benign rectal, anal, and perineal problems

Dr Ali Abuseini FRCS Ed

Benign Rectal, Anal, and Perineal Problems

Anatomy Dentate line divides

the rectal mucosa, which is generally insensitive and is lined with columnar mucosa, from the anoderm, which is highly sensitive (because of somatic innervation) and lined with modified squamous mucosa.


Anatomy (continue) The anal canal is surrounded by two

muscles - Internal sphincter innervated by

autonomic nervous system, maintaining resting anal tone and under involuntary control

- External sphincter innervated by somatic nerve fibers, generates the voluntary anal squeeze and plays the key role in maintaining anal continence


Anatomy (continue) The areas

surrounding the anorectum is divided into four spaces

- Peri-anal - Ischioanal - Supralevator - Intersphincteric

(intermuscular)

Hemorrhoids

Fibro-muscular cushions that line the anal canal

Classically found in three locations - Right anterior - Right posterior - Left lateral - Small secondary cushions may be

found lying between the main cushions

Hemorrhoids

They are part of normal anal anatomy

Play role in normal mechanism of fecal continence, they get engorged during straining or performance of Valsalva maneuver, which completes the occlusion of the anal canal and prevents stool loss with none defecatory straining

Hemorrhoids

Broadly classified as - Internal proximal

to dentate - External distal to

dentate, redundant folds of peri-anal skin, usually asymptomatic unless thromboses

Hemorrhoids

Hemorrhoids

Internal Hemorrhoids Disease Manifested by two main symptoms - Painless Bleeding - Protrusion (Pain is rare as they originate above

dentate line) Most popular etiologic theory states

that Hemorrhoids result from chronic straining at defecation

Continued straining causes engorgement and bleeding, as well as hemorrhoidal prolapse

Hemorrhoids

Internal Hemorrhoids Disease (continue)

Grades - Grade 1 Bleeding without prolapse

- Grade 2 prolapse that spontaneously reduce

- Grade 3 prolapse necessitating manual reduction

- Grade 4 irreducible prolapse

Hemorrhoids

Internal Hemorrhoids Disease History - Bleeding - Protrusion - Chronic Constipation (extensive bathroom

readers) Physical examination - Visual inspection may reveal prolapsing

hemorrhoidal tissue appearing as rosette of three distinct pink-purple hemorrhoidal groups

- If no prolapse, anoscopy reveals redundant anorectal mucosa proximal to dentate line in the classic locations

Hemorrhoids

Internal Hemorrhoids DiseaseManagement Ranges from (depending on hemorrhoid

grade)

Reassurance to operative hemorrhoidal

excision

Hemorrhoids

Internal Hemorrhoids Disease / Management

Therapies classified into three categories

Diet and lifestyle modification None operative and office procedures Operative hemorroidectomies

Hemorrhoids


(1)Diet and life style modification All patients grade 1 or 2 and most patients with

grade 3 Correct constipation High fiber diet Liberal water intake Fiber supplement Sitz bath (soothing effect ability to relax anal

sphincter) Topical creams

Hemorrhoids

Internal Hemorrhoids Disease / Management(2)None operative and office procedures If diet and life style modification are not effective

Rubber band ligation Ligation of hemorrhoid with elastic bands Successful in 2/3 to 3/4 in patients with grade 1 or 2 - Complications - Bleeding - Pain - Thromboses - Perianal sepsis (pain, fever, difficult urination)

Hemorrhoids

Hemorrhoids


(2)None operative and office procedures

Infrared coagulation applied to apex of each hemorrhoid at top of anal canal

Infrared radiation coagulates tissue protein and evaporates water from cell

Extent of tissue destruction depends on intensity and duration of the application

Not effective in treating large amount of prolapsing tissue, most useful for grade 1 and small grade 2 hemorrhoids

hemorrhoids


(2)None operative and office procedures Sclerotherapy Less popular nowadays Injection of sclerosant into anorectal

submucosa to decrease vascularity and increase fibrosis (injection at apex of hemorrhoids at anorectal ring)

Agents used (phenol in oil, sodium morrhuate, and quinine urea)

Hemorrhoids


(3) Operative Hemorrhoidectomies Reduction of blood flow to anorectal ring Removal of redundant hemorrhoidal tissue Fixation of redundant mucosa

Procedures Hemorrhoidectomy Stapled Hemorrhoidectomy

Hemorrhoids

External Hemorrhoids Asymptomatic except when secondary thrombosed Thrombosis may result from defecatory straining or

extreme physical activity or may be random event Patient presents with constant anal pain of acute onset Physical examination identifies external thrombosis as

purple mass at anal verge Management - Depends on patients symptoms - In the first 24 – 72 hours after onset, pain increase

and excision is warranted - After 72 hours, pain generally diminishes

Hemorrhoids

External Hemorrhoids

If operative treatment is chosen, entire thrombosed hemorrhoid has to be excised

Incision and drainage of clot shouldn’t be done as this can lead to re-thrombosis and exacerbation of symptoms

Anal Fissure

Tears or splits in the anoderm just distal to dentate line

Acute or chronic Acute fissures are caused

by mechanical force generated by the passage of large bowel movement through an anal canal that is too small to accommodate it safely and easily (though they can be caused by diarrhea)

Posterior midline 90% of fissures in females, and 99% of those in males

Anal Fissure

Decreased blood flow or increased mechanical stress may account for the propensity of these fissures to occur at this location

Repeated injury (hard or watery bowel movement ) may result in development of chronic fissure

Anal Fissure

Clinical Evaluation

Symptoms Pain (knife like or tearing sensation) Bright red rectal bleeding after bowel

movement, minor and seen on toilet paper Associated with anal spasm that persist for

several hours after each bowel movement

Anal Fissure

Clinical EvaluationPhysical Examination Difficult , extremely tender anus Split in anoderm, about 1 cm long, in posterior

midline just distal to dentate line In chronic fissure Classic triad - Hypertrophy of anal papilla - Anal fissure - Sentinel skin tag (with exposed internal anal sphincter muscle

at base of fissure)

Anal Fissure

Multiple fissures or fissures that occur away from anterior or posterior midline, should raise suspicions that other problems may be present

Anal Fissure

ManagementAcute anal fissure History less than 4 – 6 weeks None operative - Fiber supplement - Stool softeners - Generous water intake - Sitz bath - Local anesthetic ointment Rapidly alleviate symptoms and bring about

complete healing

Anal Fissure

ManagementChronic anal fissure Longer than 4 – 6 weeks Respond less to none-operative measures Surgical procedure of choice lateral internal

anal sphintrotomy Cure in 95 -98% Complications - Incontinence to flatus 0 – 18% - Soiling 0 – 7% - Fecal incontinence 0 – 0.17%

Anal Fissure

Management

Therapeutic alternatives Topical Nitroglycerin (cause neurogenic

relaxation of internal sphincter( Nifedipine gel or ointment (reduce local

demand for O2 and mechanical contraction of the muscle

Topical Diltiazem Botulinum Toxins (from clostridium botulinum)

eliminate spasm and contraction of sphincter

Anorectal Abscess

Pathophysiology Most anorectal abscesses are of cryptogenic They begin as infections in the anal glands

that surrounds the anal canal and empty in the anal crypts at the dentate line

The ducts leading to and from glands become obstructed by feces or traumatized tissue, the secondary infection develops and follow the path of least resistance

Anorectal Abscess

Clinical Evaluation Categorized according to space in which they

occur Peri-anal, Ischioanal, Supralevator, Intersphincteric (intermuscular)

Perianal abscesses are the most common, together with ischioanal abscesses account for 90% of perianal infections

Presentation (Pain, fever, chills, malaise, s/t systemic toxicity)

Anorectal Abscess

Anorectal Abscess

Clinical EvaluationExamination Fluctuant, erythematous, tender area in the

perineum or perianal area In case of supralevater or intersphenteric

abscesses, there may be no external manifestations, however, digital rectal examination may reveal tender mass above anal canal

Management Adequate Drainage

Fistula in Ano

Communication between anal canal and anal skin Usually begins in a crypt at the dentate line and

follows a course either between the internal and external sphincters (the most common location) resulting in ischioanal abscess, or above sphincter leading to supralevator abscess

After abscess drainage (one of three possibilities) - Fistula heals spontaneously OR - Abscess heals to recur in the future OR - Abscess heals but chronic draining fistula

remains

Fistula in Ano

Clinical Evaluation After drainage of Abscess, fistula is usually

associated with chronic serosanguinous to seropurulent discharge

As long as fistula remains open and draining, patient report little pain

If fistula close externally, abscess may develop Physical Examination reveals 2 – 3 mm opening

in the perianal skin, with surrounding induration Fistula tract can be palpated as firm cord

between external opening and anal canal

Fistula in Ano

Clinical Evaluation The relation ship between

external opening to internal opening is suggested by Googsall’s rule

Fistula In Ano

Clinical Evaluation Fistulas are classified into

four categories according to their relation to anal sphincter

- Intersphincteric

- Trans-sphincteric

- Supra-sphincteric

- Extra-sphincteric

Fistula In Ano

Management Chronic fistulas call for surgical treatment Unroofing entire fistula tract (fistulotomy) and

leaving wound open to heal secondarily Fistula that course through significant amount

of sphincter muscle, can’t be opened entirely because incontinence will result. In this condition the fistula is partially open with the musculature left intact and encircled with seton (tight (cutting seton) or un-tight)

OR close internal opening with advancement flap

Pilonidal Sinus Disease

Derived from Latin words pilus (hair) and nidus (nest) It denotes a chronic subcutaneous infection and foreign

body reaction to hairs imbedded in the skin or to abnormalities of follicles in the natal cleft

Most common in men between the onset of puberty and 40 years of age, and in obese persons

Clinical evaluation

- most patient experience an episode of acute abscess formation

- After abscess resolves, sinus tract develops

- Later in most cases sinus tract resolve, however, in the minority chronic disease or recurrent disease develops


Physical examination One or more small dermal pits at the base of

intergluteal cleft Tracking from the pits (usually proceeding in a

cranial and lateral direction) appears as areas of induration

If there is abscess, the area will be erythematous, tender and draining pus may be evident

Pilonidal Sinus Disease Management Abscess must be drained (incision & drainage) 40% of acute pilonidal abscesses treated with incision and

drainage develop into chronic sinuses Operations for sinus tract - Closed techniques (coring out follicles and brushing the tracts),

very high recurrence rate - Laying open (un-roofing) the tract with healing by granulation,

healing time 48 days, recurrence rate 13% - Wide and deep excision of the sinus alone, healing time 72

days, recurrence rate 13% - Excision and primary closure, healing time two weeks,

recurrence rate 15%


Management None operative conservative approach

- Meticulous hair control (natal cleft shaving)

- improved perineal hygiene

- Limited lateral incision and drainage for treatment of abscess

Hydradenitis Suppurativa

Chronic recurrent inflammatory process involving the apocrine glands of the axilla, the groin, and peri-anal region

Occlusion of follicles and abnormalities of apocrine ducts are believed to be the causative factors

Disease can result in chronically draining wounds and sinus tracts and can become quite painful and debilitating

Hydradenitis Suppurativa

Management Medical may afford temporary relief of

symptoms Most patients eventually require surgical

therapy Incision and drainage or un-roofing of sinus

reserved for early and acute disease Local excision provides adequate control of

symptoms, recurrence rate higher than 50% Wedge excision with secondary granulation

Pruritus Ani

Dermatologic condition of the perianal skin characterized by uneasiness or itching in the area around anus

Predisposing factors - Poor peri-anal hygiene (related to incontinence,

diarrhea, or excessive hair) - Over hygiene - Excessive moisture - Irregularities of peri-anal skin (from hemorrhoids,

fistulas, or previous surgery) - Skin hypersensitivity - Diet - Decreased resistance to infection - Injury to peri-anal skin

Pruritus Ani

Clinical Evaluation History and physical

examination to suggest possible causes of pruritus

Inspection of peri-anal skin with gentle retraction of buttocks under bright lighting

Characteristic finding is erythematous or thickened skin which result in whitish appearance with accentuation of the radial anal skin creases

Skin may be excoriated or ulcerated (with thickening process called Lichenification)

Large excoriations can coalesce forming weeping ulcers

Pruritus Ani

Clinical Evaluation Digital rectal examination to assess competence of anal

sphincter at rest and at maximal squeeze Anoscopy and proctoscopy should be performed

Management Cause has to be eliminated Keep peri-anal area dry Avoid trauma to area Peri-anal area should be gently washed, never scrubbed Avoid irritating foods (tomatoes, pepper, citrus fruits and

juices, coffee, colas, beer, milk , nuts and any food stuff found to be associated with increased gas, indigestion and diarrhea

Maintain regular bowel habbits

Pruritus Ani

Management (continue) Avoid creams, lotions and emollients Hydrocortisone cream may be applied for one

week If candidal yeast infection is found, try

antifungal lotion, solution or powder If standard measures fail to elicit

improvement, fungal and viral cultures and even biopsy may be necessary to exclude an infectious or neoplastic cause

Solitary Rectal Ulcer Syndrome Clinical condition characterized by rectal bleeding,

copious mucous discharge, anorectal pain and difficult evacuation

SRUS can have single rectal ulcer, multiple ulcers or even no ulcers

When present, ulcers usually occur on the anterior rectal wall just above the anorectal ring

Ulcers usually appear as shallow lesions with punched out gray-white base that is surrounded by hyperemia

Cause unclear, associated with chronic inflammation or trauma (internal intussception or prolapse of the rectum, direct digital trauma, or forces to evacuate hard stool)

Solitary Rectal Ulcer SyndromeManagement Treatment is directed at alleviating symptoms or

interfering with some of the proposed etiologic mechanisms

Conservative therapy (e.g. high fiber diet, lifestyle changes etc) should be tried first

Pharmacologic therapy (e.g. anti-inflammatory enemas and suppositories), limited success but worth trying

If symptoms persists, localized resection may be considered

Patients with prolapse, prolapse need to be treated either with perineal procedures or abdominal procedures

Questions

Which is true regarding anal sphincter function

a. when the rectum is distended, the external sphincter relax and the

internal sphincter contract. B. when the rectum is distended. The internal sphincter contract and

the external sphincter relax.

C. The External sphincter is responsible for resting anal pressure

D. The internal sphincter is responsible for resting anal pressure.

E. The external sphincter has an autonomic nerve sensation

The most common complication after hemorroidectomy is which of the following?

A. Urine retention B. Rectal bleeding C. Incontinence D. wound infection E. Anal stricture.

The fistula in ano traversing the external anal sphincter and intersphincteric plane is categorized as:

A. Intersphincteric B. Transsphincteric C. Suprasphincteric D. Extrasphincteric E. Subsphincteric

Which is not true regarding perianal abscess.

A. cryptoglandulr theory explain its pathology B. clinically presented as severe perianal pain C. once diagnosed ,the initial treatment is IV

antibiotics D. if it is not treated can be complicated by

fistula in ano E. can be treated by catheter drainage.

Pilonidal Sinus Disease which false A. the commonest site is natal cleft B. conservative treatment is effective in

some cases. C. can be complicated by abscess

formation D. If an abscess is found it should be

drain E. Recurrence rate is very low after

surgery

benign rectal, anal, and perineal problems

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