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 ANAL AND
PERIANAL
DISORDERS
 ANATOMY
Anal canal- 4 cm. long
Surrounded by the anal sphincter
mechanism
Except during defecation, its lateral walls
are kept in apposition by the levatores
ani muscles and the anal sphincters
 ANATOMY
Upper half of the anal canal is lined by
columnar epithelium
Lower half- stratified squamous
(epithelium (modified skin
Dentate line- the junctions of two types
of mucosa
 THE UPPER HALF
Lined by columnar epithelium
Thrown into vertical folds- anal columns
Joined together at their lower ends by
small semilunar folds- anal valves
At the base of each valve are small
sinuses into which open 4-8 anal glands
Some of these glands reach the
intersphincteric spaces and lead to
abscess formation
 THE LOWER HALF
Lined by stratified squamous epithelium
which gradually merges at the anus with
the perianal epidermis
There are no anal columns
Nerve supply is from somatic inferior
rectal nerve
Sensitive to pain, temperature, touch
and pressure
 ANAL SPHINCTER
MECHANISM
Internal sphincter- thickened
continuation of the rectal wall smooth
muscles- involuntary sphincter
:External sphincter- three parts
subcutaneous, superficial and deep
Puborectalis muscles: cause the rectum
to join the anal at an acute angle
ANATOMY
ANATOMY
ANATOMY
ANATOMY
PUBORECTAL SLING
 COMMON ANAL SYMPTOMS
ANAL BLEEDING
ANAL PAIN
PERIANAL ITCHING
”“SOMETHING COMING DOWN
PERIANAL DISCHARGE
 ANAL BLEEDING
Bleeding piles
Anal fissures
Ulcerated anal carcinoma
 ANAL PAIN
ANAL FISSURE
COMPLICATED PILES
 PERIANAL ITCHING
LOW-GRADE FUNGAL INFECTION
BACTERIAL INFECTION
 SOMETHING COMING“
”DOWN
PROLAPSED PILES
RECTAL PROLAPSE
PEDUNCULATED ANAL POLYP
 PERIANAL DISCHARGE
FISTULA-IN ANO
PROCTITIS
VILLOUS ADENOMA
ULCERATED ANAL CARCINOMA
 HEMORRHOIDS
Vascular swellings involving the internal
or external venous plexuses
Extremely common- constipation
Lack of fiber in the modern ”civilized” diet
Unknown in underdeveloped countries
 PATHOGENESIS
Excessive venous enlargement at the lower
ends of the anal mucosa columns
Usually located at the 3, 7, 11 o’clock positions
Caused by straining to pass small hard stools
Increased intraabdo. Pressure inhibits venous
return- venous distension
Bulging mucosa is dragged distally by the hard
stools
Persistent straining at stool causes the pelvic
floor to downwards, extruding the anal mucosa
CLINICAL CIRCUMSTANCES
Chronic constipation
Chronic diarrhea
Pregnancy
Portal hypertension
PILES
INTERNAL PILES
EXTERNAL PILE
 SYMPTOMS
Perianal irritation and itching
Aching discomfort and pain exacerbated
by defecation
Hemorrhoidal prolapse
Rectal bleeding
 CLASSIFICATION
First degree piles never prolapse
Second degree piles prolapse during
defecation but then return spontaneously
into the anal canal
Third degree piles remain outside the
anal margin unless replaced digitally
 COMPLICATIONS
Any piles may bleed from stool trauma
during defecation
Large piles may thrombose if they
prolapse and their venous return is
obstructed by sphincter tone
Venous infarction and ulceration
Sphincter tone and spasm aggravate the
pain at defecation and prolapse
PROLAPSED BLEEDING
HEMORRHOIDS
 DIAGNOSIS
Perianal examination
Skin tags
Perianal orifices
PR examination
palpable, soft folds
Rule out malignancy
Proctoscopy
Internal piles bulging into the lumen
Thrombosed piles- congested purplish mass at the
anal margin, tight spasm makes PR exam. Painful
Strangulated piles- necrotic, ulcerated mass
 CONSERVATIVE
MANAGEMENT
High fiber diet
Avoid constipation, straining at
defecation, avoid on the lavatory reading
Prolapsd piles should be replaced
digitally after defecation
Overuse of creams causes maceration
of the perianal skin
 SURGICAL TREATMENT
Injections with irritant solution- fibrotic
reaction- atrophy of the piles
Banding- application of Baron’s band
Hemorrhoidectomy- surgical excision
NO PILES
 ANAL FISSURE
Longitudinal tear in the mucosa and skin
of the anal canal
,Caused by passage of a large
constipated stool
Located nearly in the midline of the
posterior anal margin
The fissure causes sphincter spasm and
acute pain defecation, which persists for
up to an hour
 ANAL FISSURE
Fresh bleeding at defecation- the
bleeding is slight and noted on the toilet
paper
History is diagnostic of an anal fissure
PR examination is impossible due to
pain
Treatment- anal stretch, internal
sphincterotomy
 SYMPTOMS
Perianal pain, exacerbated by defecation
Minor anal bleeding
 PERIANAL ABSCESSES
Presentation: perianal pain, tenderness
and swelling
Infection of the anal gland which drain at
the base of the anal columns along the
dentate line
Duct obstruction by feces may initiate
the infection
 PERIANAL ABSCESS
Infection tends to spread laterally
through the external sphincter
-Ischiorectal abscess
Pararectal abscess
Early diagnosis- oral antibiotics treatment
may abort the infection
Established abscesses require incision and
drainage
 PERIANAL ABSCESS
Large ischiorectal abscess requires
packing to keep the neck of the cavity
open
Granulation tissue gradually fills the
space from its depths
 PILONIDAL ABSCESS
Occurs in the skin of the natal cleft
Incision and drainage followed by further
excision
PILONIODAL ABSCESS
TREATMENT
 ANAL FISTULA
,Develops as a complication of perianal
ischiorectal, pararectal abscesses
Fistula tracks from the lower rectum or
upper anal canal through the abscess site to the perianal skin at the point of previous
drainage
 ANAL FISTULA
Intermittent discharge in the perianal
region
A small papilla of granulation tissue is
seen on the skin within 2-3 cm. of the
anal margin
Blue dye injected into the external orifice
Lower fistula- lay open
Fistula above puborectalis- banding
ANATOMY
 RECTAL PROLAPSE
It is a hernia of the rectum through the
pelvic floor- the mucosa and the muscle
wall intussuscept through the anal canal
Early stage- prolaps occurs only with
defecation and retracts spontaneously
Later stage- the rectum may prolapse
.when the patient stands up
The patient reduces the prolapse
manually
Rectal prolapse
 Rectal prolapse
Powerpoint: anal and perianal disorders
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