Anal Pap and Dysplasia
What is Anal Dysplasia?
Anal Dysplasia is a pre-cancerous condition associated with past or present exposure to Human Papillomavirus (HPV). It refers to abnormal changes in the cells that make up the lining (mucosa) of the anal canal. Abnormal cells clustered together form a visible pattern called a lesion. Low-grade lesions may progress to high-grade lesions, which are more serious as they can progress sooner to cancer. But not all lesions progress. Some may regress, meaning they shrink or even disappear. Some may persist, meaning they remain present without changing.
The anus extends from the anal opening to about 1.5 inches inside the body to join the rectum. The portion inside the body is called the anal canal. Anal Dysplasia occurs mainly in two places: in the "junction," where the anal canal meets the rectum; and in the peri-anal skin, just outside of the anal opening.
Goals of treatment
Anal pap tests, High Resolution Anoscopy (HRA) and proper treatment can prevent abnormal cells that are not yet cancerous (called dysplasia) from becoming tumors that will require chemotherapy, radiation treatment, and/or surgery. Pap smears of the cervix and colposcopy are highly successful in preventing cervical cancer in women, and it is likely that the same success can be achieved with anal cancer in men and women. The goal is to destroy the abnormal cells before they become cancer.
What is an anal Pap?
An anal Pap test is performed by inserting a swab into the anus and moving it around the entire anal canal to collect some superficial cells. Those cells are then examined in a lab, under a microscope. If the cells look abnormal to the lab technologist, the next step is a closer inspection of the anal canal using a special microscope called a colposcope. This procedure is called High Resolution Anoscopy (HRA) or anal colposcopy.
How is HRA performed?
HRA is an in-office surgical procedure that requires no particular preparation. In fact, enemas and suppositories are not recommended prior to the procedure. The procedure is performed while you rest comfortably on your left side on the exam table. First, the provider will do a DIGITAL anal exam, utilizing a special compounded anesthetic/numbing gel, examining your anal canal, with his gloved finger, trying to locate any lumps or bumps. He then inserts a clear/plastic anoscope and places a swab, soaked in vinegar in your anal canal where it will remain for two minutes. After two minutes, the vinegar soaked swab will be removed and the anoscope will be re-inserted. With the assistance of additional vinegar and Lugol’s iodine solution, the provider will be able to more specifically define the borders of abnormal tissue. A biopsy (sampling of abnormal areas) may be taken.
Is a biopsy necessary?
The Pap smear is a screening tool for superficial cells, but a biopsy is the only way to make an actual diagnosis. The biopsy is done as part of the HRA procedure. Pain after a biopsy is often minimal, and over-the-counter Tylenol or Advil is usually enough to make you comfortable. You might experience a small amount of bleeding with bowel movements for a few days. This occasionally lasts up to a week. You should not insert anything into the anus (suppositories, fingers, toys), or have anal sex until the bleeding stops.
The biopsy report may describe low grade or high grade lesions. This information is critical in determining the best type of treatment. Low grade lesions do not necessarily require treatment, but they should be monitored with periodic HRA. High grade lesions require treatment to hopefully prevent the possibility of progression of the abnormal cells to cancer, which could also spread to other parts of the body.
What is Infrared Cautery?
Infrared Cautery (IRC) is the application of light for a short period of time (about 1.5 seconds) to destroy (ablate) abnormal anal cells. This is considerate an in-office surgical procedure. The light emitted by the IRC also seals the tiny blood vessels, so there is minimal bleeding. No suppositories or enemas are required for this procedure. Local anesthetic will be utilized. Minor bleeding may occur for up to two weeks. Nothing should be placed in the anal canal until all bleeding and discomfort stop.
Is that all there is to it?
Not quite. Depending on your individual diagnosis and severity of Anal Dysplasia, follow up treatments are most likely necessary to see if there are any additional areas that require treatment. Sometimes two or three treatments are required before all abnormal cells are identified and destroyed. Treated areas can return with new/repeat infections, stay dormant for a while or new areas can develop high grade Dysplasia. But a few trips to the office are better than having to go to the OR for surgery or getting hospitalized for cancer.