skinner RB, Fox TL, Owens ML. Topical imiquimod 5% cream as an effective treatment for external genital and perianal warts in different patient populations. Sex Transm Dis 2003; 30: 124–8. 12. Sohn N, Robilotti JG. The gay bowel syndrome, a review of colonic and rectal conditions in 200 male homosexuals. AM J Gastroenterol 1977; 67: 478–84. 13. Wexner SD. Sexually transmitted diseases of the colon, rectum and anus. Dis Colon Rectum 1990; 12: 1048–62. 14. Thomas JPS, Grace RH. The treatment of perianal and anal condyloma acuminata: a new operative technique. Proc R Soc Med 1978; 71: 180–5. 15. Gollock JM, Slatford K, Hunter JM. Scissor excision of anogenital warts. Br J Venereal Dis 1982; 58: 400–1. 16. Krebs HB, Wheelock JB. The CO2 laser for recurrent and therapy resistant condylomata acuminatum. J Reprod Med 1985; 30: 489–92. 17. Volen D. Intact viruses in CO2 Laser plumes spur safety concern. Clin Laser Monthly 1987; 5: 101–3. 18. Swerdlow DB, Salvati EP. Condyloma acuminatum. Dis Colon Rectum 1971; 14: 226–9. 19. Boot JM, Stolz E. Intralesional interferon -2b treatment of Condylomata acuminata previously resistant to podophyllin resin application. Genitoruin Med 1983; 65: 50–3. 20. Langley PC, Tyring SK, Smith MH. The cost effectiveness of patient-applied versus provider-administered intervention strategies for the treatment of external genital warts. Am J Managed Care 1999; 5: 69–77. 21. Abcarian H, Sharon N. Long term effectiveness of immunotherapy of anal condyloma acuminatum. Dis Colon Rectum 1982; 10: 648–51. . 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,. abdominal pain, lower and upper gastrointestinal bleeding, malabsorption, obstruction, and perforation.(26, 27) The clinician must understand that gastrointestinal disease can occur in the. technique 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