Anal Pain Identified as Key High-Grade Anal Dysplasia Symptom

Anal pain and anal lesions may identify patients at risk of high-grade anal dysplasia for whom routine screening with high-resolution anoscopy could be beneficial

medwireNews: Anal pain and anal lesions are associated with high-grade dysplasia and should be included in the clinical presentation of individuals considered at high risk of disease progression, study findings show.

Results from 161 high-resolution anoscopy (HRA) biopsy specimens from 91 patients referred for screening identified 27 with high-grade dysplasia, 26 with low-grade dysplasia and 38 with no dysplasia.

Most (69%) of these patients were asymptomatic, but 15% reported bleeding, 12% anal pain and 11% pruritus, while 45% had anal lesions on physical examination.

Of these symptoms, just anal pain and anal lesions were associated with the grade of dysplasia. Patients with high-grade dysplasia had a five times greater odds of having anal pain than did either those with low-grade or no dysplasia.

Patients with high- or low-grade dysplasia also had a four times greater odds of having anal lesions on physical examination than patients with no dysplasia.

But only anal pain was significantly and independently associated with high-grade dysplasia in multivariate analysis.

Researcher Sandy Fang, from Johns Hopkins Hospital in Baltimore, Maryland, USA, and colleagues note in JAMA Surgery that less than half of all patients with anal dysplasia had anal lesions and so while as a clinical predictor it is not very sensitive, “the lack of a palpable or visible lesion should not preclude a patient from undergoing more extensive screening.”

Other factors significantly associated with high-grade dysplasia were younger patient age and the presence of high-grade dysplasia on anal Papanicolaou (Pap) smears. Anal Pap smear and pathological findings on HRA were consistent in 66% of patients. Male gender also showed a trend towards an increased risk, but it was not significant.

HIV viral status was not an independent predictor of dysplasia, but this is likely to be due to most of the participants being HIV positive, at 77%, and referred by the institution’s HIV care centre, the researchers point out.

It is for this reason that they say their findings are “not applicable to large populations”. Rather, they say they “should be considered a preliminary description of clinical and symptomatic risk that could potentially be applied in appropriate settings such as HIV clinics.”

In a related editorial, James Fleshman, from Baylor University Medical Center in Dallas, Texas, USA, suggests, however, that anoscopy without high resolution may be sufficient to detect clinical characteristics, such as anal lesions, that are likely to cause symptoms and says that this should form the basis of routine screening rather than HRA, with the benefit of taking less time and effort.  


Hicks CW, Wick EC, Leeds IL, et al. Patient symptomatology in anal dysplasia. JAMA Surg 2015; Advance online publication 15 April. doi:10.1001/jamasurg.2015.28

Fleshman J. Considering standards of care for anal cancer. JAMA Surg 2015; Advance online publication 15 April. doi:10.1001/jamasurg.2015.48

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