BENIGN ANORECTAL

SURGICAL DISORDERS
PRESENTER: KERUBO MOSETI.
OBJECTIVES
• Introduction 
• Surgical anatomy.
• Examination of the anus.
• Common anal conditions.
INTRODUCTION:
• Anal and perianal disorders makeup about 20% of all OPD surgical
referrals.
• These conditions are extremely distressing and distressing and
embarrassing to patients.
• These patients endure the symptoms for a long time before seeking
medical care.
SURGICAL ANATOMY.
• The anal canal is 3-4 cm long, it is directed downward and backward from the
rectum to end at the anal orifice.
• The mid of the anal canal (dentate line) represents the junction between the
endoderm and the ectoderm. It is the intermediate layer.
• Function- provides continence for flatus and faeces
• Upper half (mucous part) lined by columnar epithelium and the lower
half(cutaneous part) by squamous epithelium, thus adenocarcinoma affects the
upper half while squamous cell carcinoma affects the latter half.
• Location- situated below the pelvic diaphragm and lies in the anal triangle of the
perineum btwn the right and left ischio-anal fossae.
• The fossae allows expansion during defeacation.
ANAL SPHINCTER
• Comprises of 2 muscles
• Internal anal sphincter-involuntary muscle that is a continuation of the rectal circular
muscles.
• External anal sphincter- voluntary muscles that surround the internal sphincter has 3 parts-
Subcutaneous-lower most portion of the external sphincter.
Superficial part
Deep part.
Function of the internal anal sphincter- involuntary;
• Contraction / tonus is stimulated and maintained by the sympathetic fibres from the
superior rectal & hypogastric plexus.
• Contraction/ tonus is inhibited by parasympathetic fibers by pelvic splancnic nerves.
External anal sphincter function- voluntary
• Made up of striated muscle 
• Supplied by the somatic inferior rectal nerve(terminal branch of the pudendal nerve) and
perineal branch of S4
• Sensitive to pain, touch, temperature.
• It surround the whole length of the anal canal.
Anorectal ring:
• Distinct muscular ring formed at the junction of the rectum and the anal canal.
• Formed by the internal anal sphincter, deep part of the external anal sphincter and
the puborectalis.
• Can be felt by a finger in the anal canal, it helps to increase the anorectal angle.
• Surgical division of this ring results in rectal incontinence.
ANATOMY- NEUROVASCULAR SUPPLY.
Blood supply:
• Upper half – superior rectal vessels
• Arterial supply- superior rectal artery
• Lower half and the surrounding anal skin- inferior rectal vessels, derived
from the internal pudendal a branch from the internal iliac vessels.
• Arterial supply- inferior rectal artery- branch of pudendal artery
• Middle rectal arteries- assist with blood supply to the anal canal by
anastomosing with the superior and inferior rectal arteries. These
are branches of internal iliac artery.
VENOUS DRAINAGE.
• Upper half- internal rectal venous plexus(haemorrhoidal plexus)
• Lies in the submucosa of the anal canal and drains the superior rectal vein- branch of
inferior mesenteric vein
• Commmunicates freely with the external plexus thus with the middle and inferior
rectal veins.
• External rectal venous plexus lies outside the muscular coat of the anal canal.
• Also drained by superior rectal veins that continue as inferior mesenteric vein.
• Lower half- drained by the inferior rectal vein into internal iliac vein
• Middle part-middle rectal vein into internal iliac vein.
• The middle rectal veins forms an anastomosis with superior and inferior rectal veins
thus an important site of portal & systemic vein anastomosis.
LYMPHATIC DRAINAGE.
• Above the mucocutaneous junction drain along the superior rectal vessels to the lumbar
lymph nodes.
• Below this line the drainage is to the inguinal lymph nodes.
• Examination of the anus.
• This requires careful attention to circumstances (couch, light, gloves)
• The Sims (left lateral position) is satisfactory.
• The examination proceeds by:
a. Inspection
b. Digital examination with index finger
c. Proctoscopy
d. Sigmoidoscopy
COMMON ANAL CONDITIONS.
• Anal incontinence
• Haemorrhoids
• Anal fissure
• Rectal prolapse
• Anorectal prolapse
• Fistula-in- ano
• Benign anorectal strictures.
COMMON ANORECTAL SYMPTOMS
• Anal bleeding
• Anal pain and discomfort 
• Perianal itching and irritation
• Something coming down
• Perianal discharge
ANAL INCONTINENCE.
• Def- inability to control the evacuation of flatus or stool.
• Normal anal continence depends on:
1. An intact spinal cord reflex.
2. An adequate sphincteric mechanism.
3. An appropriate cortical inhibitory control.
Causes of incontinence.
• Congenital malformations of the anus in which the sphincter is partially or
completely lacking.
• Acquired causes:- medical conditions e.g mental deficiency, senility, spinal cord
lesions, diabetes mellitus
• Anorectal disease e.g rectal prolapse, piles, chronic inflammatory bowel disease,
faecal impaction, destruction of the anus.
• Sphincteric causes ,classified as:.
Structural- there is anal disruption/ atrophy of part of the sphincter muscles.
Neuropathic-aka idiopathic, nerve supply to the sphincter is damaged due to chronic
straining or complicated vaginal delivery ( prolonged second stage)
Combination of both.
Cont 
• Neurological and physiological diseases e.g spina bifida, spinal
tumours and trauma (spinal injuries).
Clinical types:
• True incontinence
• Partial incontinence
• Overflow incontinence
Diagnosis:
• Clinical: Hx & P.E (soiling perineum or underwear, etc)
Treatment:
• There is no satisfactory treatment for many causes of incontinence.
Conservative mgt:
• Satisfactory for minor degree of incontinence e.g anorectal lesion,
faecal impaction.
• These maybe in the form of stool bulking or constipating agents, anal
plugs which expand within and thus seal the canal.
Operative treatment: dependant on the causes of incontinence.
• Thiersch's operation
• Colpoperinerrhaphy- for obstetrical injury
Cont:
• Sphincteroplasty- in cases of traumatic postoperative incontinence.
• Sphincter reefing.
• Colostomy.
HAEMORRHOIDS.
• Def- these are enlarged mucosal folds that contain blood vessels in or
around the lower part of the bowel.
• These cushions act as a plug to the anal canal and contribute 15-20%
to the resting pressure of the anal canal.
• Piles may internal or external according to whether they are
internal or external to anal orifice.
Internal haemorrhoids
• Def- dilation of the superior haemorrhoidal veins above the dentate
line.
Each pile consists of:
• Mass of dilated vein
• Artery 
• Connective tissue
• Mucosal investment.
Location: right anterior, right posterior and left lateral situated
respectively 11,7,3 o'clock with patient in the lithotomy position.
External haemorrhoids
• Relate to venous channels of the inferior hemmorhoidal plexusdeep in
the skin surrounding the anal verge and are not true haemorrhoids.
• Usually recognised as a result of a complication which is mostly a painful
solitary acute thrombosis.
• Commonly termed as a perianal haematoma due to rupture of a dilated
anal vein that occurs after severe straining.
CFs:
• Sudden onset of a painful lump at the anus
• o/e- swelling that is tense & tender, bluish in colour, covered with smooth
shining skin.
Aetiology of Haemorrhoids.
• Primary or secondary.
Primary causes:
These are attributed to several predisposing causes;
1. Hereditary factors- structural weakness of the vein
2. Anatomical factors.
3. Portal congestion.
4. Chronic constipation
5. Sphincteric tone (high)
Cont:
• These are due to underlying organic cause such as;
1. Pregnancy 
2. Venous obstruction
3. Straining on micturition
4. Venous congestion
5. Carcinoma of the rectum
Clinical features:
• Bleeding at defecation
• Prolapse
• Discharge with pruritus ani
• Pain 
• Thrombosed piles.
Degree or stage-wise classification:
• 1st degree- bleeding
• 2nd degree- protrusion but spontaneous reduction.
• 3rd degree- protrusion that requires manual reduction.
• 4th degree- irreducible protrusion.
Haemorrhoids:
Assessment and Diagnosis:
• Careful history
• Abdominal examination
• Anorectal examination 
• Investigation e.g proctoscopy
Treatment:
• Conservative 
• Specific surgical treatment
Conservative management:
• Treatment for 90% of the cases:
1. Fibre diet- avoid constipation or diarrhoea if causative.
2. Lidocaine jelly,hydrocortisone cream, nitroglycerine cream.
3. Others- sclerotherapy (5% phenol with almond oil),band ligation,
infrared photocoagulation.
Surgical treatment.
Aim:
• To restore the anal canal to normal or near normal functional and
anatomical status.
Procedure:
• Involves eliminating the vascular cushions alone or in combination
with relocation of the squamous epithelium.
• Haemorrhoidectomy- open vs closed.
• Haemorrhoidopexy/ stapled haimerrhoidectomy.
Rx- external haemorroids
• LA evacuation if the patient presents within 48hrs.
• Later presentation do conservative management,
Complications- if untreated haematoma undergoes:
• Resolution
• Ulceration
• Suppuration- forming an abscess
• Fibrosis- resulting in a skin tag.
ANAL FISSURE (FISSURE-IN-ANO)
• Def- a longitudinal split in the distal canal that extends from the anal
verge proximally towards but not beyond the dentate line.
• It is a linear ulcer of the lower half of the anal canal.
• Posterior fissure- most common, while the anterior fissure is common
in women arises following vaginal delivery.
• Fissure in any other location suspect- Crohn's d'se,
STDS,TB, Hidranadenitis supprativa.
TYPES
• Acute vs chronic 
Acute Fissure:
• Cause; trauma caused by straining to pass hard stool or repeated
passage of diarrhea.
• Acute onset- thus a short Hx
• Painful 
• No sentinile pile o/e
• Rx- conservative.
Chronic fissure.
Xtised by hypertrophied anal papilla internally and a sentinel tag externally.
Ass with sentinel pile.
Cause: 
• repeated trauma, 
• anal hypertonicity, 
• vascular insufficiency sec. to inc. in sphincter tone or hypoperfusion of the posterior
commissure in comparison to the remainder of the anal circumference. 
CFs:
• Itchindg- due to irritation of sentinel tag/ discharging ulcer.
• A sentinel pile/tag- a skin tag that is formed due to chronic inflammation and fibrosis.
• Rx- conservative, but may require surgery.
Aetiology 
• Passage of large, hard stools, which maybe the initiating factor;
• Inappropriate diet
• Previous anal surgery
• Childbirth 
• Laxative abuse
Symptoms;
• With daefecation the ulcer is stretched causing pain and mild
bleeding.
Rx
• Aim; increase the blood supply to promote healing of the ulcer/fissure
Non surgical :
• Stool bulking agents
• Hot tub baths/ sitz bath
• Local ointments- lignocaine/ nitroglycerine
• Dietary modifications 
• Botox injections
Surgical :
• Sphincterotomy- open vs closed.
RECTAL PROLAPSE.
• Def- protrusion of the lowest segment of the large intestine through
the anus.
• 2 types-
• Partial/incomplete- the mucous membrane lining the anal canal
protrudes via the anus only.
• Complete- whole thickness of the bowel protrudes from the anus.
• Common in females and occurs at extremes of age.
Aetiology 
In children, these are the predisposing factors:
• Vertical straight course of the rectum.
• Reduction of supporting fat in the ischiorectal fossa
• Straining of stool- during defecation
• Chronic cough.
In adults the predisposing causes is dependent on the type of prolapse:
Partial-
• Advancing degrees of prolapsing piles
• Loss of sphencteric tone
• Urethral obstruction- causing straining.
• Operations for fistula.
Cont 
Complete-
• Seen as the sliding hernia of the rectovesical/ rectovaginal pouch due
to the stretching of the levator and from pregnancy.
CFs-
• Prolapse is first noted during defeacation
• Discomfort during defeacation
• Bleeding
• Mucous discharge
• Irregular bowel habits that may lead to incontinence
Management:
Children:
• It disappears spontaneously by the age of 5 yrs.
• Conservative measures are sufficient:
• Avoid constipation and straining at stool during defaecation
• Strapping of the buttocks  together to discourage prolapse during
defaecation
• Perirectal injection with alcohol phenol maybe used to fix the lax
mucosa to the underlying tissue.
Cont 
Adult :
• Partial prolapse-
• Provided sphincter tone is satisfactory, it can be treated by ligature
excision of prolapsed mucosa.
• Injection of 5% phenol oil in submucosa, 10-15ml in total- fixates lax
mucosa to the underlying tissue.
• Electrical stimulation with sphincteric exercises.
• Complete prolapse-
• Indication for surgery.
Complications
• Irreducibility
• Infection
• Ulceration
• Severe haemorrhage from one of the mucosal veins
• Thrombosis and obstruction of the venous returns leading to edema
• Gangrene
ANORECTAL ABSCESS
• Acute form of anal sepsis.
• Aetiology 
• Infection from obstructed anal glands- most common
• Underlying rectal d'se- neoplasm
• Immunocompromised- DM, AIDS.
• Trauma
• TB
• Foreign body
• Actinomycoses
• Inflammatory bowel d'se- esp. Crohn's 
Pathology:
• According to the Park's cryptoglandular theory:
• Infection starts in one of the crypts of Morgagni and extends along
related anal gland.
• Happens via the inter sphinteric plane to form an abscess.
• Modes/ tracks of spread to produce different types of abscesses:
1. Perianal
2. Ischiorectal
3. Submucous 
4. Pelvirectal.
Perianal 
• Confined by the terminal extensions of the longitudinal muscle.
• It is a suppuration of the anal gland or a thrombosed external pile.
• Location- subcutaneous portion of external sphincter.
CFs;
• Severe pain in perianal region
• Difficulty in sitting
• Tender smooth and soft swelling in the perianal region.
Rx;
• Sitz bath
• Abx
• I&D under G.A
Ischiorectal 
• Results from an extension of intermuscular  abscess via external sphincter.
• Can be blood borne as well.
• Fat in this fossa is more likely to be infected as it is least vascularized.
• Both fossa are connected one fossa infection may lead to the infection of
the other side- horse shoe abscess.
CFs-
• Tender, indurated, brawny swelling in the skin over the ischiorectal fossa.
• Fever 
• Swelling is not well localized- thus it is difficult to elicit fluctuation.
Cont 
Rx-
• Cruciate I&D
• Pus for c/s
• Look for any internal opening (internal fistula).
Submucous :
• Occurs above the dentate line.
• Can be drained with a sinus forceps thru a proctoscope.
FISTULA-IN-ANO
• A track lined by granulation tissue that connects deeply in the anal
canal or rectum and superficially on the skin around the anus.
• It is a connection between the deep anal canal or rectum and
superficial skin around the anus
• Shows a chronic phase of anorectal sepsis xtised by:
1. Chronic purulent discharge
2. Cyclical pain ass with abscess re-accumulation- followed by
intermittent decompression
Aetiology 
• Cryptoglandular sepsis- very common with uncertain aetiology.
• Associated with these systemic diseases:
IBD-Crohns and ulcerative colitis
TB
Malignancy 
Lymphogranuloma venerom- caused by chlamydia trochamatis.
Actinomycosis-caused by actinomycoses israelii common with URTIs,
commonly spreads thru tissues ass with abscesses.
• Others- trauma, radiation exposure.
Classification
• Location of the opening in relation to the anorectal ring:
 Low level- subcutaneous, low anal submucous
 High level-open into anal canal at/ above the anorectal ring e.g pelvirectal,
high anal.
• Relation to anal sphincter- Park's classification
• Type 1- intersphincteric 70% Low level anal fistula
• Type 2- trans-sphincteric 25% high level anal fistula
• Type 3- supra sphincteric 4%
• Type 4- extra sphincteric 1%, rare type. The tract passes outside all sphincter
muscles to open in the rectum.
Complex vs simple Fistula-in-Ano
• Complex-modification of the parks classification
• Describes a fistula whose Rx poses a higher risk of impairment of continence.
• Anal fistula is termed as complex when the track crosses > 30-50% of the
external sphincter.
• Examples- higher trans sphinteric, supra sphinteric, extra sphinteric.
• Features:
 Anterior in females
 Has multiple tracks
 Recurrent 
 Patients with co-morbidities.
Clinical presentation
• Persistent drainage via internal or external opening. It irritates the skin
and causes discomfort  at the anus, also ass with pain.
• Indurated tract- palpable on DRE.
• External opening easily found- by locating internal opening- challenge.
EUA- successful identification in 86%
• Aim- to identify the external and internal opening
• Identify the course of the tract
• Identify the presence of secondary connections.
• Identify the presence of other rectal diseases.
Special investigations.
• Trans rectal ultrasound/ endoanal sound
• Fistulogram 
• MRI

MANAGEMENT.
• Goals- abolish the pri and sec fistula
• Prevent fistula recurrence
• Preservation of continence
Cont 
• Mgt options include:
• Fistulotomy 
• Fistulectomy 
• Setons 
Recurrent advancements- 
• Advancement flaps
• Tissue
Fxns of a seton:
• Provide drainage
• Induce chronic fibrosis
• Cuts the fistulous tract with preservation of the sphincteric mechanism.
BENIGN ANORECTAL STRICTURES.
• Narrowing of the anal canal that results from intraluminal
inflammation/ scarring.
• Stenosis / contracture prevents sphincteric dilatation.
Causes:
• Trauma- burns, surgery
• Reduced use- immobilization
• Damage / degeneration of the nerves
• Congenital disorders
Clinical presentation 
• Hx of anorectal surgery, radiation to pelvic area, chronic anorectal disorder.
• Progressive difficulty in defecation- feeling of incomplete bowel evacuation/ pipe
stem stools.
• Pain 
• Bleeding 
• Discharge
• Pruritus 
• Late cases- sub-acute, intestinal obstruction
• Inspection- reveals narrowing of the anal canal.
• DRE- discloses anal tenderness & tightness
Diagnostic tests
• Visual inspection and DRE- confirms dx
• Proctoscopy& biopsy- only diagnostic tests performed for this
disorder.

Rx:
• Dilation: digital, instrumental (Hegar's) or balloon.
• Surgical: removal of scar tissue (most effective).
Clinical case study
A 50 year old man complained that he frequently passed blood stained
stools for the past 1 yr without pain. Recently , he noticed that his
bowel protruded out during the time of defecation & this
caused discomfort. The doctor examined the patient and came to a
diagnosis.
1. What is the clinical condition that the patient has that bleeds during
defecation?
2. What is the anatomical basis of the condition?
3. Why is the bleeding not painful?