Nal Diseases: The Bottom Line !

Anal Diseases
The bottom line !
Dr. Mahmoud W. Qandeel

Outlines
• Anatomy
• Physiology
• DRE
• Anal fissure
• Anal abscess
• Anal fistula
• Hemorrhoids
• PNS
• Anal tumors

Anatomy
• Surgical Anal canal is about 4cm long.
• It extends from the anal verge to the anorectal junction.
• Pecten is a hairless part of the external anal canal that exposed by
traction (keratinized stratified squamous epithelium)
• The junction between the Pecten and large bowel mucosa is known as
dentate line .

• Above dentate line there is transitional zone extends (from 1cm to 2cm )
having sensitive modified non-keratinized squamous epithelium.
• Above transitional zone there is insensitive large bowel mucosa
(columnar epithelium).
• Anatomical anal canal is about 3cm long .

• It extends from anal verge to the dentate line.

Margin
vs
Verge
vs
Canal

Muscle layers :
• Internal sphincter is a condensation of circular smooth muscle of the

rectum and is continuous with circular muscle of the whole GI tract.
(autonomic nervous system).
• It maintains tone and resting pressure within anal canal (anal

continence).

• External sphincter consist of ending of longitudinal muscle of the
rectum at the anus as series of fibrous bands which radiate to the
perianal skin (somatic nerves).
• The circular muscle of the external sphincter consists of lower part of

levator ani, known as the puborectalis sling.
• It has three parts; deep, superficial and subcutaneous

• The internal sphincter (involuntary) accounts for 80% of resting
pressure, whereas the external sphincter (voluntary) accounts for 20%
of resting pressure and 100% of squeeze pressure.
• The external anal sphincter contracts in response to sensed rectal

contents and relaxes during defecation.

• As the external sphincter contracts, the anal canal lengthens.
• With straining, it shortens.
• The internal anal sphincter imparts the resting pressure (~90 cm H2O).
• Squeeze pressure, generated by external sphincter contraction, more
than doubles resting pressure.
• The pressure differential between the rectum and anal canal (low to
high) is the principal mechanism that provides continence.

Blood supply
• The anal area receives an intercommunicating blood supply from

superior, middle, inferior rectal arteries
• Venous drainage goes mainly to superior rectal vein then portal system,
but from anal sphincter and below the drainage goes towards systemic
circulation .

Lymphatic drainage
• Above dentate line

– To inferior mesenteric and internal iliac nodes
• Below dentate line

– To superficial inguinal nodes

Spaces

Physiology
• The rectum functions as a capacitance organ, with a reservoir of 650 to
1,200 mL compared to an average daily stool output of 250 to 750 mL.
• The anal sphincter mechanism allows defecation and maintains

continence.

Defecation has four components:
(1) Mass movement of feces into the rectal vault;

(2) Rectal-anal inhibitory reflex, by which distal rectal distention causes
involuntary relaxation of the internal sphincter and the external
sphincter contracts (this process is known as sampling and allows for
determination of contents as gas, liquid, or solid);
(3) Voluntary relaxation of the external sphincter mechanism and
puborectalis muscle; and
(4) Increased intraabdominal pressure.

• The anorectal angle is the angle between the anal canal and the rectum.
• This angle is approximately 75 to 90 degrees at rest and becomes more
obtuse ,straightening with straining and evacuation.
• The ability of the puborectalis to relax and to allow this straightening of
the angle facilitates defecation.

Continence requires
• Normal capacitance,
• Normal sensation at the anorectal transition zone,
• Puborectalis function for solid stool,
• External sphincter function for fine control, and
• Internal sphincter function and hemorrhoidal pillars for resting pressure.

Common symptoms of ano-rectal disorders
• Bleeding
• Anal pain
• Itch
• Faecal leakage / hygiene problems
• Swelling
• Discharge

Digital rectal examination

Importance
• Abdomen can be considered as a box, with six surfaces.
• Top, the diaphragm; sides, the flanks; Anterior, ant abdominal wall,
which we usually examine in detail.
• Post, spine and back, usually ignored and bottom, genitals, per rectal
and per vaginal examination.
• It gives and idea of pelvic collections and masses, apart from local
pathology of the ano-rectum.

No abdominal examination is complete without a PR examination
A. It is done to palpate
1. Carcinoma rectum.
2. Stricture rectum.
3. Polyps.
4. Thrombosed piles.
5. BPH and carcinoma prostate.
6. Secondaries in the recto-vesical pouch (Blumer shelf).
7. Sphincter tone.
8. Pelvic abscess (is felt as boggy swelling)/tip of pelvic appendix.
B. To feel the internal opening of anal fistulas.
C. In bimanual palpation of the bladder or pelvic tumours.
D. In acute abdominal conditions—it reveals dilated empty rectum with
tenderness. Dr. Mahmoud W. Qandeel
Indications
• Rectal bleeding
• Perianal symptoms e.g. pain/itching/discharge
• Urinary symptoms in men (for BPH)
• Assessment of anal tone in neurological exam/trauma
• Change of Bowel habit – constipation, diarrhea, tenesmus

• An examination may also confirm proper Foley catheter placement and
facilitate placement of rectal tubes and suppository medication.
• According to the American Urological Association (AUA), a digital rectal

examination is indicated for all men, starting at age 40, for a baseline
determination of prostate status.

Contraindications
• Although there are no circumstances in which a digital rectal examination is overtly
contraindicated, caution should be exercised in examining infants and young children.
• DRE (The palpation part) should be avoided in Acute anal fissure
• Relative contraindications are
– Severely neutropenic patients
– Patients with prostatic abscesses or prostatitis
• The old medical adage often holds true: The only reason not to do a digital rectal
examination is if the patient is without a rectum or the clinician is without a finger.

Procedure steps
• Gather equipment
– Gloves
– Apron
– Lubricant
– Paper towels

Introduction
• Introduce yourself.
• Confirm patient details – name / DOB
• Explain the examination:
“I need to perform a rectal examination, which will involve me inserting a
finger into the back passage. It will be a little uncomfortable, but shouldn’t
be painful and will only last a very short time”
• Gain consent.
• Request a chaperone.
Preparation
• Wash hands.
• Don apron & gloves.
• Gain adequate exposure:

– Ask patient to remove trousers / underwear & to cover themselves with the
blanket provided
– Leave the room & allow them time to do this
– Maintaining patient dignity is of the highest priority
• Position the patient in the left lateral position with their knees to their chest.
Inspection
• Separate the buttocks & inspect for:
– External bleeding (e.g. brisk GI bleeding or anal pathology such as squamous cell anal cancer)
– Fissures; normally at 6 o clock or 12 o clock position. (majority posterior midline)
Fistula; consequence of abscess or a complication of Crohn’s.
– Discharge; mucus, blood, faeces
– Abscesses; red, painful, swollen
– Skin tags; can be normal or indicative of Crohn’s or previous hemorrhoids
– Hemorrhoids with their degree;
– Prolapse;
– Cancer/polyps; on anal ring
– Excoriation; sore, red skin from mechanical abrasion (e.g. wiping!), in diarrhea.
– Anal warts; STD

External inspection on straining
• Ask pt. to strain.

– Rectal prolapse upon straining.
– Hemorrhoid prolapse.
– Incontinence.
• Ask if straining is painful.

Palpation
1. Lubricate the examining finger.

2. Warn the patient you are about to insert the finger.
3. Insert finger gently into the anal canal.
4. Palpate the prostate anteriorly (in males):
• Comment on the size / symmetry & texture of the prostate
• It should be smooth, symmetrical & approximately the size of a
walnut
• Female: palpate cervix [anterior of rectum]:
• Mass in pouch of Douglas.

5. Rotate the finger 360 degrees to assess the entirety of the
rectum:
• Note location & texture of any masses / irregularities – e.g.
2cm irregular mass at 11oclock
• Is there stool in the rectum? – soft vs impacted
6. Assess anal tone by asking the patient to squeeze your finger.

7. Withdraw finger
• Inspect withdrawn fingertip for:
• Blood, melena.
• Stool color.
• Pus.
• Mucous.

8. Clean patient using paper towels .
9. Cover patient with the sheet provided & explain the
examination is over.
10. Allow them privacy to get dressed.
11. Dispose of clinical waste.
12. Wash hands.

To complete the examination…
• Thank the patient.
• Summarise your findings.
• Suggest further investigations

– Bloods – CBC
– Fecal occult blood
– Flexible sigmoidoscopy / colonoscopy – direct visualisation of lesions +/-
biopsy
– CT Abdo / Pelvis – to identify potential malignant masses
/ lymphadenopathy / collections

Likely Findings

Complications
• One possible complication of digital rectal examination is vasovagal
syncope, which is typically treated with rest and administration of fluids.
• Disseminated infection resulting from prostatic abscess or acute

prostatitis that was massaged too vigorously.

Anal fissure
• Anal fissure is a split in the anoderm ( a tear involving the pectin )
• Usually due to low fiber diet, constipation and passage of hard stool
• 90% posteriorly and 10% anteriorly;
• In women more to found anterior due to
obstetric history
• Location elsewhere should prompt evaluation.

Symptoms include
• Tearing pain with defecation and
• Severe anal spasm that lasts for hours afterward and
• Blood (usually on the toilet paper).
Digital rectal examination if possible (so painful) show

• Tightly closed puckered anus
• By gently parting the anal margin the lower end of the fissure can be seen.
• Increased sphincter tone,
• Muscular hypertrophy in the distal one-third of the internal sphincter,
• An external skin tag or sentinel pile may also be present.

• Could be acute or chronic
• Chronic if more than 6 weeks ; signs:
– Sentinle skin tag
– Hypertrophied papilla
– Fissure with heaped up scarred edges
– IAS visualized
– Keratinisation

• Atypical fissures are those that occur laterally or be multiple
• Differential diagnosis includes
– Crohn Disease,
– Tuberculosis,
– Anal Cancer,
– Anal intercourse,
– HIV,
– Cytomegalovirus,
– Herpes Simplex Virus,
– Chlamydia, and
– Syphilis.
Treatment
90% of patients with acute fissure heal with medical treatment that includes
• Increased fiber,
• Sitz baths,
• Laxatives,
• Topical local anesthesia like lidocaine gel
• Topical agents to relax IAS
– Nifedipine ointment (0.2%) TID
– Diltiazem ointment
– GTN cream

• If chronic fissure or failed management of acute , surgery is required,
options include BOTOX therapy or lateral internal sphincterotomy.
• Botox provides a temporary chemical sphincterotomy that lasts for 3

months and offers 60% success versus lateral internal sphincterotomy
which is 95% successful.
• Recurrence and minor incontinence occur in fewer than 10% of

patients.

Success rate
• GTN 50-85% 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

Anal Abscess
• Cryptoglandular abscess results from infection of the anal glands in the
crypts at the dentate line.
• The initial abscess occurs in the intersphincteric space.
• Infection then can spread
(1) Superficial to the external sphincter into the perianal space;
(2) Cephalad in the intersphincteric plane;
(3) Through the external sphincter into the ischiorectal space (which in turn may connect
posteriorly via the deep postanal space, resulting in a horseshoe abscess); or
(4) Deep to the external sphincter into the supralevator space.

• Diagnosis usually is obvious, with severe anal pain and a palpable,
tender, fluctuant mass, may has fever.
• An intersphincteric abscess yields only a painful bulge in the rectal wall

and no external manifestations.

Treatment
• Treatment is surgical drainage, with the skin incision kept close to the anal verge to
avoid the possible creation of a long fistula tract.
• Intersphincteric abscesses are drained by an internal sphincterotomy over the entire
length of the abscess.
– Draining an intersphincteric abscess externally will result in a supralevator fistula,
which are technically challenging to repair.
• Perianal and ischiorectal abscesses are drained through the perianal skin.
• Supralevator abscesses, originating from intersphincteric abscesses, should be
drained into the rectum.
• Outcome from drainage alone shows that 40% of patients develop a chronic fistula.

• Antibiotic therapy is not necessary unless the patient
(1) Is immunocompromised,
(2) Is diabetic,
(3) Has extensive cellulitis, or
(4) Has valvular heart disease.
• Immunocompromised patients may present with anal pain without

fluctuance because of the paucity of leukocytes.
– The painful indurated region must still be drained, and the underlying
tissue must undergo biopsy and culture.

Anal Fistula
• Anal fistula: it is an abnormal communication between primary opening
inside the canal and secondary opening in the peri-anal skin .
• Patients present with persistent fecopurulent perianal drainage from the
external opening of the fistula.
• ~ 30-40% of all perineal abscesses once drained goes on to develop a fistula
• ~ 80-90% of perineal abscesses that yielded enteric organisms will develop a fistula
 A chronic abscess is a fistula while an acute fistula is an abscess

 Cryptoglandular origin
Causes
• 95% crypto glandular - i.e. origin in ano-rectal crypts at dentate line

• 5% rarities
- Crohn’s
- TB
- Hidradenitis suppurativa
- Traumatic
- Malignancy
- Complicated diverticular disease
- Radiation
- Anastomotic leakage
Classification of Fistulas
• Inter-sphincteric: most common

• Trans- sphincteric: 2nd
• Supra-sphincteric
• Extra-sphincteric

Goodsall’s rule
External opening posterior to 3-9 o'clock position open in posterior midline of the anal canal
External opening anterior to 3-9 o'clock position open radially in the anal canal
~80-90% accurate

Treatment
• Treatment depends on the level that the fistula traverses the external
sphincter and preexisting sphincter function.
• Intersphincteric and low transsphincteric fistulas >> Fistulotomy

– For, posterior midline fistulas, up to 50% of the sphincter can safely be divided.
• Anterior and high transsphincteric fistulas >> sphincter-sparing

techniques. (e.g seton)
– In women, anterior fistulas should never be treated with a fistulotomy because
the risk of incontinence is too high.

• Placement of a soft, noncutting seton permits resolution of surrounding inflammation
while preserving sphincter musculature, often acting as a first-stage operation.
• Fibrin glue injection and anal fistula plug the success of these techniques has 25% to 40%.
• The Ligation of Intersphincteric Fistula Tract (LIFT) procedure success rates of 60% to 75%.
– This procedure requires dissection in the intersphincteric plane, isolation of the fistula tract, and ligation
of both sides of the tract.

Hemorrhoids
• Hemorrhoids are vascular and connective tissue cushions that exist in
three columns in the anal canal:
• Right anterolateral,
• Right posterolateral, and
• Left lateral.
• They are thought to aid in anal continence by providing bulk to the anal
canal.

• Hard stools, prolonged straining, increased abdominal pressure, and
prolonged lack of support of the pelvic floor contribute to the abnormal
enlargement of hemorrhoidal tissue.
Presentation
• The patient may report dripping or squirting of blood in the toilet.
• Occult blood loss resulting in anemia is rare, and other causes of anemia,
such as a more proximal colorectal lesion, should be investigated.
• Prolapse of hemorrhoidal tissue may occur, extending below the dentate line;
many of these patients complain of mucus and fecal leakage and pruritus.
• Severe pain if thrombosed external pile .
Classification
• Internal hemorrhoids are above the dentate line and thus covered with
mucosa.
• These may bleed and prolapse, but they do not cause pain.
• External hemorrhoids are below the dentate line and covered with
anoderm.
• These do not bleed but may thrombose, which causes pain and itching,
and secondary scarring may lead to skin tag formation.

Complications
• Hemorrhage
• Strangulation
• Thrombosis
• Ulcerations
• Gangrene
• Fibrosis
• Suppurations

Spot Diagnosis?

• Before treatment, order colonoscopy to exclude proximal mucosal
disease, particularly neoplasia, if
– The extent of hemorrhoidal disease is incongruent with the patient’s
symptoms,
– Presence of other GI symptoms
– The patient is due for colonoscopic surveillance ( >50 y),
– The patient has risk factors for colon cancer, such as a family history

Treatment

Postoperative complications
• The most common early postoperative complication after hemorrhoid
surgery is urinary retention.
– This typically occurs in 10% of patients.

– The incidence of postoperative urinary retention is more common in men
and is directly related to the volume of intravenous fluids administered.
– In addition, it may be related to narcotic administration and regional
anesthesia.

• Other complications include
– Bleeding (0.03%–6%),
– Anal stenosis (0%–6%),
– Infection (0.5%–5%), and
– Incontinence (2%–12%).
• Other complications unique to stapled hemorrhoidopexy include

rectovaginal fistula, rectal perforation, rectal occlusion, and chronic pain
related to an inappropriately distal staple line.

Pilonidal sinus & abscess
• Pilo = hair Nidal = nest
• More common in men 4:1
• Acquired theory vs congenital theory?
• Peak incidence 15 -35 year
• Most are asymptomatic, with midline pores 2-3 in number 5 cm away from
anus
• Patients present with pain, swelling, and drainage when the sinuses become
infected.
– Symptoms are distinguished from perianal abscess by the lack of anal pain, the more
superior location of the fluctuant mass, and the presence of midline cutaneous pits.
Pilonidal sinus Pilonidal sinus abscess

• The presence of hair in the gluteal cleft seems to play a central role in
the pathogenesis of this disease.
– This is consistent with the observation that pilonidal disease rarely occurs in
those with less body hair.
• Other risk factors include

– Obesity,
– Local Trauma,
– Sedentary Lifestyle,
– Deep Natal Cleft, and
– Family History.
• Chronic trauma >> Jeep rider’s disease

Treatment
• Early conservative treatment
• Natal cleft hygiene
• Removal of hair outside and inside
• Early infection Antibiotics for anaerobic bacteria
• 80% phenol injection

Treatment is surgical
Open method Closed method
• Excision, cavity left open • Excision and primary closure
• Daily dressing • Many options
• Healing 6-8 weeks

Healing by 2y intent

Z plasty Rhomboid flap

Healing using Vac Therapy

Anal Neoplasms

A. Tumors of the Anal Margin
1. Squamous cell carcinoma

• Behaves like cutaneous squamous cell carcinoma,
• Well differentiated and keratinizing,
• Treated with wide local excision and chemoradiation if large or involving
the sphincter complex.
2. Basal cell carcinoma

• Is a rare, male-predominant cancer that is treated with local excision.

3. High-grade squamous intraepithelial lesions (also known as Bowen
disease)
• Are becoming common in HIV-positive patients and also are more

frequently seen in other immunosuppressed patients, such as solid
organ transplant recipients.
• Local excision or destruction of identified lesions during high resolution
anal mapping with 9% acetic acid can prevent progression to cancer.
• Long-term surveillance is required.

4. Paget disease
• Is an intraepithelial adenocarcinoma, most commonly discovered in
elderly patients.
• Paget disease begins as a benign in situ neoplasm, thought to originate
from apocrine cells, which presents as a pruritic, erythematous rash that
mimics eczema or psoriasis.
• Biopsy provides diagnosis; however, any patient with suspected Paget
disease should also undergo colonoscopic evaluation
– up to 50% of Paget disease have a coexisting visceral carcinoma requiring an
abdominal perineal resection [APR].
• Treatment of noninvasive disease is wide local excision of all lesions.

B. Anal Canal Tumors
1. Epidermoid carcinoma
• Is nonkeratinizing and derives from the anal canal 6 to 12 mm above the
dentate line.
• Usually presents with an indurated, bleeding mass.
• On examination, the inguinal lymph nodes should be examined specifically,
because spread below the dentate line passes to the inguinal nodes.
• Diagnosis is made by biopsy, and 30% to 40% are metastatic at the time of
diagnosis.
• Preoperative staging requires CT of the abdomen and pelvis and PET scan
to rule out metastatic disease.

Treatment
• Chemoradiation according to the Nigro protocol: 3,000-cGy external beam
radiation, mitomycin C, and 5-fluorouracil.
• Surgical treatment is reserved for locally persistent or recurrent disease only.

• The procedure of choice is abdominoperineal resection; perineal wound
complications are frequent.

2. Adenocarcinoma
• Is usually an extension of a low rectal cancer but may arise from anal glands
and has a poor prognosis.
3. Melanoma
• Accounts for 1% to 3% of anal cancers and is more common in the fifth and
sixth decades of life.
• Symptoms include bleeding, pain, and a mass, and the diagnosis is often
confused with that of a thrombosed hemorrhoid.
• At the time of diagnosis, 38% of patients have metastases.
• Treatment is wide local excision, although the 5-year survival rate is < 20%.

A 23 years old lady complains of painful defection associated
with fresh per- rectal blood. Possible diagnosis to consider is;
(12/2017)
a. Hidradenitis suppurtive
b. Dermoid cyst
c. Pilonidal sinus
d. Anal fissure
e. Pruritus ani

A 23 years old lady complains of painful defection associated
with fresh per- rectal blood. Possible diagnosis to consider is;
(12/2017)
a. Hidradenitis suppurtive
b. Dermoid cyst
c. Pilonidal sinus
d. Anal fissure
e. Pruritus ani

A 35 years old female patient underwent incision and drainage
of a perianal abscess 2 months ago now she presented to your
clinic with an intermittent pain and smelly discharge from the
site of previous surgery , what is the most common problem
that you would expect and you should check for : (12/2017)
a)Perianal fistula
b)Anal fissure
c)Incontinence
d)Complication of her hemorrhoids
d)Necrotizing fasciitis
A 35 years old female patient underwent incision and drainage
of a perianal abscess 2 months ago now she presented to your
clinic with an intermittent pain and smelly discharge from the
site of previous surgery , what is the most common problem
that you would expect and you should check for : (12/2017)
a)Perianal fistula
b)Anal fissure
c)Incontinence
d)Complication of her hemorrhoids
d)Necrotizing fasciitis
40 year old male come to your clinic asking for advice about his anal
fissure . One of the following sentences is an appropriate advice ?
(7/2017)
A . Surgery is primary treatment for acute anal fissure .
B . Anal fissures are usually located in the lateral aspect of the canal .
C . Anal fissure in patients with Crohn disease usually indicate
malignancy .
D . Medical treatment is successful in 20% of case's .
E . Surgical treatment may be complicated by incontinence

40 year old male come to your clinic asking for advice about his anal
fissure . One of the following sentences is an appropriate advice ?
(7/2017)
A . Surgery is primary treatment for acute anal fissure .
B . Anal fissures are usually located in the lateral aspect of the canal .
C . Anal fissure in patients with Crohn disease usually indicate
malignancy .
D . Medical treatment is successful in 20% of case's .
E . Surgical treatment may be complicated by incontinence

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Anal Diseases

The bottom line !

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Anatomical anal canal is about 3cm long .

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Internal sphincter is a condensation of circular smooth muscle of the

• It maintains tone and resting pressure within anal canal (anal

Dr. Mahmoud W. Qandeel

• The circular muscle of the external sphincter consists of lower part of

• It has three parts; deep, superficial and subcutaneous

Dr. Mahmoud W. Qandeel

• The external anal sphincter contracts in response to sensed rectal

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• The anal area receives an intercommunicating blood supply from

Dr. Mahmoud W. Qandeel

• Above dentate line

• Below dentate line

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• The anal sphincter mechanism allows defecation and maintains

Dr. Mahmoud W. Qandeel

(1) Mass movement of feces into the rectal vault;

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• According to the American Urological Association (AUA), a digital rectal

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Gain adequate exposure:

Dr. Mahmoud W. Qandeel

• Ask pt. to strain.

Dr. Mahmoud W. Qandeel

1. Lubricate the examining finger.

Dr. Mahmoud W. Qandeel

6. Assess anal tone by asking the patient to squeeze your finger.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Suggest further investigations

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Disseminated infection resulting from prostatic abscess or acute

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Digital rectal examination if possible (so painful) show

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Botox provides a temporary chemical sphincterotomy that lasts for 3

• Recurrence and minor incontinence occur in fewer than 10% of

Dr. Mahmoud W. Qandeel

• GTN 50-85% successful s/e: severe headaches

• Diltiazem 60-80% successful s/e: nil generally

• Botox 60-90% successful s/e transient minor leakage