Problems in Tropical Proctology

Case Report

Austin J Surg. 2016; 3(1): 1081.

Problems in Tropical Proctology

Weledji EP¹* and Enoworock G²

¹Department of Surgery, University of Buea, Cameroon

²Department of Pathology, University of Buea, Cameroon

*Corresponding author: Weledji EP, Department of Surgery, Faculty of Health Sciences, University of Buea, Regional Hospital Buea, PO Box 126, Limbe, S.W. Region, Cameroon

Received: February 01, 2016; Accepted: March 22, 2016; Published: March 29, 2016


Anorectal pathology is a growing problem in the developing (tropical) world. Five proctology cases and other anorectal pathologies that highlight the problems of diagnosis and management in a developing tropical country (Cameroon) in West Africa are discussed. Proctological procedures can be safe and effective therapeutic modalities. However, the problems of proctology practice in the developing world include: patients’ ignorance and fear of anorectal procedures rendering fecal incontinence; insufficient health education accentuating late diagnosis and management of anorectal disease; a poor referral system; the lack of trained colorectal surgeons and pathologists; limited resources; and the greater need for understanding sexually transmitted diseases such as HIV/AIDS in the practice of proctology.

Keywords: Haemorrhoids; Cloacal injury; Rectal prolapse; Anal tuberculoma; HIV ulcer; HIV-associated malignancies


HIV: Human Immunodeficiency Virus; AIDS: Acquired Immune Deficiency Syndrome


Anorectal pathology is a growing problem in the developing world. The adoption of the western low fibre diet aggravates the symptoms of haemorrhoids and anal fissures. In addition, sub- Saharan Africa has the highest prevalence of HIV/AIDS and HIV is one of the sexually transmitted organisms that affects the anorectum with a predilection for the external anal sphincter [1,2]. Included in this group are the other sexually transmitted organisms associated with high risk behaviors including anorectal intercourse that cause proctitis and anogenital ulcerations. Other viral organisms include cytomegalovirus, Herpes Simplex Virus (HSV), human papilloma virus (condylo-mataacuminatum), and molluscumcontagiosum. Bacterial organisms include Campylobacter jejuni, Chlamydia trachomatis, Lymphogranuloma venereum, Haemophilusducreyi (chancroid), Neisseria gonorrhoeae (gonorrhoea), Donovaniagranulomatis (granuloma inguinale) and Treponemapallidum (syphilis). The presence of more than one offending organism is common and the presenting symptoms may range from gastrointestinal (diarrhoea, rectal bleeding) to visible lesions in the anus and perineum [2]. The diarrhoea associated with the opportunistic colonic infections (CMV and bacterial colitis/proctitis), is severe and encourages anal ulceration, fissures and pruritis. The tenesmus from diarrhea causes straining that aggravates haemorrhoids. Thus stool cultures for salmonella, shigella, campylobacter and cryptosporidium with microscopy for giardia, ova, cysts and amoebae are mandatory [1,2]. An understanding of HIV/AIDS is therefore important to the practice of proctology as these patients frequently present with proctological diseases. The distribution of the most common anorectal pathologies reported in HIV patients include anal ulcer (29–32%), anal condyloma (32–43%), anal fissure (6–33%), anal fistula (6–33%), perirectal abscess (3–25%) and haemorrhoids (4– 14%..3With increasing survival of HIV/AIDS patients on Highly Active Anti-Retroviral Therapy (HAART) the other non-AIDS related anorectal disorders requiring treatment predominate. The two factors most associated with poor wound healing are AIDS and a poor performance status (ASA or Korsakoff’sscore) [3-5]. Two-thirds of AIDS patients needing surgical treatment for anorectal disease were rendered symptom- free. So treatment is well-worth doing as the survival is close to patients with AIDS who did not have anorectal disease [5,6]. This paper ascertained the short-comings and problems of proctology practice in a typical sub-saharan country (Cameroon) located at the West African coast (the Gulf of Guinea) through 5 case presentations.

Case Presentation

Problem 1

The lack of trained colorectal surgeons, pathologists and resources

Case: Chronic massive prolapsed haemorrhoids managed by ablation and correction in a poor resourced area.

We report a case of a 75-year-old man with symptomatic chronic circumferentially prolapsed haemorrhoids and associated obstructive defaecation (Figure 1a). He had several failed attempts at surgical repair by general medical practitioners. The specialist’s knowledge that failed haemorrhoidectomy may be due to an associated rectal mucosal prolapse led to the successful approach of ablation and correction of the associated rectal mucosal prolapse with a modified Delorme’s procedure akin to a stapled anopexy (Figure 1b).