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Back to medical school

• -anorectal disorders

Ian Botterill, Dept Colorectal Surgery Leeds
General Infirmary
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Wide variety of pathologies

• congenital / acquired
• benign / malignant
• traumatic
• infective / inflammatory
• gender / age related

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Common symptoms of ano-rectal disorders

• bleeding
• anal pain
• itch
• faecal leakage / hygiene problems
• swelling
• discharge

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Examination

• abdomen
• groins (lymph nodes)
• dermatoses

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Ano-rectal examination

• chaperoned
• relaxed patient
• left lateral
• good light
• knee elbow position
• use pts hand to elevate right buttock
• /- anoscopy in 1y care

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Ano-rectal examination

• External appearance -skin condition -swellings
  -soiling / discharge -perineal descent -scars

• Digital examination -sphincter tone -squeeze
  pressure -cervix / prostate -coccyx -retrorect
  al space -rectocoele

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Anatomy
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Haemorrhoids

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

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Haemorrhoids

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

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Cause of haemorrhoidal problems

• altered bowel habit
• raised intra-abdominal pressure
• straining

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Treatment of haemorrhoids

• Diet -five helpings fibre / d
• Out-patient -injection sclerotherapy -ban
  ding -photocoagulation

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Surgical treatment

• For 3rd / 4th degree haemorrhoids
• Open haemorrhoidectomy
• Closed haemorrhoidectomy
• Ligasure haemorrhoidectomy
• Stapled haemorrhoidopexy (PPH)

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Results of haemorrhoidectomy

• gt90 daycase
• least initial pain -stapled
  haemorrhoidopexy -Ligasure haemorrhoiodectomy
• quickest return to work -stapled
  haemorrhoidopexy -Ligasure haemorrhoidectomy
• most costly PPH / ligasure
• lowest recurrence (prolapse) conventional

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Complications of haemorrhoidectomy

• Local - stenosis - faecal leakage
  - recurence - bleeding -
  retention of urine
• severe perineal sepsis (esp IDDM
  immunosuppressed)

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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 gt
  haemorrhoidectomy - refer gangrenous or those
  that fail to settle
• interval haemorrhoidectomy if still problematic

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Anal skin tags
Sx anal swelling / hygiene problems Diagnosis
perineal examination alone Differential
Crohns disease / anal warts Rx reassurance /
excision
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Rectal mucosal prolapse full thickness rectal
prolapse
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Rectal mucosal prolapse

• result of straining
• associated with pruritus ani / mucous discharge
• diagnosis _at_ anoscopy
• Rx - dietary correction - advised to
  avoid straining at stool - injection
  sclerotherapy

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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
Fourniers gangrene) skin necrosis (possible
Fourniers gangrene) anal spasm throbbing pain
(inter-sphincteric abscess) Treatment ID
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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
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Fistula in ano

• 95 cryptoglandular - ie origin in
  ano-rectal crypts at dentate line
• 5 rarities - Crohns - TB -
  hidradenitis suppurativa - traumatic -
  malignancy - complicated diverticular
  disease - radiation - anastomotic leakage

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Classification
Inter-sphincteric 70 Trans-sphincteric 25 Supr
a-sphincteric 5 Extra-sphincteric lt1
Simple v. complex
Complex -branching tracts / 2y
tracts -associated abscess -associated pathology
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Goodsalls 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
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Management of fistula in ano
Strike a balance between -cure of
fistula -prevention of further anorectal
abscess -preservation of continence
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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

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Anal fissure

• focal linear deficiency of anal mucosa
• posterior gt anterior
• acute v. chronic -chronic IAS exposed , gt
  6/52, keratinisation
• simple v. complex

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Anal fissure
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Anal fissure management

• stool softeners
• dietary advice
• topical LA
• chemical sphincterotomy -topical -injecte
  d
• surgical sphincterotomy

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Anal fissure surgery through the ages

• anal stretch
• lateral sphincterotomy
• chemical sphincterotomy - topical -
  injectable

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Anal fissure treatment

• GTN 40-50 successful s/e severe
  headaches
• Diltiazem 60-80 successful s/e nil
  generally
• Botox 60-90 successful s/e transient
  minor leakage
• Sphincterotomy 98 successful s/e 2
  passive leakage

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Proctitis

• Biopsy mandatory (with exception of prior prosate
  / cervical brachytherapy)
• UC / Crohns / indeterminate / infective
• Stool culture
• Biopsy prior to starting suppositories
• Suppositories often preferable to oral therapy

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Pilonidal sinus / abscess
Abscess often deep-seated do not respond to
antibiotics
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Pilonidal sinus disease
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Z plasty
Uli Szymanovski Developed Z plasty wound closure
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Rhomboid flap
Healing by 1y intention 90 of time as with Z
plasty
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Healing by 2y intent
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Healing using Vac Therapy
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Perianal haematoma

• Thromobosis of superficial haemorrhoidal veins
• Discrete circular lump at / beyond anal verge
• Incise drain

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Pruritus ani
Night gt day Rule out coexistent dermatoses /
renal failure / liver disease If fungal disease
suspected gt skin scrapings Ano-rectal examination
proctoscopy. Treat ano-rectal pathology
(haemorrhoids / faecal incontinence / anal tags
etc).
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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 gt 80 successful - s/e
  occasional cellulitis / ulcer / incontinence

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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

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Faecal incontinence

• Causation
• Obstetric injury (8-30 sphincter injury rate at
  childbirth)
• Post-surgical
• Faecal impaction
• Neuropathy / MS / Parkinsons
• Poor mobility / impaired cognition
• Diarrhoea
• IBS / rectal non-compliance

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Assessment of faecal incontinence

• History
• Examination
• Endoanal USS (sphincter injury)
• Anorectal manometry (rest squeeze strength)
• Pudendal nerve terminal latency (sensation)

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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

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Treatment incontinence

• dietary measures
• treat diarrhoea / impaction / IBS
• non-operative - collagen injections -
  anal plug
• sacral nerve stimulation
• sphincter repair
• artificial sphincters
• graciloplasty

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Anal stenosis

• Post-surgical
• Cancer
• Crohns
• Previous chronic anal fissure
• Radiation
• Systemic sclerosis
• Need EUA to assess all these

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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
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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

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Hidradenitis suppurativa
Superficial fistulating condition assd with
chronic skin sepsis Axillae gt groins gt
perineum Clinical diagnosis (/- biopsy)
typically have disease elsewhere Rx drain sepsis
/ rotating antibiotics / infliximab / stop smokng
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Anal papillae
Sx nil (asymptomatic finding
typically) Diagnosis at anoscopy Biopsy
rarely required Treatment leave alone
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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

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AIDS
HSV
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Other perineal problems-pressure sores
Post-sacral Over ischial tuberosity Normally have
clear cut antecedant history
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summary

• diverse pathology
• high degree of overlap between 1y and 2y care
• refer bleeding
• refer odd-looking lesions