anal pain james francombe consultant colorectal surgeon warwick hospital
TRANSCRIPT
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ANAL PAIN
JAMES FRANCOMBEJAMES FRANCOMBE
CONSULTANT COLORECTAL CONSULTANT COLORECTAL SURGEONSURGEON
WARWICK HOSPITALWARWICK HOSPITAL
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ANAL PAINANAL PAIN
•RELATIVELY COMMONRELATIVELY COMMON
•SEE OFTEN IN CLINICSSEE OFTEN IN CLINICS
•SEE OFTEN AS EMERGENCYSEE OFTEN AS EMERGENCY
•TREATMENT PERCEIVED EASYTREATMENT PERCEIVED EASY
•TREATMENT CAN BE DIFFICULTTREATMENT CAN BE DIFFICULT
•OUTCOME VARIABLEOUTCOME VARIABLE
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ANAL PAINAETIOLOGY
• FISSURE IN ANOFISSURE IN ANO•ABSCESS/SEPSIS/FISTULAABSCESS/SEPSIS/FISTULA•TRAUMATICTRAUMATIC•NEOPLASTICNEOPLASTIC•THROMBOSED HAEMORRHOIDSTHROMBOSED HAEMORRHOIDS•THROMBOSED PERIANAL THROMBOSED PERIANAL HAEMATOMAHAEMATOMA•RECTO-ANAL INTUSSUSCEPTIONRECTO-ANAL INTUSSUSCEPTION
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HAEMORRHOIDSHAEMORRHOIDS
DO NOT CAUSE PAIN ....... UNLESS THROMBOSED
THEY ITCH, FEEL SWOLLEN, UNCOMFORTABLE, ANGRY, FLARE UP BUT THEY DO NOT CAUSE PAIN UNLESS THROMBOSED
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THROMBOSED HAEMORRHOIDS
PAIN RELIEFPAIN RELIEFLAXATIVESLAXATIVESSPHINCTER RELAXATION SPHINCTER RELAXATION ( ANOHEAL/GTN)( ANOHEAL/GTN)‘‘THE FROZEN FINGERTHE FROZEN FINGER’
IF ALL ELSE FAILS
SURGICAL EXCISION
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THROMBOSED
PERIANAL
HAEMATOMA
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THROMBOSED PERIANAL HAEMATOMA PAINFULPAINFUL ACUTE ONSETACUTE ONSET MAY HAVE BEEN MAY HAVE BEEN
STRAINING/COUGHING STRAINING/COUGHING PROLONGED SITTINGPROLONGED SITTING
SPONTANEOUSSPONTANEOUS
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THROMBOSED PERIANAL HAEMATOMATREATMENT ANALGESIA
ANOHEAL LAXATIVES ICE-PACK
USUALLY RESOLVE SPONTANEOUSLY
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THROMBOSED PERIANAL HAEMATOMATREATMENT
SURGICAL IF MEDICAL FAILS
INCISE AND DRAIN LA (SKIN TAGS)
EXCISE ?GA (NO TAGS)
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FISSURE IN ANOFISSURE IN ANO
•COMMON
•PAINFUL DEFECATION ‘PASSING GLASS’
•BLOOD SPOTS AND DRIPS
•INTERMITTENT
•PAIN AFTER 1-2 HOURS
•OFTEN CONSTIPATED ‘HARD MOTION’
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FISSURE IN ANOFISSURE IN ANOISCHAEMIC ULCER -USUALLY POSTERIORISCHAEMIC ULCER -USUALLY POSTERIOR
SPHINCTER SPASM - POOR BLOOD SUPPLYSPHINCTER SPASM - POOR BLOOD SUPPLY
NATURALLY SLOW TO HEAL DUE TO ABOVENATURALLY SLOW TO HEAL DUE TO ABOVE
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FISSURE IN ANO
TREATMENTTREATMENT
DECREASE PAINDECREASE PAIN -LIGNOCAINE GEL-LIGNOCAINE GEL
REGULATE BOWELSREGULATE BOWELS -LAXATIVE-LAXATIVE
SPHINCTEROTOMYSPHINCTEROTOMY -CHEMICAL-CHEMICAL
-SURGICAL-SURGICAL
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FISSURE IN ANOFISSURE IN ANOSPHINCTEROTOMYSPHINCTEROTOMY -CHEMICAL-CHEMICAL•DILTIAZEM 2% TOPICAL BD 6 WEEKSDILTIAZEM 2% TOPICAL BD 6 WEEKS
•RCT BETTER THAN GTN (LESS SIDE EFFECTS)RCT BETTER THAN GTN (LESS SIDE EFFECTS)
•BOTOX INJECTIONSBOTOX INJECTIONS
•HEALS 75% AT 6 WEEKSHEALS 75% AT 6 WEEKS
•RELAPSE MAY BE HIGHRELAPSE MAY BE HIGH
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FISSURE IN ANOFISSURE IN ANOSPHINCTEROTOMYSPHINCTEROTOMY -SURGICAL-SURGICAL
BEWARE OF WOMEN POST CHILD BIRTHBEWARE OF WOMEN POST CHILD BIRTH
FAILED MEDICAL /BOTOX TREATMENTFAILED MEDICAL /BOTOX TREATMENT
TAILORED SPHINCTEROTOMY TAILORED SPHINCTEROTOMY
OPEN IF POSSIBLEOPEN IF POSSIBLE
UPTO 10% GAS INCONTINENCE-USUALLY UPTO 10% GAS INCONTINENCE-USUALLY TEMPORARY.TEMPORARY.
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FISSURE IN ANOFISSURE IN ANO
POOR MEDICAL RESPONSE TO POOR MEDICAL RESPONSE TO TREATMENTTREATMENT
SENTINEL TAGSENTINEL TAG
LONG HISTORY >6 MONTHSLONG HISTORY >6 MONTHS
FIBRES OF IAS EXPOSEDFIBRES OF IAS EXPOSED
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ABSCESSABSCESS•COMMONCOMMON
•EMERGENCYEMERGENCY
•CRYPTOGLANDULAR THEORY OF ORIGINCRYPTOGLANDULAR THEORY OF ORIGIN
•PERCEIVED ‘JUST AN ABSCESS’PERCEIVED ‘JUST AN ABSCESS’
•USUALLY LEFT TO JUNIOR SURGEONUSUALLY LEFT TO JUNIOR SURGEON
•POOR OPERATIONPOOR OPERATION
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ABSCESSABSCESS•ACUTE SITUATIONACUTE SITUATION
•INCISE AND DRAININCISE AND DRAIN
•BIOPSY SKIN (?CROHNS)BIOPSY SKIN (?CROHNS)
•RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA)RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA)
•PACK GENTLY (IF AT ALL –NEW EVIDENCE)PACK GENTLY (IF AT ALL –NEW EVIDENCE)
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FISTULAFISTULA•ABNORMAL CONNECTION BETWEEN 2 ABNORMAL CONNECTION BETWEEN 2 EPITHELIASED SURFACES. EPITHELIASED SURFACES. A TUNNELA TUNNEL
•DEVELOP FROM ABSCESS (25% FORM DEVELOP FROM ABSCESS (25% FORM FISTULA)FISTULA)
•DISCHARGE INTERMITTENTLY PRECEDED BY DISCHARGE INTERMITTENTLY PRECEDED BY PAINPAIN
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FISTULA CLASSIFICATIONFISTULA CLASSIFICATION
INTERSPHINTERICINTERSPHINTERIC
TRANS-SPHINCTERICTRANS-SPHINCTERIC
SUPRALEVATORSUPRALEVATOR
EXTRASPHINCTERICEXTRASPHINCTERIC
+/- SECONDARY TRACTS/HORSESHOE+/- SECONDARY TRACTS/HORSESHOE
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FISTULA TREATMENTFISTULA TREATMENT
INTER-SPHINTERIC INTER-SPHINTERIC
LAY OPEN LAY OPEN
TRANS-SPHINCTERICTRANS-SPHINCTERIC
LOWLOW -LAY OPEN-LAY OPEN
HIGHHIGH -SETON/FLAP/PLUG-SETON/FLAP/PLUG
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FISTULA TREATMENTFISTULA TREATMENT
TO CURE MEANS TO CUT OPENTO CUT OPEN MEANS TO CUT SPHINCTERCUT SPHINCTER CUTS CONTINENCEMORE YOU CUT THE MORE THEY LOOSECONTINENCE DECREASES WITH AGE
FUNCTIONAL LENGTH OF FEMALE ANAL SPHINCTER APPROX 2 CM. CUT 6MM THEN 30% OF SPHINCTER CUT ----CHANCE INCONTINENCE APPROX 30%
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ANAL ANATOMY
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NEOPLASTICUSUALLY SQUAMOUS CELL CA
HOWEVER VARIETY
MELANOMA, LOW RECTAL CA
CLEAR CELL CA
RARIETIES
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TRAUMATIC SELF INDUCED-SEXUAL GAMES
INFLICTED- TRUE TRAUMA EITHER RTA, CHILDBIRTH, IMPALEMENT STUPIDITY-USUALLY WHILST UNDER THE INFLUENCE!!!!!!!
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RECTOANAL INTUSSUSCEPTION VERY EARLY PROLAPSE RECTUM TELESCOPES INTO ANAL
CANAL MAY SEE ON SIGMOIDOSCOPY SEEN ON DEF. PROCTOGRAM MAY LEAD TO COMPLETE
PROLAPSE CAN CAUSE PAIN,OFTEN MULTIPLE
INVESTIGATIONS-ALL NORMAL
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RECTOANAL INTUSSUSCEPTIONTREATMENT
BIOFEEDBACK DEFECATORY DYNAMIC
RETRAINING LAPAROSCOPIC ANTERIOR
RECTOPEXY