You are on page 1of 68

Management of Common

Anorectal Conditions
for Primary Care Providers
Richard P. Billingham, M.D., F.A.C.S.
Clinical Professor, Department of Surgery
University of Washington School of Medicine
Seattle, Washington

Common Anorectal
Symptoms:
Pain
Bleeding
Prolapse
Seepage
Difficulty cleaning
Itching

Common Anorectal
Conditions :
Hemorrhoids
Anal fissure
Perianal abscess/fistula
Pilonidal cyst/abscess
Levator syndrome
Venereal warts
Foreign bodies
Trauma

Why tell you guys*about


this?
Poorly understood by PCPs
Primary

care textbooks 30-50% incorrect!


Most providers have never had any training
in E&M of this area!

Many simple solutions well within the


skill set of PCPs
Faster disposition, increased patient
satisfaction
*Gender-neutral term

Elements of anorectal
exam
Patient in left lateral position, legs bent
Provider seated
1. External inspection
2. Digital examination
3. Anoscopy
4. Rigid sigmoidoscopy

Equipment needed
Anoscope (disposable OK)
Sigmoidoscope (disposable) and long
suction device
Other nice to have stuff:
Sawyer retractors
Single toothed tenaculum

Equipment for exam

Diagnosis?

Hemorrhoid Anatomy
3 external
hemorrhoids;
3 internal
hemorrhoids
Location:
RAQ
RPQ
LLQ

Hemorrhoids
External:
Thrombosis
Sx:

Pain, nodule; rare bleeding


Conservative management vs. excision
depending on degree of discomfort and
frequency of problem
If circumferential thrombosis, dont try in office

Thrombosed external
hemorrhoid
Why excision?
Incision,

trying to get out the clot, is


much less effective
Often

there are multiple clots, cant get them all

out
Incision through which this is done usually
closes very rapidly, allowing more clot to
accumulate
Leaves the hemorrhoidal vein to develop
another thrombosis at a later time

Excision of TEH

Use 3-5 cc of % marcaine + 1% lidocaine with epi


#30 (or #27) needle
Keep incision outside anal canal
Cautery alone vs. 3-0 chromic catgut

ETH (real time)


Key points:
Excise skin,
vein and
clot
Dont go
inside anal
canal
Cautery or
suture if
necessary

Post-excision care:
Sitz baths (for comfort only)
Darvocet and/or NSAIDs
Recheck in office in a month
No activity or diet restrictions
NO ANTIBIOTICS or topical creams
necessary

Hemorrhoidal Crisis
Thrombosis of all internal
and external hemorrhoids
Rx Alternatives:
1. Symptomatic treatment,
wait for resolution (~1 mo.)
then see surgeon for possible
non-operative management
2. Surgical hemorrhoidectomy
within 24 hours.
NO role for local therapy here

Was ist das?

Internal Hemorrhoids
Internal:
Sx:

Bleeding and/or prolapse; NOT pain

Hemorrhoids

Grade

dont hurt (except TEH)

I: Bleeding only - dietary vs.


injection
Grade II, III: Bleeding and prolapse rubber banding
Grade IV: Outpatient surgical
hemorrhoidectomy

Injection sclerotherapy
Products:
Ethanolamine
5% Na morrhuate
For grade I internal
hemorrhoids

Rubber band ligation

For Grade II or III


internal hemorrhoids

Hemorrhoid band in
place

Rubber banding
sequence

Rubber band ligation

Infrared Coagulator

Mixed internal and


external hemorrhoids

Surgical alternatives
Standard excisional hemorrhoidectomy

Surgical alternatives 2
PPH (Procedure for Prolapsed
Hemorrhoids)

Whats this?

Anal Fissure

1 cm

Anal fissure

Anal Fissure

Anal fissures
Sx: Pain, bleeding (with and after BMs)
Location: midline of body (90% posterior)

May also have external tag associated

Causes:
Constipation
Diarrhea
Inflammatory
Bad

luck

Bowel Disease

Anal fissures
Medical Rx -1% HC cream tid x 1mo
Must insert INTO the anal canal
Nitroglycerine, nifedipine, botox, etc. are no more
effective, and have more side effects
50% heal without surgery (within 1 month)

Medical Rx of anal
fissure

Why dont all fissures


heal?
Hypertonic (spastic) internal sphincter
muscle
An

extension of the smooth muscle of the


muscularis propria of the colon and rectum
Therefore, not under voluntary control
May reflect general state of smooth muscle
activation in GI tract and rest of body
Does spasm cause fissure, or vice versa?
Persistent spasm causes ischemia in midline,
keeps fissure from healing

Methods of dealing with


spastic internal sphincter
1. Cut it!

Causes surgical relaxation


In some centers, incontinence has been reported

2. Relax it pharmacologically

NTG, nifedipine, diltiazem tried-no better cure than HC


cream
Botox-costs $600, lasts 3 months, then fissure usually
comes back

So what do we do now?

Cut it!
After >6000 procedures over 30 years, we have never
had a patient develop incontinence!

Surgical Rx: Lateral


internal sphincterotomy
Patients back to work the next day with NO pain
NO chance of fecal incontinence!
~1% chance of difficulty controlling gas

Sphincter could be repaired, but no requests to date

You know what it is!

Abscess/fistula

Anal gland

Perianal abscess

Anal fistula

Abscess/fistula
Sx: Increasing pain, occ. fever;
drainage/seepage
Almost all abscesses can be drained in office!

By you!

50% will develop fistula within a month


Fistula can be left alone unless Sx (drainage,
recurrence of abscess) continue and are
sufficiently symptomatic
Surgical Rx of fistula: Outpatient fistulotomy

Myths about abscess


drainage
Local anesthesia wont work
Shouldnt inject into the wall of abscess as it
will spread infection
I need to pack this so it will drain
Im not a specialist, so I cant do this
I cant do this here in the office because itll
take too long and the patient will be too
miserable and the nurses will complain

Important principles of
abscess drainage
Adequate local (1% xylocaine + %
bupivicaine WITH epinephrine; should need
no more than 3-5 cc
Excise ellipse of skin (to delay cutaneous
healing)
Do not pack!
Antibiotics not necessary unless
immunocompromised host.
Antibiotics alone dont work!

Drainage of perianal
abscess

Drainage of perianal
abscess
Anus

Base of scrotum

Ischiorectal abscess
Larger, deeper,
and/or on both
sides of the
midline
These DO usually
need to be done
in the OR.

Anal fistulas

Anal fistulas-2

Pilonidal abscess
Top of gluteal cleft

Site of
incision

Anus

What to do???
Same as perianal
abscess!
Incision parallel to,
and 1cm away from,
midline
Remove ellipse of skin
Dont pack!
No antibiotics!
Follow-up in 3-4 wks

Four main causes of


anorectal pain
Thrombosed
external
hemorrhoid

No worse with
bowel movement

Usually no bleeding

Perianal abscess

No worse with
bowel movement

Usually no bleeding

Anal fissure

Worse with bowel


movement

Usually with
bleeding

Levator syndrome Better with bowel


movement

No bleeding

Levator syndrome
Sx: Dull aching pain, with prolonged sitting or
at night; gets better with bowel movement
May come on severely, last for 10-30 minutes and
go away
May be there (low grade) much of the time

Reassurance (after negative exam)


No narcotics; other meds not helpful
Office massage
Electrogalvanic stimulation (Phys. Rx)
O.R. massage

Seepage
Whats seeping?
Stool?

Mucus? Blood

Potential causes:
1.

BM too loose
2. Anal sphincter not tight enough (or
irregular contour)
3. Something sticking through the sphincter
and keeping it from closing
E.g.

hemorrhoids, rectal prolapse

Managing seepage
1. Thicken up BMs:
Diminish gratuitous fluid intake
Give fiber tablets (2 bid) with very little water

2. Weak sphincter

Examine, test (manometry and nerve studies, ?


ultrasound), repair if possible

3. Something hanging through sphincter


Rubber band hemorrhoids
Correct rectal prolapse

Pruritis ani

Genesis:
Moisture
Overcleansing
Overuse of toilet paper
Scratching
Using lots of OTC creams
Apparent spontaneous
appearance
NOT fungal!

Pruritis ani - Rx
1. Avoid further trauma
Soap,

scrubbing, excessive use of T.P.

2. Use TINY amt. of 1% HC cream tid


3. Cotton or corn starch (to try to keep
area dry)
4. Correct loose stools, limit gratuitous
fluid intake

What are these?

Warts (Condyloma
Acuminata)
Sx: Sometimes none, sometimes itching
Bichloroacetic acid - only helpful for tiniest
warts
Electrical cautery in office (with local)

Liquid Nitrogen has double the recurrence rate

Excision and fulguration in OR


Follow patients every 1-2 months until no
warts seen for 6 months, then annually

Fecal impaction
Cause: ???
Vigorous bowel prep may be least
uncomfortable Rx

E.g. 10 oz of Mg Citrate, or 3 oz of Fleets


phospho-soda

If manual disimpaction necessary,


Anesthetize the anus (10-20cc of anesthetic), may
need sedation
Dig it out! Sawyer retractors may be of some help

Enemas dont help

Perianal block
20-30 cc of %
Bupivicaine with
Epinephrine
1 needle,
25 or 27 gauge
10 cc syringe
(control or not)

Rectal Prolapse

Clinical Features
Female 6:1 males
Age
Females

maximal incidence in fifth decade and

beyond
Males evenly distributed with peak at 40

Symptoms may be due to prolapse itself


(bleeding, mucus, feeling of incomplete
evacuation, pressure) or to anal incontinence.

Clinical Features
Inspection.
Frequent

patulous anus.
With bearing down may become evident in left
lateral or jackknife positions; may need to do toilet
test
Mucosa may be ulcerated

Palpation usually shows decreased sphincter


tone
Sigmoidoscopy: at 8-10 cm, may be red and
inflamed, esp. anteriorly; may have solitary
ulcer there

Rectal Prolapse Associated Conditions


Pelvic floor descent
Enterocele
Rectocele
Cystocele
Uterine descensus
Non-relaxing puborectalis
Fecal incontinence

Evaluation
Evaluate colon for partial obstruction
Videodefecography
Anorectal manometry/nerve conduction
studies
Trans-anal ultrasound of sphincter
MRI

Videodefecography
Can assess recto-sacral separation, pelvic
floor descent, functional significance of
rectocele, presence of enterocele (with
double contrast), non-relaxing puborectalis,
pelvic floor descent, anorectal angle
May be able to see internal rectal prolapse
May not be able to see complete rectal
prolapse; toilet test more reliable
Must be interpreted by surgeon with clinical
correlation

Rectal
prolapse/enterocele

Management of rectal
prolapse
Encirclement procedures
Wire or band around external sphincter
50% recurrence rate

Perineal procedures
Operate through anus
Outpatient surgery
Doesnt correct enterocele, vaginal prolapse

Abdominal procedures
Rectopexy (mesh), often colon resection
Allows correction of enterocele, vaginal prolapse

Summary
Most people with hemorrhoids dont
have hemorrhoids
Hemorrhoids

dont hurt! (unless


thrombosed external hemorrhoids)

It aint rocket science


Simple office exam will usually diagnose
and begin treatment for most conditions

Summary 2
All PCPs should be familiar with Dx and
treatment of:
Anal fissures
Perianal (and pilonidal) abscesses
Thrombosed external hemorrhoids
Prolapsing internal hemorrhoids
Pruritis, warts
Rectal prolapse
Fecal impaction

Procedures appropriate
for PCP office
Excision of thrombosed hemorrhoid
Rubber band ligation of internal
hemorrhoids
Incision and drainage of perianal
abscess
Chemical and/or electrical cautery Rx of
anal warts
(Fecal disimpaction)

You can do it!

P.I.T.A Medal