PERINEAL DISEASES
Disease Etiopathogenesis
Haemorrhoids dilated veins of the
arteriovenous blood vessels &
connective tissue in the anal
canal that may abnormally
enlarge or protrude.
Etiopathogenesis
1. Increasing blood pressure on
hemorrhoidal vessels
a. Obstipation
2. Full-blooded anal area:
a. Squat, spicy food,
alcohol, pregnancy
3. Weakness of connective
tissue:
a. Aging, pregnancy
4. Mechanic – crack of piles
holding connective tissue
bundles
5. Vessel theory
Disease forms:
• Chronic hemorrhoidal disease
• Acute hemorrhoidal disease
(thrombosis of hemorrhoidal
piles)
• Bleeding hemorrhoids
causing secondary anemia
Clinical Diagnosis Treatment
Degrees: Conservative therapy
I degree – falls into the lumen of anoscope • Bowel movement correction
(diet, habits)
II degree – drops out during • Anal hygiene
bowel movements, goes back in on its own • Medications:
o Anal lubrication
III degree – drop out during o Stool softeners
bowel movements, hand help is needed to bring o Flavonoids!
it back in For acute disease: NSAIDS,
painkiller
IV degree/ rectal prolapse – prolapsing
continually, cannot be reduced Invasive (I-II degree)
1. Infrared Photocoagulation
Internal Haemorrhoids External 2. Injection of sclerosant,
• Often painless. Haemorrhoids 1. Inspection – most painful 3. Rubber band ligation (Barron
• bleeding after • Severely painful haemorrhoids, thrombosed, procedure)
defecation (blood is perianal mass ulcerated or not, are seen on a. Gold standard
noted on toilet tissue) • Bleeding inspection of the anus. For I-II degree
• Perianal mass Examination:
• Pruritis prolapsed, 2. Anoscope – is essential in Surgery (Hemorrhoidectomy):
• mucus discharge thrombosed,
evaluating painless or bleeding
4. Milligan morgan (open surgery)
• a sensation of infiltrated a. III-IV degree
hemorrhoidal piles haemorrhoids. b. Failure of invasive
incomplete evacuation
• Ulceration- Grade IV treatment.
3. Sigmoidoscopy or colonoscopy –
Complications: Rectal bleeding should be 5. Long’s procedure (circular
Internal: prolapse→ accumulation of mucus & attributed to haemorrhoids only stapler)
fecal debris in external anal tissue→ irritation & after more serious conditions are a. For II-III degree
inflammation. excluded (e.g. cancer) b. For internal haemorrhoids
only
External: For acute disease:
- Acutely thrombosed (due to excessive - only start with surgery if only one
straining)→ necrosis of overlying skin & node is inflamed (otherwise do
bleeding. conservative)
- Strangulation of haemorrhoid - Surgery done 3-4 days after start
of inflammation
Anal fissure a longitudinal break or tear in the skin
of the anal canal distal to the dentate
line
Etiopathogenesis:
I0 :
• Trauma of anal canal skin
o Chronic spasm/ ↑ tone of the
internal anal sphincter
o Chronic constipation (Hard stool)/
diarrhea
o Anal sex
o Vaginal delivery
90% located at the posterior
commissure
II0 :
• Due to underlying disease
o Previous anal surgery
o IBD
o Infection
o Impaired blood supply to the anal
mucosa
o Non-healing ulcer
Locate lateral/anterior to posterior
commissure
Rectal prolapse one or more layers of the rectum
protrude through the anus
At risk ages: <3yrs, female: 60-70yrs,
male: <40yrs
Etiopathogenesis:
• ↑ intraabdominal pressure
o excessive straining, constipation
• weakness of pelvic floor muscle
o Old age, multiple pregnancies
• Cystic fibrosis in children
• Sharp, severe pain during
and after defecation
• Rectal bleeding (bright red
& minimal)- blood on toilet • Wide raised edges
paper
• Perianal pruritis
• Chronic constipation
• Painless rectal mass
• Fecal incontinence
• Constipation
• Pruritis around anus
• Rectal bleeding
Inspection:
• superficial or deep anal canal skin defect
(anterior/lateral/posterior)
• Skin tags
DRE:
• Pain
• Spasm of the internal anal sphincter
Anoscope:
Inspection:
Done when patient squats or strains
• Partial: radial folds present in mucosa
• Complete- concentric mucosal folds
DRE: anal sphincter weakness and mass
Video defecography: barium is instilled into the
rectum & video recording is made of anorectal
region during the process of defectaion.
Proctoscopy, Colonoscopy- prior to surgery
Conservative treatment:
• Adequate fibre and water
• Stool softeners (docusate)
• Nitroglycerin – 0,2- 0,3% ointment
(2xd)
• Vasodilator therapy: Calcium
channel blockers (verapamil)
• Botulinum toxin
*If persistent symptoms after
>8weeks of conservative treatment→
do endoscopy to check for IBD
Surgical treatment:
Indications:
- Fissure more than 1 year
- Inefective conservative treatment
Operations
• Sphincterotomy (lateral, posterior)
• Sphincterotomy
• Fissurectomy (excision of fissure)
• Dilatation of the anal sphincter
Mucosal prolapse:
• Reduction- digital repositioning of
rectum
• Injection sclerotherapy
Full thickness prolapse:
• Laparoscopic rectopexy
with/without sigmoidectomy –
rectum put back in
• Delrome procedure- done in childre
• Altmaier procedure- excison pf
prolapsed rectum
Paraproctitis a purulent inflammation of the cellular tissues Local symptoms • Inspection • Surgical incision &
surrounding the rectum (symptoms of inflammation) • Palpation drainage
• Pain • DRE- very painful • Analgesics
Classification: • Swelling • CT- best option • Stool softeners
According to According to origin: • Red-coloured skin • MRI→ for deeper abscess, fistula
time: • Non-specific • Fever • Transanal US
• Acute (cryptoglandular) • Loss of function
• Chronic • Specific (actinomycosis, General symptoms Forms
(anorectal TB, syphilis) • Raised body fever (a) Subcutaneous (most common in children)
fistula) • Traumatic • Symptoms of intoxication (b) Submucous
(c) Ischiorectal
*Obstruction of anal
(d) Pelviorectal
glands by thick
debris→stasis & bacterial
overgrowth→ abscess
formation
Anorectal an abnormal connection between
fistula the epithelialized surface of the
anal canal and the perianal skin
*Abscess extends into perirectal
spaces→ possible fistula
formation→ bacteraemia & sepsis
• Purulent drainage (from anal
canal or surrounding
perianal skinn)
• Pain during defecation
• History of recurrent abscess
• Secondary openings can be
seen
Classification: • Incision – for low fisula
According to count According to • Fistulotomy – for low fisula
of opening: relationship with • Fistulectomy – fistula excised out
Complete fistula sphincters: fully
(internal and external • Intrasphincteric • Setons
openings and fistula • Transsphincteric o Cutting seton
tract) • Extrasphincteric o Elastic seton- if inflamed tissue
(used for 2-3 months until
Incomplete fistula *Classification only inflammation ↓)
(internal fistula for complete fistula
opening and the • Fistulectomy (take out fistula tract)
tract) + anoplasty (close internal hole with
rectal wall)- done if not much
damage to sphincter (no
incontinence) but ↑ risk of
recurrence

Diagnosis:
• Fistula probe with methylene blue- can see
depth, main opening and direction
• Pelvic MRI- to see involved sphincters
• Endoscopy (sigmoidoscopy)