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-anorectal disorders

Ian Botterill, Dept Colorectal Surgery

Leeds General Infirmary

Wide variety of pathologies

• congenital / acquired

• benign / malignant

• traumatic

• infective / inflammatory

• gender / age related

Common symptoms of ano-rectal disorders

• bleeding

• anal pain

• itch

• faecal leakage / hygiene problems

• swelling

• discharge

Examination

• abdomen

• groins (lymph nodes)

• dermatoses

Ano-rectal examination

• chaperoned• relaxed patient• left lateral• good light• knee elbow position• use pt’s hand to elevate

right buttock• +/- anoscopy in 1y care

Ano-rectal examination

• External appearance-skin

condition -swellings

-soiling / discharge-perineal

descent -scars

• Digital examination-sphincter tone

-squeeze pressure -cervix / prostate

-coccyx-retrorectal

space -rectocoele

Anatomy

Haemorrhoids

• Symptoms: - anal canal bleeding, pruritus, swelling,

pain

Haemorrhoids

• Classification- 1y: bleed, do not prolapse- 2y: prolapse & reduce spontaeously- 3y: prolapse & require manual reduction- 4y: prolase, not reducible

Cause of haemorrhoidal problems

• altered bowel habit

• raised intra-abdominal pressure

• straining

Treatment of haemorrhoids

• Diet -five helpings fibre / d

• Out-patient-injection sclerotherapy-banding-photocoagulation

Surgical treatment

• For 3rd / 4th degree haemorrhoids

• Open haemorrhoidectomy

• Closed haemorrhoidectomy

• Ligasure haemorrhoidectomy

• Stapled haemorrhoidopexy (PPH)

Results of haemorrhoidectomy

• >90% daycase• least initial pain -

stapled haemorrhoidopexy -Ligasure haemorrhoiodectomy

• quickest return to work: -stapled haemorrhoidopexy-Ligasure haemorrhoidectomy

• most costly: PPH / ligasure• lowest recurrence (prolapse) ; conventional

Complications of haemorrhoidectomy

• Local- stenosis- faecal leakage - recurence- bleeding- retention of urine

• severe perineal sepsis (esp IDDM & immunosuppressed)

Painful prolapsed haemorrhoids

• natural history (worst pain days ~ 3-7, then settles)

• most resolve with conservative Rx- lactulose / topical anaesthetic creams / ice / paracetamol & NSAIDs /

relief of anal spasm (GTN or diltiazem)

- failure to resolve > haemorrhoidectomy - refer gangrenous or those that fail to settle

• interval haemorrhoidectomy if still problematic

Anal skin tags

Sx: anal swelling / hygiene problems

Diagnosis: perineal examination alone

Differential: Crohn’s disease / anal warts

Rx: reassurance / excision

Rectal mucosal prolapse & full thickness rectal prolapse

Rectal mucosal prolapse

• result of straining

• associated with pruritus ani / mucous discharge

• diagnosis @ anoscopy

• Rx- dietary correction- advised to avoid straining at stool- injection sclerotherapy

Ano-rectal sepsis

Sx: perineal pain (throbbing), possible prior history of similar

Exam: tender fluctuant mass +/- discharge, may be toxic

Beware: diabetics (risk of rapidly progressive infection & Fournier’s gangrene)

skin necrosis (possible Fournier’s gangrene)

anal spasm & throbbing pain (inter-sphincteric abscess)

Treatment: I&D

Fistula in ano

~ 30-40% of all perineal sepsis once drained goes on to develop a fistula

~ 80-90% of perineal sepsis that yielded enteric organisms will develop a fistula

Fistula in ano

• 95% cryptoglandular - ie origin in ano-rectal crypts at dentate line

• 5% rarities - Crohn’s - TB - hidradenitis suppurativa - traumatic - malignancy - complicated diverticular disease - radiation - anastomotic leakage

Classification

Inter-sphincteric 70%

Trans-sphincteric 25%

Supra-sphincteric ~5%

Extra-sphincteric <1%

Simple v. complex

‘Complex’:

-branching tracts / 2y tracts

-associated abscess

-associated pathology

Goodsall’s rule

External opening posterior to 3-9 oclock position open in posterior midline of the anal canal

External opening anterior to 3-9 oclock position open radially in the anal canal

~80-90% accurate

Management of fistula in ano

Strike a balance between

-cure of fistula

-prevention of further anorectal abscess

-preservation of continence

Management of fistula in ano

• Divide tissues overlying track ( to allow healing by 2y intent) - lay open - cutting seton

• Occlude internal opening & provide external drainage-

anal fistula plug - rectal or anal advancement flap

• Prevention of further ano-rectal sepsis - draining seton

Anal fissure

• ‘focal linear deficiency of anal mucosa’

• posterior > anterior

• acute v. chronic-chronic: IAS exposed , > 6/52, keratinisation

• simple v. complex

Anal fissure

Anal fissure management

• stool softeners

• dietary advice

• topical LA

• chemical sphincterotomy -topical -injected

• surgical sphincterotomy

Anal fissure surgery through the ages

• anal stretch

• lateral sphincterotomy

• chemical sphincterotomy - topical - injectable

Anal fissure treatment

• GTN 40-50% successfuls/e: severe headaches

• Diltiazem 60-80% successfuls/e: nil generally

• Botox 60-90% successfuls/e transient minor

leakage• Sphincterotomy 98% successful

s/e 2% passive leakage

Proctitis

• Biopsy mandatory (with exception of prior prosate / cervical brachytherapy)

• UC / Crohn’s / indeterminate / infective

• Stool culture

• Biopsy prior to starting suppositories

• Suppositories often preferable to oral therapy

Pilonidal sinus / & abscess

Abscess often deep-seated – do not respond to antibiotics

Pilonidal sinus disease

Z plasty

Uli Szymanovski

Developed ‘Z’ plasty wound closure

Rhomboid flap

Healing by 1y intention ~90% of time as with Z plasty

Healing by 2y intent

Healing using Vac Therapy

Perianal haematoma

• Thromobosis of superficial haemorrhoidal veins

• Discrete circular lump at / beyond anal verge

• Incise & drain

Pruritus ani

Night > day

Rule out coexistent dermatoses / renal failure / liver disease

If fungal disease suspected > skin scrapings

Ano-rectal examination & proctoscopy.

Treat ano-rectal pathology (haemorrhoids / faecal incontinence / anal tags etc).

Pruritus treatment

• Avoid synthetic / tight underwear• Avoid perfumed soaps etc • Avoid scratching• Use hairdryer to dry skin• Avoid steroid creams• Treat anal pathology / diarrhoea• Dermatology involvement

• Methylene blue injections > ~80% successful - s/e occasional cellulitis / ulcer /

incontinence

Faecal incontinence- understand continence first!

• Brain / higher centres• Spinal cord• Reflex arcs• Pudendal nerves• Ano-rectal sensation ‘sampling’• Stool consistency• Rectal compliance• Anal sphincter complex

Faecal incontinence

• Causation

• Obstetric injury (8-30% sphincter injury rate at childbirth)

• Post-surgical • Faecal impaction• Neuropathy / MS / Parkinson’s• Poor mobility / impaired cognition• Diarrhoea• IBS / rectal non-compliance

Assessment of faecal incontinence

• History• Examination

• Endoanal USS (sphincter injury)

• Anorectal manometry (rest & squeeze strength)

• Pudendal nerve terminal latency (sensation)

Assessment of incontinence• Cleveland clinic score

- severity of soiling - frequency of soiling - use of pads

- lifestyle disruption

• History of back injury / neurolgical disorder

• Urinary incontinence

• Saddle anaesthesia

Treatment incontinence

• dietary measures• treat diarrhoea / impaction / IBS • non-operative

- collagen injections- anal plug

• sacral nerve stimulation• sphincter repair• artificial sphincters• graciloplasty

Anal stenosis

• Post-surgical• Cancer• Crohn’s• Previous chronic anal fissure

• Radiation• Systemic sclerosis

• Need EUA to assess all these

Anal cancer

Sx: itch, bleeding, pain (if below dentate line), swelling, ulcer, groin node

Exam: hard, irregular, friable area. Groin nodes possible. ? Coexists with anal warts

Differential: haemorrhoids, anal fissure, anal warts, STD

Diagnosis: EUA & biopsy

Anal cancer-treatment

• Chemo-radiotherapy• Ongoing perineal surveillance• Average local control ~ 70%• Average cure ~ 70%• Salvage surgery for recurrence

- APER with rectus flap to perineum

• Rarely is local excision alone sufficient

Hidradenitis suppurativa

Superficial fistulating condition ass’d with chronic skin sepsis

Axillae > groins > perineum

Clinical diagnosis (+/- biopsy) – typically have disease elsewhere

Rx: drain sepsis / rotating antibiotics / infliximab / stop smokng

Anal papillae

Sx: nil (asymptomatic finding typically)

Diagnosis: at anoscopy

Biopsy: rarely required

Treatment: leave alone

AIDS & the perineum

• Wide variety of pathology - fissures / abscesses / fistulae / infections / anal

cancer / cutaneous lymphoma - florid warts - pruritus - incontience

• General principle - suspect immunocompromise - culture / biopsy- avoid agresssive surgery- treat in conjunction with Infectious Diseases

/ Sexual Health

AIDS

HSV

Other perineal problems-pressure sores

Post-sacral

Over ischial tuberosity

Normally have clear cut antecedant history

summary

• diverse pathology

• high degree of overlap between 1y and 2y care

• refer bleeding

• refer ‘odd-looking’ lesions