BENIGN RECTAL, ANAL, AND

PERINEAL PROBLEMS
Benign Rectal, Anal, and Perineal
Problems
Anatomy
 Dentate line divides the
rectal mucosa, which is
generally insensitive and is
lined with columnar
mucosa, from the
anoderm, which is highly
sensitive (because of
somatic innervation) and
lined with modified
squamous mucosa.
Benign Rectal, Anal, and Perineal
Problems
Anatomy (continue)
 The anal canal is surrounded by two muscles
- Internal sphincter innervated by autonomic
nervous system, maintaining resting anal tone
and under involuntary control
- External sphincter innervated by somatic nerve
fibers, generates the voluntary anal squeeze and
plays the key role in maintaining anal continence
Benign Rectal, Anal, and Perineal
Problems
Anatomy (continue)
 The areas surrounding
the anorectum is
divided into four
spaces
- Peri-anal
- Ischioanal
- Supralevator
- Intersphincteric
(intermuscular)
Hemorrhoids

 Fibro-muscular cushions that line the anal

canal
 Classically found in three locations
- Right anterior
- Right posterior
- Left lateral
- Small secondary cushions may be found
lying between the main cushions
Hemorrhoids

 They are part of normal anal anatomy

 Play role in normal mechanism of fecal
continence, they get engorged during
straining or performance of Valsalva
maneuver, which completes the occlusion of
the anal canal and prevents stool loss with
none defecatory straining
Hemorrhoids

 Broadly classified as
- Internal proximal to
dentate
- External distal to
dentate, redundant
folds of peri-anal skin,
usually asymptomatic
unless thromboses
Hemorrhoids
Hemorrhoids

Internal Hemorrhoids Disease

 Manifested by two main symptoms
- Painless Bleeding
- Protrusion
(Pain is rare as they originate above dentate line)
 Most popular etiologic theory states that
Hemorrhoids result from chronic straining at
defecation
 Continued straining causes engorgement and
bleeding, as well as hemorrhoidal prolapse
Hemorrhoids

Internal Hemorrhoids Disease (continue)

 Grades
- Grade 1 Bleeding without prolapse
- Grade 2 prolapse that spontaneously reduce
- Grade 3 prolapse necessitating manual
reduction
- Grade 4 irreducible prolapse
Hemorrhoids

Internal Hemorrhoids Disease

 History
- Bleeding
- Protrusion
- Chronic Constipation (extensive bathroom readers)
 Physical examination
- Visual inspection may reveal prolapsing hemorrhoidal
tissue appearing as rosette of three distinct pink-purple
hemorrhoidal groups
- If no prolapse, anoscopy reveals redundant anorectal
mucosa proximal to dentate line in the classic locations
Hemorrhoids

Internal Hemorrhoids Disease

Management
 Ranges from (depending on hemorrhoid grade)
Reassurance
to
operative hemorrhoidal excision
Hemorrhoids

Internal Hemorrhoids Disease / Management

Therapies classified into three categories
 Diet and lifestyle modification
 None operative and office procedures
 Operative hemorroidectomies
Hemorrhoids

Internal Hemorrhoids Disease / Management

(1)Diet and life style modification
 All patients grade 1 or 2 and most patients with grade 3
 Correct constipation
 High fiber diet
 Liberal water intake
 Fiber supplement
 Sitz bath (soothing effect ability to relax anal sphincter)
 Topical creams
Hemorrhoids

Internal Hemorrhoids Disease / Management

(2)None operative and office procedures
 If diet and life style modification are not effective

 Rubber band ligation

 Ligation of hemorrhoid with elastic bands
 Successful in 2/3 to 3/4 in patients with grade 1 or 2
- Complications
- Bleeding
- Pain
- Thromboses
- Perianal sepsis (pain, fever, difficult urination)
Hemorrhoids
Hemorrhoids
Internal Hemorrhoids Disease /
Management
(2)None operative and office
procedures
 Infrared coagulation applied to
apex of each hemorrhoid at top of
anal canal
 Infrared radiation coagulates tissue
protein and evaporates water from
cell
 Extent of tissue destruction depends
on intensity and duration of the
application
 Not effective in treating large
amount of prolapsing tissue, most
useful for grade 1 and small grade 2
hemorrhoids
hemorrhoids

Internal Hemorrhoids Disease / Management

(2)None operative and office procedures
 Sclerotherapy
 Less popular nowadays
 Injection of sclerosant into anorectal submucosa to
decrease vascularity and increase fibrosis (injection at
apex of hemorrhoids at anorectal ring)
 Agents used (phenol in oil, sodium morrhuate, and
quinine urea)
Hemorrhoids

Internal Hemorrhoids Disease / Management

(3) Operative Hemorrhoidectomies
 Reduction of blood flow to anorectal ring
 Removal of redundant hemorrhoidal tissue
 Fixation of redundant mucosa

Procedures
 Hemorrhoidectomy
 Stapled Hemorrhoidectomy
Hemorrhoids

External Hemorrhoids
 Asymptomatic except when secondary thrombosed
 Thrombosis may result from defecatory straining or extreme
physical activity or may be random event
 Patient presents with constant anal pain of acute onset
 Physical examination identifies external thrombosis as purple mass
at anal verge
 Management
- Depends on patients symptoms
- In the first 24 – 72 hours after onset, pain increase and excision is
warranted
- After 72 hours, pain generally diminishes
Hemorrhoids

External Hemorrhoids
 If operative treatment is chosen,
entire thrombosed hemorrhoid
has to be excised
 Incision and drainage of clot
shouldn’t be done as this can
lead to re-thrombosis and
exacerbation of symptoms