ANAL AND PERIANAL CONDITIONS

DESTAW .B ,2022
OUTLINE OF THE PRESENTATION.
 Objectives
 Hemorrhoid.
 Ano-rectal abscesses.
 Anal fistula.
 Anal fissure .
 Rectal prolapse.
 Others.
 Objectives
 At the end of this session students are able to:
 Know common perianal conditions.
 Describe pathophysiology of common perianal
conditions.
 Diagnose and treat patients with hemorrhoid ,ano-
rectal abscesses fistula in ano ,anal fissure…...
 Describe possible causes of rectal prolapse.
 List treatment options of rectal prolapse.
 Anatomy
 Anal canal =4cm vs 2cm
 Proximal =columnar
 Distal =squamous
 Transitional zone
 Anal glands
 Continence
 Cont’ed
1.Internal anal sphincter
 Innervatted by autonomic
NS.
 Maintaining resting anal tone
 Under involuntary control
 Conte’ed
2. External anal sphincter

 Innervated by somatic
fibers
 Generates the voluntary
anal squeeze
 Hemorrhoids
 Are fibro muscular cushions .
 Left lateral, right posterior and right anterior (3,7,and
11 o'clock)
 Secondary cushions are found in between .
 Part of normal continence mechanism .
 Enlargement and /or prolapse of the hemorroidal
cushions=hemorrhoid.
 Cont’ed
 They are not related to the superior hemorrhoidal
artery and vein, to portal vein or portal HTN.
 They are part of normal anatomy.
 A skin tag is redundant fibrotic skin at the anal verge
often persisting as the residual of thrombosed
external hemorrhoid.
 Risk factors(etiologies )

 Constipation or prolonged straining.

 Increased intrabdominal pressure.

 Vascular hyperplasia or inflammatory process.

 Distal displacement of cushions because of aging

 Heavy lefting.
 Classification
1.Internal hemorrhoid
 Proximal to dentate line
 Bleeding or prolapse ,less painful
2.External hemorrhoid
 Distal to dentate line
 Are redundant folds of perianal skin
 Remain asymptomatic unless they are thrombosed
3.Intero-external hemorrhoid
Conte’d
 Internal hemorrhoid

Painless bleeding associated with bowel movement with or with out tissue
protrusion.

Bleeding in internal hemorrhoid is “bright red”.

Prolapse

Mucus discharge

Itching
P/E
Prolapse tissue
Rule out BPH in men.
Anoscopy and proctosigmoidoscopy
 Grades of internal hemorrhoid
Grade I
bleeding without prolapse
Grade II
Prolapse that spontaneously reduces.
Grade III
prolapse requiring manual reduction
Grade IV
irreducible prolapse
 Complications
Bleeding
Strangulation
Thrombosis
Gangrene
Suppuration
pylephlebitis
Ulceration
Fibrosis
 Treatment of symptomatic hemorrhoid
 Simple reassurance
 Fluid intake and high fiber supplementation
 Sitz bath
 Topical creams
 Rubber band ligation (RBL)
 Sclerotherapy
 Infrared radiation
 Surgery
 Rubber band ligation (RBL)
 Currently the most common method in
use for the out patient treatment.
 One to three bands are applied
 Complications
Bleeding
Pain if band is applied to distal to
dentate line.
Thrombosis
Life threatening perianal
spesis
 Infrared photocoagulation
• Infrared radiation coagulates tissue protien and
evaportes water from cell.
• Duration 1 to 1.5 seconds.
• Three to four times.
• Most beneficial for grade I and small Grade II
hemorrhoids .
• Less painful than RBL.
 sclerotherapy
• Less popular nowadays .
• Injection of an irritant material into anorecatal
mucosa
• To decrease vascularity and increase fibrosis
• Phenol in oil,sodium morrhate or quinine urea
 Procedure for prolapsed hemorrhoid
(stapled hemorrhoidectomy)
• PPH
• PPH removes a short circumferential segment of
rectal mucosa proximal to the dentate line using a
circular stapler.
 External hemorrhoids
 Distended vascular tissue distal to
dentate line.
 Thrombosed external hemorrhoid.
Sudden onset of severe pain
Tender and tense swelling in the
anal verge
 Thrombectomy vs
hemorroidectomy.
24 to 72 hours
 Surgical management
 Rule out Crohn’s disease pelvic floor abnormality or fissure in ano .
 Reserved for failed RBL and infrared photocoagulation and
external hemorrhoid.
 Bowel preparation
 Anesthesia ;LA,SA or GA
 Prone Jackknife or lithotomy.
 Closed hemorroidectomy (Ferguson)
 Open hemorroidectomy (Milligan Morgan)
 Closed submucosal
hemorrhoidectomy(Ferguson)
 Resection of hemorrhoidal
tissue and wound closure.
 The apex of the
hemorrhoidal plexus is then
ligated and the hemorrhoid
excised
 All three hemorrhoidal tissues
may be excised at the same
time
 Open hemorroidectomy
 AKA Millgean-Morgan hemorrhoidectomy
 Wound are left open and heal by secondary intention.
Whitehead’s Hemorrhoidectomy
 Involves circumferential excision of hemorrhoidal
tissue proximal to dentate line
 After excision, the rectal mucosa is then advanced
and sutured to the dentate line
 Nowadays abandoned.
 Complications hemorrhoidectomy
 Post-operative pain
 Urinary retention
 Bleeding
 Infection
 Incontinence
 Anal stenosis
 Anal fissure
 Ectropion
 Anorectal abscesses
As a result of local,walled off
infections of cryptogenic
origin( 90%)
The glands are thought
obstructed by feces or trauma.
Other possible causes
malignancy ,TB,Actinomycosi
s ,cigarette smoking
hematogenous.
 Classification
 Perianal (60%)
 Ischiorectal
 Supralevator
 Intersphincteric
 Sub mucosal
 Deep post anal
 Horse shoe abscess
 Perianal abscesses
Most common
Occurs in the perianal spaces.
Can result ischiorectal abscess
Ischiorectal abscesses may be
large but not visible ,DRE
Intersphincteric abscess.
difficult to Dx so requires EUA
Cont’ed
 ISCHIORECTAL ABSCESS

 Large erythematous indurated mass in the buttocks

 Fever and leukocytosis are common but not always
present.
 Large ischiorectal abscess frequently represents horse
shoe extension.
 Clinical features
• Perianal pain.
• Fever.
• Chills and malaise.
• Spontaneous drainage and prulunt discharge.
• Fluctuant ,erthemateous, tender area.
 Treatement
 Adequate drainage.
 Cruciate incision near to
anal verge.
 Antibiotics for patients
having systemic
symptoms and
immunocompromised, ,va
lvular heart disease .
 Supralevator abscess
 Uncommon and difficult to diagnose.
 Can mimic intra-abdominal conditions.
 Digital rectal examination may reveal an indurated,
bulging mass above the anorectal ring.
 If the abscess is secondary to an upward extension of
an intersphincteric abscess, it should be drained
through the rectum.
 Conte’d

 If a supralevator abscess arises from the upward

extension of an ischiorectal abscess, it should be
drained through the ischiorectal fossa.
 If the abscess is secondary to intra-abdominal
disease, the primary process requires treatment and
the abscess is drained via the most direct route
(transabdominally, rectally, or through the
ischiorectal fossa).
 Anal fistula(fistula in ano)
Communication from anal canal to perianal skin .
Commonly results from ano-rectal abscesses.
50% drained ano-rectal abscess results fistula.
Trauma ,Crohn’s disease ,malignancy ,radiation ,infections may
also produces fistula.
A complex, recurrent, or non-healing fistula should raise the
suspicion of one of these diagnoses.
Internal and external opening.
 Diagnosis
 Persistent drainage of an
abscess from internal or
external openings.
 Indurated tract often
palpable.
 Difficult to assess internal
opening.
 Goodsall’s rule.
Park’s classification
 Special studies
Fistulography(nowadays obsolete).
Sigmoidoscopy and colonoscopy.
To rule out associated malignancy,IBD and other tracts
in rectum.
Anorectal ultrasonography(endoscopic)
MRI
Accurate measure for imaging of anal fistula
More sensitive and specific to identify fistulous tracts
For the evaluation of complex fistulous disease.
 Treatment

 Simple intersphincteric fistulas can often be treated by

Fistulotomy (opening the fistulous tract).
Curettage and
Healing by secondary intention,
 Transsphincteric fistula(high vs low type)
Low type <30% of sphincteric involvement =
sphincterotomy
High type > 30% sphincteric muscle
involvement=Seton
 conted

Suprasphincteric fistula
Seton(cutting or draining.)
Failure to heal of complex fistula may ultimately
require fecal diversion (colostomy.)
Advancement flap.
LIFT(Ligation of Intersphincteric Fistulous Tract).
Fibrin glue and fistula plug
 Anal fissure
• Tear or split in the anoderm just distal to the dentate line.
• A tear in anoderm results from spasm of internal anal
sphincter.
• Acute vs chronic
• Posterior midline =90% in females 99% in males
• Anterior= 10%
• Decreased local blood flow or increased mechanical stress.
 Cont’ed
 Trauma to anal canal
passage of hard stool or loose watery stools
Scarring, stricture or stenosis from prior
surgery or anal injury
 poor posterior anal canal
blood flow and generalized hypertonia of the
internal anal sphincter are causes of anal fissures.
 Types
Acute anal fissure
Less than 4 to 6 weeks.
Little induration or edema of edges
spasm of internal anal sphincter
Chronic anal fissure
Present for longer peroids (> 6 weeks)
Indurated margins ,a base consisting of either scar or
internal sphincter
Skin tag at lower end
Spasm of anal sphincter
 Clinical features
 Anal pain =knife like Pain or tearing
 Bright red rectal bleeding associated with bowel
movement
P/E
 visual inspection by splitting anoderm
 Chronic anal fissures traids may be found .
 Treatment
 Acute anal fissure
1. Treated non operatively
2. Fiber supplemnts
3. Stool softeners
4. Generous intake of water
5. Sitz bath(warm water)
6. Local anesthetic ointemnts.
 Chronic anal fissure
Respond less successfuly to non operative meaures
Topical nitroglycerin ointemnt.
headache
2% nifidipone ointemnt.
Botulinium toxin injection .
Medical therapy is effective in most acute fissures, but will
heal only approximately 50% of chronic fissures.
Lateral internal anal sphincterotomy
Calibrated balloon dilatation
• Multiple fissures or fissures occurring away from
anterior or posterior midline indicates the presence
of associated disease .

10%
<1%
<1%

90%
 Rectal prolapse
 Circumferecial full-thikness protrusion of rectum
through anus .
 1st degree prolapse
 Complete prolapse(procidentia )
 Internal prolapse
 Mucosal prolapse(partial thickness protrusion )
 Female to male =6:1
 Rectal prolapse
Predisposing factors
Infants
Absent sacral curve
Reduced anal tone
Children
Diarrhea
Severe whooping cough
Decreased ischiorectal fat due to malnutrition
Adults
Torn perineum
Straining from urethral stricture
Elderly
Atony of sphincter
 Rectal prolapse

• More common with age in women but does not

correlate with aging in men.
Pathophysiology
 weak levator ani muscle and anal sphincter
 A redundant rectosigmoid colon
 A deep culdesac
 Loss of fixation of rectum to sacrum
 Clinical features
 Tenesmus
 Sensation of tissue protruding
per anus that may or may not
spontaneously reduce.
 Sensation of incomplete
evacuation
 Mucus discharge or leakage
 Incontinence or diarrhea to
obstruction
 Investigations
 Anorectal manometry
 Tests of pudendal nerve terminal motor latency
 EMG
 Cinedefecography
 Colonoscopy
 Barium enema to rule out malignancy
 Ct colonography
 Treatment
• Acute complete rectal prolapse
Reduction
If the rectum prolapses after reduction
tapping of the buttocks is helpful.
Topical salt or sugar
 Surgical management
 Primary therapy is surgical
 More than 100 types of procedures are described for rectal
prolapse
 Abdominal operations
 Most preferred approach for anesthesia fit patients .
1.Reduction of the pernieal henria and closure of the the culd-de-
sac(Moschowitz)
2.Fixation of the rectum either with a prosthetic sling(Ripsten and
Wells rectopexy) or by suture rectopexy
3.Resection of sigmoid colon (colorectal anastmosis)
4.Resection and rectopexy.
 Perineal approaches
 Best for elderly and debilitating patients.
1. Reefing rectal mucosa (Delorme procedure)
2. Resecting the prolapsed bowel from perineum
(perineal rectosigmodiectomy or Altemeier’s
procedure .
3. Anal Encirclement (Thiersch)
Obsolete
For elderly patients with dementia ,short life span
 References
 Principles of surgery ,Schwartz ,11th Ed.
 Shackelford’s surgery of alimentary tract,7 th ed.
 ACS,7th ed.
 Short practice of surgery,Bailey and loves,26th ed.
 Internet
Thank you !!!