No Butts About It: The What and Why Behind Your High Resolution Anoscopy
Why do I need a High Resolution Anoscopy (HRA)?
If you have been referred for an HRA it may be because your last anal pap test showed abnormal findings. While this can mean a number of things, it needs to be determined if it is dysplasia.
What is anal dysplasia?
Anal dysplasia is abnormal cells (or a lesion) in the lining (skin) of the anal canal.
Anal dysplasia can be low-grade (mild) or high-grade (moderate to severe).
Some low-grade lesions may progress (get worse) to high-grade lesions. High-grade lesions are very common. High-grade lesions can progress to cancer. About 1/1,000 of high-grade lesions per year will progress to cancer.
Not all lesions get worse. Some can remain without changing and some may even disappear. Anal dysplasia occurs mainly in two places: inside the anal canal and in the skin of the perianus.
Where is the anus and perianus?
The anus, also called the anal canal, is a short tube, about 1½ inches long, at the end of your rectum through which stool leaves the body.
The skin around the outside of the anus is called the perianus.
What causes anal dysplasia?
Anal dysplasia is caused by the human papillomavirus (HPV).
What is HPV?
HPV is the most common sexually transmitted virus. Around 75-80% of sexually active people have been infected with HPV, and this is much higher in people with HIV. There are over 40 different HPV types that may infect the genital area.
Oncogenic (cancer-causing) HPV, also called high-risk HPV (especially HPV 16 and 18) can cause cancers of the cervix, vagina, and vulva in women; penis cancer in men; and anal cancer and some mouth/throat cancers in men and women. Non-oncogenic HPV or low-risk HPV (most commonly HPV 6 and 11) can cause warts in the genital and anal areas. These warts are called condyloma acuminatum.
HPV lives only in skin cells (epithelium) and no other kinds of cells. The only way to get it from another person is through skin-to-skin spread. That usually means contact between genital skin of one person and genital skin of another person. It is currently believed that HPV is rather easily acquired.
Most infections with HPV will go away on their own within 2 years of infection. But in some cases the infection does not go away and is then called chronic. Chronic infection with high-risk HPV may cause dysplasia and could eventually cause cancer.
People living with HIV are more likely to have a persistent infection of HPV. People living with HIV have a higher chance of getting dysplasia compared with people without HIV.
What are the signs/symptoms?
There are often no specific symptoms of anal dysplasia until it is quite advanced.
The following symptoms can be from dysplasia, but can also be caused by other common conditions including anal infections, anal trauma, hemorrhoids and warts:
Feeling a lump at the anal opening
Pain or pressure around the anus
Itching or discharge from the anus
Change in bowel habits
Swollen lymph nodes (glands) in the anal or groin areas
Who is at risk of getting anal dysplasia?
Everyone. The people who have the following risk factors are at an increased risk:
Multiple sexual partners
Receptive anal sex
History of anal warts, sexually transmitted infections, fissures, fistulas and hemorrhoids
Women, particularly those with a history of cervical or vulvar dysplasia or cancer
Over 50 years old
Being infected with HPV
Testing and diagnosing (screening):
Regular medical check-ups with anal examinations by your doctor will help detect early cancers, but not anal dysplasia. Anal Pap smears can help detect precancerous changes, such as the early signs of dysplasia, but may not be able to identify lesions (which may or may not develop into precancerous formations).
Lesions can be identified during an anal canal examination called High Resolution Anoscopy (HRA), which is performed by an anoscopist. In people at high risk for anal cancer, the anal Pap smear and HRA should be done yearly.
What happens during an evaluation for anal dysplasia?
History: Your provider will ask you about how you are doing, your health habits, past illnesses and treatments.
Digital Exam: An exam of the anus and rectum. Your provider inserts a lubricated, gloved finger into the anus and lower part of the rectum to feel for anything that seems unusual.
Anal Pap (anal cytology) and Cobas® HPV test: A moist swab, like a Q-Tip® is passed into the anal canal and cells that come off on the swab are examined under a microscope. This procedure helps to check for abnormal cells in the anus and 14 high-risk HPV types. It takes about 10 seconds and causes minimal discomfort.
HRA with possible biopsy: The provider will use a plastic instrument called an anoscope and look at the anal canal with a special microscope called a colposcope. If an abnormal area is seen, then a very small piece of anal tissue may be removed (biopsy) and sent to a specialist (pathologist) to check for signs of cancer. The procedure takes about 15 minutes.
What can I do to prepare for my HRA?
Patients do not need to do anything special in order to prepare for high resolution anoscopy. Some medications and supplements can cause a risk of increased bleeding, such as aspirin, ibuprofen, vitamin E and certain herbs. If you are taking any of these, please call your doctor ahead of time for guidance. Starting 24 hours before your exam, avoid using any douches, enemas or creams that are applied to the anal canal. It is also important to avoid anal sex.