Int. J. Med. Sci. 2009, 6
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s2009; 6(2):77-84
© Ivyspring International Publisher. All rights reserved

most frequently found BAD. The distribution of stages in 317 pruritus ani patients was: mild
(91), moderate (178), severe (29), and chronic (19). Anal symptoms in patients with BAD
included: bleeding (58.6%), itch (53.7%), pain (33.7%), burning (32.9%), and soreness (26.6%).
Anal lesions could be predicted according to patients’ answers in the questionnaire: haem-
orrhoids by anal bleeding (p=0.032), weeping (p=0.017), and non-existence of anal pain
(p=0.005); anal fissures by anal pain (p=0.001) and anal bleeding (p=0.006); pruritus ani by
anal pain (p=0.001), itching (p=0.001), and soreness (p=0.006).
Conclusions: The knee-chest position may allow for the accumulation of more detailed
information about BAD than the left lateral Sims’ position, thus enabling physicians to make
more reliable anal diagnoses and provide better differentiated therapies.
Key words: haemorrhoids, pruritus ani, fissure-in-ano, thrombosed external haemorrhoid, benign
anorectal diseases, Sims’ position, knee-chest-position
Introduction
Patients suffering from any symptoms related to
the anus frequently and often incorrectly assume that
their symptoms are due to haemorrhoids [1,2,3,4].
Lockhart-Mummery once wrote "nearly every lesion
around the anus is liable to be called 'piles' by the
patient and not infrequently by the referring doctor
also" [5]. This practice still prevails: "Almost everyone
suffers from haemorrhoids at some time in their lives"
[6]. "Haemorrhoids and their symptoms are one of the
most common afflictions in the western world" [7].
The exact incidence of haemorrhoids is unknown
as estimates vary [1,6,8,9]. In the US about 1.5 million
prescriptions for anorectal preparations are written
yearly [10]. The cost of treating benign anal diseases
(BAD) in the United States exceeds 2 billion dollars
annually [11].The German National Insurance Fund
Int. J. Med. Sci. 2009, 6


1. Which symptom, sign or cause prompted you to seek help in
our outpatient clinic? (Mark as many items as apply)
anal bleeding - in toilet paper, faeces or lavatory
anal itch
anal pain or discomfort
anal burning (baking)
anal soreness
anal lump
faecal soiling
anal weeping
anal mucous
anal incontinence
dubious abdominal pain
constipation
diarrhoea
faecal occult blood test (FOBT)
dubious anaemia
screening colonoscopy
elevation of tumour markers
2. How long have you suffered from these symptoms or signs?
up to one week
two to four weeks
two to twelve months
I do not have any signs or symptoms
3. Did you treat yourself or seek help from a doctor?
I treated myself without the help of a doctor
At first I treated myself then I looked for help from a doctor
I immediately looked for help from a doctor
Definitions

Figure 1: Protruding haemorrhoids combined with skin
tags around the anus (definitions table 2 and table 4).Figure 2: Chronic anterior anal fissure, diameter of
5-8mm, combined with a leftlateral thrombosed external
haemorrhoid (definitions table 2).
Int. J. Med. Sci. 2009, 6 79

Figure 3: Posterior cavity, diameter 10x5mm, representing
an old chronic anal fissure which has healed as indicated by
a blanket of an epithelial layer.

Figure 4: Non perforated leftlateral thrombosed external
haemorrhoid (definition table 2), diameter 10 – 15 mm with
an anterior skin tag (definition table 4).
Figure 7: Weeping anal skin with superficial round splits
and longitudinal superficial lesions (stage 2 of pruritus ani,
definition table 3) at everted distal anal canal. Normally the
distal anal canal is closed so that these tiny, passing lesions
are not seen. Lesions diameter: 1 – 3 mm.

Int. J. Med. Sci. 2009, 6 80

Figure 8: Reddened, weeping skin, with superficial ulcers
and excoriations disrupted by pale, whitish areas with no
more hairs (stage 3 of pruritus ani, definition table 3).

Figure 9: Red superficial lesions situated in whitish areas of
anal skin covering skin tags situated around the anus (stage 3
of pruritus ani, definition table 3).

Figure 10: Pale, whitened, thickened, dry, leathery, scaly
skin with no hairs and no superficial ulcers or excoriations

Figure 12: Funnel shaped anus the buttocks being per-
manent in touch. They leave if parted a brownish border at
its extreme edges (definition table 4).
Int. J. Med. Sci. 2009, 6 81

Figure 13: Funnel shaped anus. A red anterior border
indicates its extreme edges. Skin tags, a longitudinal split at
rima ani indicates local inflammation (stage 2 of pruritus
ani). Figure 14: Hairy anus. Hairs spread out almost carpet like
to the anal verge (definition table 4).

Statistics
Means +/- standard deviation were computed
for continuous variables such as age. Frequencies and
percentages were calculated for categorical data such
as the male to female ratio, history of symptoms, and
anal lesions. Bivariate analyses were performed by
using t-tests to compare independent groups and
point-biserial correlations coefficients to analyse rela-
tionships between continuous and dichotomous
variables. Bivariate relationships between pairs of

with BAD
Participants
without BAD
P values
(t-test)
Number of partici-
pants
539 268
Males (number, %) 238 (44.2%) 124 (46.3%)

NS*
Age all
(mean+/-standard
deviation, years)
Men
Woman
56.5 (+/-15.0)

54.5 (+/-15.5)
58.0 (+/-14.4)
48.3 (+/-15.9)

48.9 (+/-16.0)
47.8 (+/-15.9)
< 0.01

< 0.01
< 0.01
BMI all (mean +/-
standard deviation)

Patients with
one BAD
N (%)
Patients with
MAL

N (%)
Haemorrhoids 401 (100.0) 296 (73.8) 105 (26.2)
Pruritus ani 317 (100.0) 155 (48.9) 162 (51.1)
Fissure-in-ano 70 (100.0) 5 (07.1) 65 (92.9)
Thrombosed ex-
ternal haemor-
rhoids
29 (100.0) 5 (17.2) 24 (82.8)
Anal fistula 4 (100.0) 1 (25.0) 3 (75.0)
Total number 539 (100.0) 371 (68.8) 168 (31.2) Stage 2 was by far the most frequently found
stage in 317 patients presenting with pruritus ani.