Assignment

Applied surgery
 Assignment
Submitted To: Dr. Asad Naqvi
Submitted By: Dr. Khadija
Bakhtawar
Sap Id: 70059756
Semester: MID 5th
Course title: applied surgery
No. Contents
1. Physical findings of patient
2. Presenting symptoms
3. Presenting complaint
4. Differential diagnosis
5. History
6. Physical examination(DRE)
7. Diagnosis
8. Causes
9. Treatment
10. Intra & post-operative management
11. Discharge
12. Anorectal diseases
 CASE PRESENTATION
➢ A 37 year old male civil servant, with 9 years of anal
protrusion, with associated occasional bleeding, a year
history of non-reducibility, a week history of associated
pain.
➢ Patient presented at general surgery clinic via OPD with
anal protrusions which started year 2001 with constipation
and passage of hard stools, and later became associated with
protrusion of anal tissue that was spontaneously reducible, 5
years later, he noticed bright red blood which comes via
anus immediately after passage of stool.
➢ There was associated history of pain which started a week before admission, there is no
history of passage of mucous, his diet, majorly consisted of beverages, indomine, bread at
home.
➢ There is no past history of chronic cough, chronic diarrhea nor abdominal swelling.
➢ Before presentation to the managing team ,he had used herbal preparations on several
occasions for past 8 years, and two weeks before presentation in the unit patient was
placed on oral methronidazole and ampicillin , with sitz bath by general surgery term A ,
but he was not relieved of symptom.
PRESENTING COMPLAINT
➢ Anal protrusions 9yrs duration

Presenting symptoms
➢ Extreme itching around the anus.
➢ Irritation and pain around the anus.
➢ Itchy or painful lump or swelling near
your anus.
➢ Painful bowel movements.
➢ Fresh red blood on your tissue after
having a bowel movement.

DIFFERENTIAL DIAGNOSIS
➢ Hemorrhoids can be differentiated by ;
o physical appearance
o historical features
o palpation
o DRE
o Anoscopy
PAST MEDICAL SURGICAL HISTORY
➢ He had no surgeries in the past. He’s not a known hypertensive, diabetic, sickle cell
disease nor bronchial asthmatic patient.
➢ Drug History: No known drug allergy.
FAMILY HISTORY
➢ Single, and 2nd among seven siblings in a monogamous setting. Takes alcohol products
sparingly and stopped 4years ago, does not take tobacco product of any form.
O/E:
➢ A young man, not in obvious painful distress.
➢ Not pale, anicteric, acyanossed, not warm to touch.
➢ No peripheral lymphadenopathy, nor pedal edema.
➢ Abdomen: full and soft, moves with respiration,
➢ No scars, male pattern hair distribution.
➢ No areas of tenderness,
PHYSICAL EXAMINATION
➢ During an anal examination, the doctor look at skin
around the anus
➢ Patient position was left lateral decubitus
➢ Do a digital rectal examination, in which a gloved,
lubricated finger is gently inserted into the anus
 ➢ Checked the inside of the anal canal where the internal hemorrhoids are located with a
short lighted probe called an anoscope.

DRE:
➢ Good anal hygiene with good sphincter tone
➢ No fissures, hemorrhoids present, small at 6 and 12o’clock positions, tender
with bluish distended veins, rectal cavity contained fecal pellets, no masses,
rectalmucosal wall is free and mobile prostate not enlarged.
CVS:
➢ Pulse rate - 80bpm regular full volume
➢ B.P. – 90/70mmhg.
➢ H.S. – 1&2 only.
➢ Apex beat - 5th I.C.S. lateral to midclavicular line
➢ RS : RR – 20 cpm
➢ Trachea central
➢ PN – resonant
➢ BS – vesicular
➢ CNS: Conscious and alert
DIAGNOSIS
➢ 30 gangrenous hemorrhoids
➢ Grade IV hemorrhoids

HEMORRHOIDS
➢ Hemorrhoids are swollen veins in your
lower rectum. Internal hemorrhoids are
usually painless, but tend to bleed.
➢ External hemorrhoids may cause pain
Cause of hemorrhoids
➢ Hemorrhoids can develop from
increased pressure in the lower
rectum due to: Straining during bowel
movements.
➢ Sitting for long periods of time as he was civil servant
➢ Having chronic diarrhea or constipation.
TREATMENT
➢ Admitted by consultant from general
surgery team A TO C
➢ Book after theatre fee paid, and Prepared
for surgery(hemorroidectomy)
➢ with ducolax Suppository
➢ consent retrieved
➢ NPO for 24 hrs.
➢ Serum E/U/Cr
➢ PCV – 30%
➢ FBS
➢ Urinalysis (early morning )
➢ Proteinuria 30mg/dl(+)
➢ Bilirubinuria (+).
➢ No other abnormalities detected
.Consultant informed.
INTRA/POST-OPERATIVE
MANAGEMENT
➢ Patient was assessed by the
anesthesiologist and spinal
anesthesia was administered and
failed thereafter placed on TIVA.
➢ He was placed in lithotomy
position and draped, lurch
procedures done, and pellicles of
hemorrhoids excised while
hemostasis secured.
➢ Rectum was parked with Vaseline
gauze and anal orifice Dressed.
➢ During the course of surgery, his
vital signs where monitored.
➢ He was placed on intravenous
ciprofloxacin 200mg bd for
5/7intravenous flagyl 400mg tds
for 5/7I m pentazocine 30mg
alternate with IM diclophenac
6hrly for 48hrs then after PRN
.tabs vitamin c T bd for 10/7NPO
to food only for 24 hrs. IV 5% D/S
8hrly for 24 hrs.’ .Sitz bath tds
+PRN after toileting
POST OP COMPLICATIONS NOTICED
➢ Dribbling feces from anus during sitz bath and at anal orifice during daily inspections , he
was placed on kegills exercise
➢ Bleeding from op site on 1st and 3nd , patient was reassured
➢ Pain at op site, he was placed on analgesics, intramuscular analgesics later oral tramadol
50 mg bd.
➢ Vital signs were stable throughout his stay in the hospital
DISCHARGE
➢ Patient was discharge on 5TH day post-op on the following tabs flagyl 400mg tds,
capampiclox 500mg qds and tabs tramadol 50mg bd, sitzbath tds and kegills exercise bd
all for 7 day to see at next two Monday clinic for follow-up.
Anorectal diseases
Hemorrhoids
Internal vs. external hemorrhoids
➢ Hemorrhoids are classified as internal, external, or mixed.
Internal hemorrhoids
➢ Prolapse of internal hemorrhoids, with possible incarceration and strangulation, may
cause pain by triggering an anal sphincter complex spasm. → possible ischemia and
necrosis of internal hemorrhoids → worsening anal sphincter complex spasm → potential
external hemorrhoid thrombosis → cutaneous pain
➢ Develop above the dentate line, which is not innervated by cutaneous nerves; distension
does not cause pain.
➢ Bleeding and/or prolapsed internal hemorrhoids irritate sensitive perianal skin → perianal
itching
External hemorrhoids
➢ Develop below the dentate line, which is innervated by cutaneous nerves; distention; of
this innervated skin due to a clot or edema results in severe pain.
➢ Acute thrombosis triggers cutaneous pain, lasting 7–14 days → thrombosis resolves →
residual skin or skin tags of distended anal skin
➢ Hemorrhoids are not varicose veins (widening of the veins)! However, anorectal varices
do exist and may occur, e.g., as a result of portal hypertension. The terms anorectal
varices and hemorrhoids are often used interchangeably, but this is incorrect.
Etiology
➢ Excessive straining; (e.g., from chronic constipation, frequent bowel movements,
chronic cough, heavy lifting, benign prostatic hyperplasia)
➢ Extended periods of sitting (e.g., due to occupation or sedentary lifestyle)
➢ Connective tissue disorder (e.g., Ehlers Danlos syndrome, scleroderma)
➢ Pregnancy
Classification
 Internal hemorrhoid stages
Grade Palpation findings
I Hemorrhoids do not prolapse (only project into the anal canal); above the dentate
(pectinate) line; reversible; often bleed
II Prolapse when straining, but spontaneously reduce at rest

III Prolapse when straining; only reducible manually

IV Irreducible prolapse; may be strangulated and thrombosed with possible ulceration
Clinical features
Internal hemorrhoids
➢ Often painless, bright red bleeding at the end of defecation (potentially dull, aching pain
with severe sphincter spasm)
➢ Perianal mass in the event of prolapse
➢ Pruritus
➢ Discharge (containing mucus or fecal debris)
➢ Ulceration (in grade IV)
External hemorrhoids
➢ Painful perianal mass
➢ Pruritus
➢ Clinical examination
➢ Inspect perianal area for external
hemorrhoids and prolapsed internal
hemorrhoids; exclude other
conditions (e.g., anal skin tags,
polyps).
➢ Digital rectal examination may
show abnormal masses or
tenderness or bleeding

Diagnosis
Anoscopy
➢ For assessing the anus and distal
rectum
➢ Useful when hemorrhoids are
suspected but rectal examination is
inconclusive
➢ In addition, proctoscopy may be
used to support anoscopy findings.
Other procedures
➢ Flexible sigmoidoscopy, colonoscopy, or barium enema: to exclude suspected
malignancy (especially in patients over the age of 40)

Differential diagnoses
➢ Anal skin tags: folds of skin at the anal verge, often at 12 o'clock in the lithotomy
position (benign, but may become inflamed or itch)
➢ Hypertrophied anal papillae
➢ Polyps
➢ Anal and colorectal carcinoma
➢ Anal fissures
➢ Anorectal varices
➢ Proctitis
➢ Condyloma acuminata
➢ Inflammatory bowel disease (often associated with anal fistulas and abscesses)
Pathophysiology
➢ Constipation and prolonged straining are
widely believed to cause hemorrhoids
because hard stool and increased
intraabdominal pressure could cause
obstruction of venous return, resulting in
engorgement of the hemorroidal plexus
➢ Defecation of hard fecal material increases
shearing force on the anal cushions

Clinical features
Internal hemorrhoids
➢ Often painless, bright red bleeding at the end of defecation (potentially dull, aching pain
with severe sphincter spasm)
➢ Perianal mass in the event of prolapse
➢ Pruritus
➢ Discharge (containing mucus or fecal debris)
➢ Ulceration (in grade IV)
External hemorrhoids
➢ Painful perianal mass
➢ Pruritus
➢ Clinical examination
➢ Inspect perianal area for external hemorrhoids and prolapsed internal hemorrhoids;
exclude other conditions (e.g., anal skin tags, polyps).
 ➢ Digital rectal examination may show abnormal masses or tenderness or bleeding.

Treatment
Hemorrhoids should only be
treated in a symptomatic patient!
Management of hemorrhoids
Conservative treatment
➢ Indications: grade I–II
internal hemorrhoids and
external hemorrhoids
➢ Interventions
➢ Lifestyle modifications:
weight loss, exercise, high
fiber diet, avoid fatty and
spicy foods, increase water
intake
➢ Alter stool habits (e.g.,
avoid excessive straining or
> 5 min periods on the
toilet)
➢ Sitz baths
➢ Stool softeners (e.g.,
docusate)
➢ Topical or suppository analgesia (e.g., lidocaine)
➢ Topical anti‑inflammatory (e.g., hydrocortisone, especially with pruritus, but no longer
than 1 week)
➢ Topical antispasmodic agents (e.g., nitroglycerin)
Outpatient treatment
➢ Indications: all internal hemorrhoids with symptoms persisting despite conservative
treatment and grade III internal hemorrhoids
Interventions
➢ Rubber band ligation (RBL)
➢ Sclerotherapy
➢ Infrared coagulation
Surgical treatment (stages III–IV)
➢ Submucosal hemorrhoidectomy
➢ Ferguson approach (closed approach )
➢ Milligan‑Morgan approach (open approach )
 ➢ Stapled hemorrhoidopexy (e.g., using the Longo procedure): only effective for internal
hemorrhoids

Complications
➢ Hemorrhoid disease
➢ Internal: prolapse of internal hemorrhoid → accumulation of mucus and fecal debris in
external anal tissue → local irritation and inflammation
➢ External: may become acutely thrombosed (e.g., with excessive straining) → necrosis of
overlying skin and bleeding
➢ Postoperative
➢ Pain
➢ Thrombosis
➢ Bleeding
➢ Perineal/pelvic sepsis

Anal abscess & fistula

Anal abscess is a pus-filled cavity that most commonly develops from an infected anal crypt
gland following obstruction and bacterial overgrowth.
Patients with anal fistulas may present with a visible perianal site draining pus and discomfort
during defecation.
Etiology
❖ Most common cause: flow obstruction and infection of the anal crypt glands (90% of
cases)
❖ Less common causes
❖ Chronic inflammatory bowel disease (IBD): Crohn's disease, ulcerative colitis (less
commonly)
❖ Acute infections of the gastrointestinal tract: e.g., complicated diverticulitis, acute
appendicitis
❖ Radiation-induced proctitis
❖ Iatrogenic
❖ Foreign body
Pathophysiology
❖ Typical development
o Obstruction of anal glands by thick debris → stasis and bacterial overgrowth →
abscess formation
o Abscess may extend into adjacent perirectal spaces → possible fistula formation ,
bacteremia and sepsis
❖ Rare forms of development: Pathophysiology and localization depend on the specific
comorbidities (e.g., Crohn’s disease) Malignancy: e.g., colorectal cancer
Clinical features
Abscesses
 ❖ Perianal abscess
o Dull perianal discomfort and pruritus
o Erythematous, subcutaneous mass near the anus found by manual inspection
❖ Perirectal abscess
o Rectal or perirectal drainage (bloody, purulent, or mucoid)
o Severe pain, fever, and chills
o Pain exacerbation with sitting and defecation
Fistulas
❖ Purulent drainage (from anal canal or surrounding perianal skin)
❖ Pain during defecation
Digital rectal examination
❖ fluctuant
❖ indurated mass, pain with pressure
Diagnostics
❖ CT/MRI or anal ultrasonography: confirmatory tests for deeper abscesses
❖ Further testing: to identify possible fistulae and comorbidities (malignancy, IBD)
❖ Endoscopy
❖ MRI
❖ Fistula probe (with methylene blue)
Treatment
Abscesses
❖ Early surgical incision and drainage
❖ Postoperative
❖ Sitz baths
❖ Analgesics and stool softeners
Fistulae
❖ Fistulotomy (standard approach)
❖ Possible seton placement (enables adequate drainage and fibrosis)
❖ Possible fibrin glue or fistula plug
❖ Additional administration of antibiotics and immunosuppressant in patients with
Crohn's disease

Anal fissure
Definition
Longitudinal tear of the anal canal; distal to the dentate line
Etiology
Primary (due to local trauma):Location: 90% of all anal fissures located at the posterior
commissure (6 o'clock in the lithotomy position)
Types of trauma:
❖ Chronic spasm/increased tone in the internal anal sphincter
❖ Low fiber intake
❖ Chronic constipation or diarrhea
❖ Anal sex
❖ Vaginal delivery
Secondary (due to underlying disease):Location: may occur lateral or anterior to the posterior
commissure
Underlying conditions:
❖ Previous anal surgery (e.g., possible stenosis of anal canal)
❖ Inflammatory bowel disease (IBD; e.g., Crohn's disease)
❖ Granulomatous disease (e.g., tuberculosis)
❖ Infections (e.g., chlamydia, HIV)
❖ Malignancy(e.g., leukemia)
Pathophysiology
❖ Overdistension or disease of the anal mucosa → laceration of the anoderm
o Spasm of the exposed internal anal sphincter leads to pulling along the laceration,
which impairs healing and worsens the extent of laceration with each bowel
movement.
o The resultant pain results in voluntary avoidance of defecation and constipation,
which worsens distension of the anal mucosa.
❖ The posterior commissure is believed to have a very poor blood supply, which
predisposes it to ischemia (exacerbated by poor perfusion during increased anal pressure).
Clinical features
❖ Sharp, severe pain during defecation
❖ Rectal bleeding (often bright red and minimal; should not be confused with other types of
bleeding such as in colorectal cancer or hemorrhoids)
❖ Perianal pruritus
❖ Chronic constipation
Diagnostics
❖ Clinical examination: Superficial or deep laceration in anterior, lateral, or posterior anal
canal. In addition, chronic fissures may present with fibrotic and infective changes: Wide,
raised edges Skin tags (sentinel pile) at the fissure's distal end. Hypertrophied anal
papillae at the fissure's proximal end
❖ Clinical history
❖ Digital rectal examination: if diagnosis is uncertain or to exclude a suspected underlying
pathology (e.g., rectal tumor)
 ❖ Anoscopy: Indicated if clinical findings are unclear or if symptoms persist despite
adequate treatment
❖ Possible biopsy and histological investigation (to exclude a carcinoma, especially when
presentation is atypical)
Differential diagnoses
❖ Perianal ulcer
❖ Anal fistula or abscess
❖ Anal carcinoma
Treatment
Conservative
First‑line treatment for most anal fissures. Includes:
❖ Dietary improvement (e.g., adequate ingestion of dietary fiber and water)
❖ Stool softeners (e.g., docusate)
❖ Anti‑inflammatory and analgesic creams and/or suppositories (e.g., 2% lidocaine jelly)
❖ Sitz baths
❖ Local anesthetic injection
❖ Topical vasodilator therapy: calcium channel blocker gel (e.g., nifedipine) or glyceryl
trinitrate ointment (GTN)
Interim
❖ Persistent symptoms despite > 8 weeks of conservative therapy → endoscopy to exclude
IBD
❖ If IBD is excluded, then the patient should receive definitive surgical treatment.
Outpatient procedures
❖ Botulinum toxin A (BTX) injection into the internal anal sphincter
Surgical
❖ Indicated when conservative treatment is unsuccessful
❖ The risk of fecal incontinence (e.g., high in multiparous or elderly patients) determines
the type of surgical intervention.
❖ Low risk: Sphincterotomy (e.g., lateral internal Sphincterotomy) Anal dilatation
(although there is a high risk of fecal incontinence with this procedure)
❖ High risk: Anal advancement flap
❖ Fissurectomy (excision of the fissure)

Rectal prolapse

Rectal prolapse is the protrusion of rectal mucosa (mucosal prolapse) or the entire rectum (full-
thickness prolapse) through the anal opening.
Etiology
Risk factors in adults
❖ Any cause of raised intra-abdominal pressure
❖ Chronic straining as a result of constipation and/or benign prostatic hypertrophy (BPH)
❖ Chronic cough (e.g. COPD)
❖ Pregnancy
Weakness of the pelvic floor muscles
❖ Advanced age
❖ Multiparous women
❖ Damage to the pudendal nerve or sacral roots (e.g., obstetric injury during vaginal delivery,
diabetic neuropathy, pelvic tumors)
❖ Previous perineal surgery (e.g., for the management of anal fistulas)
❖ Connective tissue disorders (e.g., Ehler Danlos syndrome)
Risk factors in children
❖ Chronic straining as a result of constipation
❖ Recurrent diarrhea
❖ Cystic fibrosis
❖ Rectal parasites (e.g., whipworm)
❖ High anorectal malformations
❖ Hirschsprung disease
❖ Damage to the sacral roots (e.g., meningomyelocele)
❖ Significant weight loss
Pathophysiology
❖ Depending on the severity of the rectal prolapse, rectal prolapse may be classified as:
Mucosal prolapse (partial prolapse)
❖ Protrusion of the rectal mucosa through the anus
❖ Typically less than 4 cm in length
❖ Much more common in children and infants
Full-thickness prolapse (complete prolapse)
❖ Usually begins as a rectal intussusception; therefore, all layers of the rectal wall protrude
through the anus.
➢ 4 cm in length (usually 10–15 cm long when fully prolapsed) Much more common in adults

Clinical features
Symptoms
➢ A painless rectal mass that protrudes through the anus
➢ Fecal incontinence
➢ Constipation
 ➢ Pruritus ani
➢ Rectal bleeding
Physical examination
The perineum should ideally be examined while the patient squats or strains.The rectum protrudes
partially or completely through the external anal opening.
Mucous prolapse
➢ Radial mucosal folds are seen on inspection
➢ Only a double layered mucous membrane can be palpated.
Full-thickness prolapse
➢ Concentric mucosal folds are seen on inspection (stacked-coin appearance)
➢ All four layers of the rectal wall can be palpated.
➢ A sulcus or groove may be present between the emerging mass and the walls of the anal
canal.
➢ A solitary rectal ulcer on the prolapsed rectum is seen in 10–25% of cases.
➢ Digital rectal examination may reveal anal sphincter weakness and a mass or other pelvic
floor pathology.
➢ Other conditions associated with pelvic floor weakness (e.g., uterine prolapse, vaginal vault
prolapse, cystocele, rectocele) may be present along with rectal prolapse.
Diagnostics
Definitive diagnosis
➢ Rectal prolapse is primarily a clinical diagnosis.
➢ Video defecography: to distinguish full-thickness rectal prolapse from mucosal prolapse
when the diagnosis is not obvious from clinical examination alone
Additional tests
➢ Proctoscopy and/or colonoscopy should be performed prior to any surgical therapy.
➢ If a rectal ulcer is present: biopsy of the rectal ulcer
➢ If fecal incontinence is present: anal sphincter manometry
➢ If pelvic floor weakness is suspected: dynamic pelvic floor MRI
➢ A sweat chloride test should be performed among children with rectal prolapse to rule out
cystic fibrosis.

Treatment
Mucosal prolapse
➢ Mucosal prolapse is generally managed nonsurgically.
➢ First-line: reduction of mucosal edema, digital repositioning of the rectum, and pressure
padding the perineum
 ➢ Second-line: injection sclerotherapy
➢ Grade III and grade IV internal hemorrhoids that are often associated with a mucosal
prolapse should be treated with hemorrhoidectomy (see “Treatment” in hemorrhoids)
Full-thickness rectal prolapse
➢ Full-thickness prolapse requires surgical treatment with perineal approach.
➢ Abdominal procedures: laparoscopic rectopexy with/without sigmoidectomy
➢ Perineal procedures : Short, full-thickness prolapse: Delorme procedure

Pruritus ani
The perianal skin tends to itch, which can result from numerous causes (see Table: Some Causes
of Pruritus Ani). This condition is also known as pruritus ani. Occasionally, the irritation is
misinterpreted by the patient as pain, so other causes of perianal pain (eg, abscess or cancer) should
be ruled out.
Etiology
➢ Most anal itching is
➢ Idiopathic (the majority)
➢ Hygiene-related: Too little cleansing leaves irritating stool and sweat residue on the anal
skin. Too much cleansing, often with sanitary wipes and strong soaps, can be drying or
irritating or occasionally cause a contact hypersensitivity reaction. Large external
hemorrhoids can make post defecation cleansing difficult, and large internal hemorrhoids
can cause mucus drainage or fecal soilage and consequent irritation.
➢ Other distinct causes are rarely identified, but a variety of factors have been implicated (see
Table: Some Causes of Pruritus Ani).
➢ In the very young and elderly, fecal and urinary incontinence predispose to local irritation
and secondary candidal infections.
➢ Once itching occurs, resulting from any cause, an itch-scratch-itch cycle can begin, in
which scratching begets more itching. Often, skin becomes excoriated and secondarily
infected, causing yet more itching. Also, topical treatments for itching and infection may
be sensitizing, causing further itching.
Evaluation
History
➢ History of present illness should note whether the problem is acute or recurrent. The patient
should be asked about topical agents applied to the anus, including wipes, ointments (even
those used to treat itching), sprays, and soaps. Diet and drug profiles should be reviewed
for causative agents (see Table: Some Causes of Pruritus Ani), particularly acidic or spicy
foods. A general sense of hygiene should be obtained by asking about frequency of showers
and baths.
➢ Review of systems should seek symptoms of causative disorders, including urinary or fecal
incontinence (local irritation), anal pain or lump, blood on toilet paper (hemorrhoids),
 bloody diarrhea and abdominal cramps (inflammatory bowel disease), and skin plaques
(psoriasis).
➢ Past medical history should identify known conditions associated with pruritus ani,
particularly prior anorectal surgery, hemorrhoids, and diabetes.
Physical examination
➢ General examination should obtain a sense of overall hygiene and note any signs of anxiety
or obsessive-compulsive behavior.
➢ Physical examination focuses on the anal region, particularly looking for perianal skin
changes, signs of fecal staining or soilage (suggesting inadequate hygiene), and
hemorrhoids. External inspection should also note the integrity of the perianal skin,
whether it appears dull or thickened (suggesting chronicity), and the presence of any
cutaneous lesions, fistulas, excoriations, or signs of local infection. Sphincter tone is
assessed by having the patient contract the sphincter during digital rectal examination. The
patient should then be asked to bear down as if for a bowel movement, which may show
prolapsing internal hemorrhoids. Anoscopy may be necessary to further evaluate the
anorectum for hemorrhoids.
➢ Dermatologic examination may reveal scabies burrows in the interdigital webbing or scalp
or signs of any other contributing systemic skin disease.
Clinical findings
The following findings are of particular concern:
➢ Draining fistula
➢ Bloody diarrhea
➢ Large external hemorrhoids
➢ Prolapsing internal hemorrhoids
➢ Perianal fecal soilage
➢ Dull or thickened perianal skin
➢ Interpretation of findings
➢ Hygiene issues, use of topical agents, and local disorders (eg, candidal infection,
hemorrhoids) are usually apparent by history and examination.
➢ In adults with acute itching without obvious cause, ingested substances should be
considered; a trial of eliminating these substances from the diet may be useful. In children,
pinworms should be suspected.
➢ In adults with chronic itching and no apparent cause, overly aggressive anal hygiene may
be involved.
Diagnosis
➢ For many patients, a trial of empiric, nonspecific therapy is appropriate unless particular
findings are noted.
➢ For example, biopsy, culture, or both of visible lesions of uncertain etiology should be
considered. If pinworms, which occur most often in school-aged children, are suspected,
 eggs can be detected by patting the perianal skinfolds with a strip of cellophane tape in the
early morning; the tape is placed sticky side down on a glass slide and viewed
microscopically.
Treatment
➢ Systemic causes and parasitic or fungal infections must be treated specifically.
➢ Foods and topical agents suspected of causing pruritus ani should be eliminated.
General measures
➢ Clothing should be kept loose, and bed clothing should be light. After bowel movements,
the patient should clean the anal area with absorbent cotton or plain soft tissue moistened
with water or a commercial perianal cleansing preparation for hemorrhoids; soaps and
premoistened wipes should be avoided. Liberal, frequent dusting with nonmedicated
talcum powder or cornstarch helps combat moisture.
➢ Hydrocortisone acetate 1% ointment, applied 4 times a day for a brief period (< 1 week),
may relieve symptoms. Sometimes, higher potency topical corticosteroids may be needed.

Levator Syndrome

❖ Proctalgia fugax (fleeting pain in the rectum) and coccydynia (pain in the coccygeal region)
are variants of levator syndrome.
❖ Rectal spasm causes pain, typically unrelated to defecation, usually lasting < 20 minutes.
The pain may be brief and intense or a vague ache high in the rectum. It may occur
spontaneously or with sitting and can waken the patient from sleep.
❖ The pain may feel as if it would be relieved by the passage of gas or a bowel movement.
In severe cases, the pain can persist for many hours and recur frequently.
❖ The patient may have undergone various rectal operations for these symptoms, with no
benefit.
Diagnosis
Clinical evaluation
❖ Physical examination can exclude other painful rectal conditions (eg, thrombosed
hemorrhoids, fissures, abscesses). Physical examination is often normal, although
tenderness or tightness of the levator muscle, usually on the left, may be present.
❖ Occasional cases are caused by low back or prostate disorders.
❖ Other causes of pelvic pain (eg, cancer) must be ruled out. In most cases, a distinct cause
of levator syndrome is not identified.
Treatment
❖ Analgesics, sitz baths
❖ Sometimes electrogalvanic stimulation
❖ Treatment of levator syndrome consists of explanations to the patient of the benign nature
of the condition. An acute episode may be relieved by the passage of gas or a bowel
movement, by a sitz bath, or by a mild analgesic. When the symptoms are more intense,
physical therapy may be effective. Skeletal muscle relaxants or anal sphincter massage
under local or regional anesthesia can be tried, but the benefit is unclear.