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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