You’ve already read our take on why routine anal Pap smears matter for anyone at elevated risk of anal cancer—especially gay and bisexual men, transgender women, and people living with HIV. But what if that little swab shows abnormal cells?
That’s where high‑resolution anoscopy (HRA) steps in.
What exactly is HRA?
Think of HRA as the anal‑canal cousin of a cervical colposcopy. A clinician inserts a short, narrow anoscope (about the length of your index finger) into the anal canal, applies 5 % acetic acid (and often Lugol’s iodine), then examines the tissue with a colposcope—a high‑powered microscope that never actually enters your body. Any suspicious spots are biopsied on the spot so we can tell mild irritation from high‑grade dysplasia. Cleveland ClinicHPVWorld
What to expect on procedure day
| Step | What Happens | How it Feels |
|---|---|---|
| 1. Quick prep | A simple saline or Fleet‑type enema an hour or two beforehand clears the view. No full colon cleanse needed. | “Mildly awkward” is the most common review. |
| 2. Positioning | You’ll lie on your left side with knees flexed (lithotomy or prone‑jack‑knife are alternatives). | Just like a rectal exam—no fancy yoga moves required. |
| 3. Scope in, vinegar on | Anoscope goes in; acetic acid tingles; the colposcope hovers outside. | Brief stinging or pressure that fades fast. |
| 4. Targeted biopsies | Tiny pinch samples (2‑3 mm) if anything glows suspiciously white. Local lidocaine is available, but many patients skip it. | Feels like a quick pinprick; most rate pain 1–3 / 10. PMC |
5. Back to normal life | Drive yourself home, hit the gym tomorrow, back to receptive anal play in about a week if biopsies were taken. | Some spotting for 24 h is common. |
Total chair time: 20–30 minutes.
Anesthesia: None. A light topical lidocaine gel is plenty for the vast majority of people. Major insurers, IANS guidelines, and large centers like Whitman‑Walker and Cleveland Clinic list HRA as an office‑based procedure without sedation. If someone wants to book you an OR with propofol, ask why—they’re outside standard of care. Whitman-WalkerCleveland ClinicBHIVA
Bottom line: HRA ≠ colonoscopy. Colonoscopy surveys the entire five‑foot colon under IV sedation; HRA inspects just the last two inches with magnification, awake and chatting.
Credentials matter—questions to ask before you drop trou
Training & certification.
• Have you completed an International Anal Neoplasia Society (IANS)–recognized HRA course or equivalent preceptorship? iansoc.orgExperience.
• How many HRAs (and directed biopsies) have you performed in the past year?Quality indicators.
• Do you document lesions with photo capture?
• What proportion of your biopsies come back as high‑grade squamous intra‑epithelial lesions (HSIL)? (≥10 % suggests competent targeting.) <10% means they over biopsyPathology partnership.
• Is my tissue read by a pathologist familiar with anal dysplasia?Treatment pathway.
• Can you perform office‑based ablation (e.g., infrared coagulation) if HSIL is confirmed, or will you refer me?
FAQ‑style quick hits
Will it hurt? Most describe mild pressure; fewer than 5 % need anything stronger than topical lidocaine.
Will my insurance cover it? Increasingly yes, if you’re in a recognized risk group; we’ll pre‑authorize for you.
How often will I need it? If pathology shows HSIL, follow‑up every 6–12 months until clearance; if only low‑grade changes, interval may stretch to 2–3 years.
Can I just have a colonoscopy instead? No. The resolution of colonoscopic cameras isn’t high enough to spot flat HSIL lesions in the anal transition zone. You’d miss the very thing we’re looking for.
What if my provider insists on anesthesia? Ask for written justification. Routine HRA under sedation adds cost and risk without proven benefit according to international guidelines. BHIVAAetna
The Tom of P‑Town Health take‑away
At Tom of P‑Town Health we:
Perform in‑office HRA (or refer to one of a handful of IANS‑trained colleagues in Boston) without sedation.
Coordinate pathology with expert cytopathologists.
Map out a full care plan—from surveillance schedules to on‑site infrared coagulation for HSIL if needed.
Early detection keeps small abnormalities from ever turning into anal cancer. If your anal Pap was abnormal—or you just want the peace of mind of expert screening—reach out. We’ll keep the magnification high, the comfort higher, and the anesthesia nowhere in sight.
Key references
Whitman‑Walker Health. High‑Resolution Anoscopy patient education page. Whitman-Walker
Cleveland Clinic. Anoscopy & High‑Resolution Anoscopy overview. Cleveland Clinic
Hillman RJ et al. Acceptability of High‑Resolution Anoscopy in Men and Women. J Lower Genital Tract Dis. 2018. PMC
International Anal Neoplasia Society. Guidelines for Practice Standards in the Detection of Anal Cancer Precursors. 2019. BHIVA
International Anal Neoplasia Society. Consensus Screening Guidelines. 2023.
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