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Abstract: A young man presented to the clinic with anal pain, running water and odor. He reported that he had treated himself with topical caustic drugs for anal warts 1.5 months ago. After 3 weeks of treatment with anti-infective drugs and topical anti-inflammatory cream, the anal pain disappeared and the ulcer healed.
Basic information】Male, 25 years old
Type of disease】Anal ulcer
Hospital】Hegang City People’s Hospital
Time of consultation】June 2018
【Treatment plan】Medication (Ceftriaxone sodium for injection + anti-inflammatory and muscle-generating cream + iodophor disinfectant solution + physiological sodium chloride solution + anti-inflammatory and muscle-generating cream)
Treatment period】3 weeks of treatment, six months of follow-up
Treatment effect] Pain gradually reduced to disappear, ulcer surface healed
I. Initial consultation
An anxious young man came into the consultation room, saying that he had anal pain and had been taking oral painkillers for the past few days, and that there was discharge, which made his underwear dirty and smelled bad. The patient was told to wash with physiological sodium chloride solution and apply hemorrhoid cream topically, but his condition has not improved, so he came to our department. On examination of the patient’s anus, we found that the skin on both sides of the anal verge was red, swollen and broken, with purulent blood discharge, which had spread to the anal canal, about 3x4cm, and painful to palpation, and the initial diagnosis was anal ulcer.
II. Treatment history
In view of the fact that the patient had been treated for anal warts, the possibility of syphilitic ulcers could not be ruled out, and he was then given laboratory tests for syphilis, routine blood tests and biochemical tests, which showed negative results for syphilis and no significant abnormalities in routine blood tests and biochemical tests. The patient was given ceftriaxone sodium for injection; the ulcerated surface was disinfected with iodophor disinfectant, rinsed with physiological sodium chloride solution, and the ulcerated surface of the anal margin was evenly coated with anti-inflammatory and muscle-generating cream.
III. Treatment effect
At the first visit, the patient had obvious anal pain, perianal pus and oozing, accompanied by odor. After 2 days of active anti-infection treatment and drug exchange, the anal discharge was significantly reduced, pain was relieved, and odor gradually disappeared. After 1 week of treatment, the ulcer area was reduced and the growth of granulation tissue was visible. After 3 weeks of treatment, the ulcer surface was completely healed and there were no self-conscious symptoms. The patient was asked to follow up within six months and no abnormality was seen.
IV. Notes
We are glad that the patient’s disease improved after active treatment and did not have to suffer from anal ulcers anymore. During the treatment period, the diet should be hygienic and regular, avoiding irritating food and cold and greasy food, and advocating light, nutrient-rich food, such as lean meat and fish. Pay attention to keeping the perianal area clean, rinse the anus repeatedly with water after stooling, and wipe dry with gauze after cleaning, do not use hand paper to dry. Wear loose underwear and underpants to avoid stimulation of the anal ulcer surface by clothing, and change clean underpants daily to keep the perianal area clean and hygienic. When itchy anal ulcer surface secretions stimulate the perianal area, do not scratch to stop itching and prevent further damage to the ulcer surface.
V. Personal insight
This case of anal ulcer was caused by improper treatment and care of anal disease. The patient did not perform standardized cleaning and drug change of the anal area after treatment, which led to perianal infection and then anal ulcer. Therefore, patients with anal diseases are prompted to standardize their treatment and not to use their own medication, especially corrosive drugs. The prognosis for anal ulcers is mostly good after active treatment. If anal ulcers do not heal for a long time, they may develop secondary to cancer, which needs the attention of doctors and patients.