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PURPOSE: This study aimed to determine the prevalence of macroscopic anal lesions and associated factors in HIV-infected outpatients during the era of highly active antiretroviral therapy. METHODS: A randomly selected sample of patients with HIV-infection receiving follow-up care in the infectious diseases department of Bichat University Hospital was invited to participate in a systematic screening program consisting of anal examination with anoscopy and a standardized questionnaire. RESULTS: Of 516 patients, 473 (92 percent) participated. Overall, 208 patients (44 percent) had at least one anal macroscopic lesion: 108 patients (22.8 percent) had human papilloma (HPV)-related lesions (condyloma with or without dysplasia), 67 (14.2 percent) had hemorrhoidal disease, 50 (10.6 percent) had anal fissures, and 44 (9.3) percent had other anal lesions. Independent significantly associated factors for anal condyloma were history of anal condyloma (OR, 2.09) and median number of episodes of sexual intercourse per month (OR, 1.03) in men who have sex with men; history of genital condyloma (OR, 26.74), and unprotected sexual intercourse (OR, 7.47) in heterosexual men; and CD4 cell count below 200/mm 3 (OR, 6.02), receptive anal intercourse (OR, 6.37), and history of anal condyloma (OR, 16.69) in women. Neither sexual behavior nor characteristics related to HIV infection were associated with hemorrhoidal disease or anal fissure. CONCLUSIONS: Because patients with HIV infections have a high prevalence of unreported anal lesions that may be highly contagious, involve risk of anal neoplasia, or negatively affect quality of life, systematic anal screening should be conducted in the HIV-infected population.

PURPOSE: Thrombosed external hemorrhoids and anal fissures are common and are responsible for severe discomfort during childbirth. However, the real incidence of these lesions is unknown. The aim of our study was to evaluate their incidence and the risk factors for these lesions during childbirth. METHODS: A prospective study with proctologic examination during the last 3 months of pregnancy and after delivery (within 2 months) was performed in 165 consecutive pregnant females. RESULTS: Fifteen females (9.1 percent) with anal lesions (13 thrombosed external hemorrhoids and 2 anal fissures) were observed during pregnancy. Fifty-eight females (35.2 percent) with anal lesions (33 thrombosed external hemorrhoids and 25 anal fissures) were observed during the postpartum period. Ninety-one percent of thrombosed external hemorrhoids were observed during the first day after delivery, whereas anal fissures were distributed, with no peak, over the two months after delivery. The 2 independent risk factors for anal lesions (among obstetric, baby’s, and mother’s information) were dyschezia, with a 5.7 odds ratio (95 percent confidence interval, 2.7–12), and late delivery, with a 1.4 odds ratio (95 percent confidence interval, 1.05–1.9). Furthermore, many thrombosed external hemorrhoids were observed after superficial perineal tears and heavier babies (P < 0.05). Only 1 of the 33 patients with thrombosed external hemorrhoids who were observed underwent a cesarean section. CONCLUSION: One third of females have thrombosed external hemorrhoids or anal fissures in the postpartum period. The most important risk factor is dyschezia. Traumatic delivery appears to be associated with thrombosed external hemorrhoids.

PURPOSE: Anal incontinence affects approximately 10 percent of adult females. Damage to the anal sphincters has been considered as the cause of anal incontinence after childbirth in the sole prospective study so far available. The aims of the present study were to determine prospectively the incidence of anal incontinence and anal sphincter damage after childbirth and their relationship with obstetric parameters. METHODS: We studied 259 consecutive females six weeks before and eight weeks after delivery. They were asked to fill in a questionnaire assessing fecal incontinence. Anal endosonography (7–10 MHz) was then performed. Two independent observers analyzed internal and external anal sphincters. RESULTS: A total of 233 patients (90 percent) were assessed, of whom 31 had cesarean section.De novo sphincter defects were observed in 16.7 percent (14 percent external, 1.7 percent internal, and 1 percent both) in the postpartum period only after vaginal delivery. These disruptions occurred with the same incidence after the first and the second childbirth. Independent risk factors (odds ratio; 95 percent confidence interval) for sphincter defect were forceps (12; 4–20), perineal tears (16; 9–25), episiotomy (6.6; 5–17), and parity (8.8; 4–19) as revealed by multivariate analyses. The overall rate of anal incontinence was 9 percent and independent risk factors (odds ratio; 95 percent confidence interval) involved forceps (4.5; 1.5–13), perineal tears (3.9; 1.4–10.9), sphincter defect (5.5; 5–15), and prolonged labor (3.4; 1–11). Among these patients only 45 percent had sphincter defects. CONCLUSION: Anal incontinence after delivery is multifactorial, and anal sphincter defects account for only 45 percent of them. Primiparous and secundiparous patients have the same risk factors for sphincter disruption and anal incontinence. Because external anal sphincter disruptions are more frequent than internal anal sphincter damage, surgical repair should be discussed in symptomatic patients.