Anorectal disorders

• ANATOMY AND PHYSIOLOGY

• Surgical anatomy
• The anal canal commences at the level where the rectum passes through the pelvic
diaphragm and ends at the anal verge. The muscular junction between the rectum and
anal canal can be felt with the finger as a thickened ridge – the anorectal ‘bundle’ or
‘ring’.
• Anal canal anatomy
• The anorectal ring
• The anorectal ring marks the junction between the rectum and the anal canal. It is
formed by the joining of the puborectalis muscle, the deep external sphincter,
conjoined longitudinal muscle and the highest part of the internal sphincter. The
anorectal ring can be clearly felt digitally, especially on its posterior and lateral aspects.
• Anal canal anatomy
• ●● The internal sphincter is composed of circular, non-striated involuntary muscle supplied by
autonomic nerves
• ●● The external sphincter is composed of striated voluntary muscle supplied by the pudendal
nerve
• ●● Extensions from the longitudinal muscle layer support the sphincter complex
• ●● The space between sphincters is known as the intersphincteric plane
• ●● The superior part of the external sphincter fuses with the puborectalis muscle, which is
essential for maintaining the anorectal angle, necessary for continence
• ●● The lower part of the anal canal is lined by sensitive squamous epithelium
• ●● Blood supply to the anal canal is via superior, middle and inferior rectal vessels
• ●● Lymphatic drainage of the lower half of the anal canal goes toinguinal lymph nodes
EXAMINATION OF THE ANUS
Inspection
• The buttocks are gently parted to allow inspection of the anus and perineum: the
presence of any skin lesions and whether they are confined to the perineum.

• Digital examination with the index finger

• With an adequately lubricated index finger, the soft tissues around the anus are
palpated for induration, tenderness and subcutaneous lesions.
• The posterior surface of the prostate gland with its median sulcus can be
palpated anteriorly in male patients; in female patients, the uterine cervix can be
palpated.
• On withdrawal, the examining finger is inspected for the presence of mucus,
blood or pus and to identify stool colour.
Proctoscopy
• Proctoscopy, performed with the patient in the same position, allows
a detailed inspection of the distal rectum and anal canal . Minor
procedures can also be carried out through this instrument, e.g.
treatment of haemorrhoids by injection or banding and biopsy.
• Examination of anal canal
A rectal examination is essential for any patient with anorectal and/or
bowel symptoms – ‘If you don’t put your finger in, you might put your
foot in it’ A proctosigmoidoscopy is essential in any patient with bowel
symptoms, and particularly if there is rectal bleeding.
ANAL FISSURE
• Definition
• An anal fissure (synonym: fissure-in-ano) is a longitudinal split in the
anoderm of the distal anal canal , which extends from the anal verge
proximally towards, but not beyond, the dentate line.
Aetiology
• Classically, acute anal fissures arise from the trauma caused by the
strained evacuation of a hard stool or, less commonly, from the repeated
passage of diarrhoea.
• Anterior anal fissure is much more common in women and may arise
following vaginal delivery.
• Most fissures are idiopathic. Recurrent, multiple or unusually extensive
fissures affecting areas other than the midline should raise the suspicion
of Crohn’s disease, which can occasionally present with anal fissure.
Occasionally, anal fissure may be associated with ulcerative colitis. A
fissure is an uncommon complication of haemorrhoidectomy and results
from a nonhealing wound combined with anal spasm.
• Anal fissure
• Acute or chronic
Ischaemic ulcer in the midline of the anal canal
• Ectopic site suggests a more sinister cause
• Symptoms:
• Pain on defaecation
• Bright-red bleeding
• Mucus discharge
• Constipation
• Clinical features
• History
• The typical presentation is severe pain on defaecation in a young patient. Pain is the
predominant symptom and may be burning, tearing or sharp in nature. It is usually painful to
wipe the anus and pain may last a few hours after defaecation. There is often associated
outlet-type rectal bleeding, with blood on the paper or dripping into the pan post
defaecation,or blood streaking of the stools. The amount of bleeding is usually minor and
there may be some staining or mucous discharge in the underwear. There may be a history of
constipation, which could be responsible for the tear, but is more likely secondary to the pain.
A full history is important to exclude previous perianal surgery, perianal abscess, trauma
during childbirth or symptoms consistent with Crohn’s disease. It is important to remember
that fissures can follow an acute attack of diarrhoea. It is important to document reproductive
history for females, as surgery may have implications for future anal continence.
• Treatment of an anal fissure
Conservative initially, consisting of stool-bulking agents and softeners,
and chemical agents in the form of ointments designed to relax the
anal sphincter and improve blood flow Surgery if above fails, consisting
of lateral internal sphincterotomy.
HAEMORRHOIDS
• Haemorrhoids are Swollen veins in the anal canal. Veins can swell inside
the anal canal to form internal haemorrhoids.Or they can swell near the
opening of the anus to form external haemorrhoids.
• Internal haemorrhoids (Greek: haima = blood, rhoos = flowing; synonym:
piles, Latin: pila = a ball) are symptomatic anal cushions and
characteristically lie in the 3, 7 and 11 o’clock positions (with the patient
in the lithotomy position.
• External haemorrhoids associated with internal haemorrhoids
(‘interoexternal piles’) result from progression of the latter to involve
both haemorrhoidal plexuses, and are best thought of as being external
extensions of internal haemorrhoids.
• Haemorrhoids are very common; however, the aetiology remains obscure.
Almost all haemorrhoids are primary, with only a tiny proportion due to other
factors, such as a cancer in the distal rectum.
• Definition
• Haemorrhoids are enlarged, prolapsed anal cushions arising from
arteriovenous communications within connective tissues
• Pathogenesis
• The pathophysiology involves degeneration of the supporting fibroelastic tissue
and smooth muscle, with enlargement of anal cushions and protrusion at the 3,
7 and 11 o’clock positions. As the cushions prolapse, there is keratinisation and
hypertrophy of the overlying anal transitional zone and eventually prolapse
Clinical features
• Haemorrhoids: clinical features
• ●● Haemorrhoids or piles are symptomatic anal cushions.
They are more common when intra-abdominal pressure is raised, e.g. in obesity,
constipation and pregnancy.
• ●● Classically, they occur in the 3, 7 and 11 o’clock positions with the patient in the
lithotomy position.
• ●● Symptoms of haemorrhoids:
• Bright-red, painless bleeding
• Mucus discharge
• Prolapse
• Pain only on prolapse
• Four degrees of haemorrhoids
• ●● First degree – bleed only, no prolapse
• ●● Second degree – prolapse but reduce spontaneously
• ●● Third degree – prolapse and have to be manually reduced
• ●● Fourth degree – permanently prolapsed
•
Third-degree haemorrhoids.
Third-degree haemorrhoids
• Complications of haemorrhoids
• ●● Strangulation and thrombosis
• ●● Ulceration
• ●● Gangrene
• ●● Portal pyaemia
• ●● Fibrosis
• Major haemorrhage: Haemorrhoids rarely cause massive lower GI
haemorrhage but should be excluded in patients presenting with a major
fresh rectal bleed resulting in significant hypovolaemia and anaemia.
An attack of piles. Prolapsed strangulated piles, as
commonly seen, on the left. A less common mass on the right with
fibrofatty covering.
Carcinoma of the rectum associated with
haemorrhoids ,a not infrequent diagnostic pitfall.
• Treatment of haemorrhoids
• ●● Symptomatic – advice about defaecatory habits, stool
• softeners and bulking agents
• ●● Injection of sclerosant
• ●● Banding
• ●● THD /HALO/ haemorrhoidopexy
• ●● Haemorrhoidectomy
Management
Stapled haemorrhoidectomy
External haemorrhoids
• External haemorrhoids
• A thrombosed external haemorrhoid relates anatomically to the veins
of the superficial or external haemorrhoidal plexus
• is commonly termed a perianal haematoma.
• It presents as a sudden onset, olive-shaped, painful blue
subcutaneous swelling at the anal margin and is usually consequent
upon straining at stool, coughing or lifting a heavy weight.
External haemorrhoids
• The thrombosis is usually situated in a lateral region of the anal
margin. If the patient presents within the first 48 hours, the clot may
be evacuated under local anaesthesia.
• Untreated it may resolve, suppurate, fibrosed and give rise to a
cutaneous tag, burst and the clot extrude, or continue bleeding.
• In the majority of cases, resolution or fibrosis occurs. Indeed, this
condition has been called ‘a 5-day, painful, self-curing lesion’
(Milligan).
ANORECTAL ABSCESSES
• The cryptoglandular theory of intersphincteric anal gland infection
(Parks) holds that, upon infection of a gland, pus, which travels along
the path of least resistance, may spread caudally to present as a
perianal abscess, laterally across the external sphincter to form an
ischiorectal abscess or, rarely, superiorly above the anorectal junction
to form a supralevator intermuscular or pararectal abscess
(depending on its relation to the longitudinal muscle), as well as
circumferentially in any of the three planes:
• intersphincteric/intermuscular, ischiorectal or pararectal
• supralevator .
ANORECTAL ABSCESSES
• Sepsis unrelated to anal gland infection may occur at the same or at
other sites , including submucosal abscess (following haemorrhoidal
sclerotherapy, which usually resolve spontaneously), mucocutaneous
or marginal abscess (infected haematoma), ischiorectal abscess
(foreign body, trauma, deep skin-related infection) and pelvirectal
supralevator sepsis originating in pelvic disease.
• Crohn’s disease, may be the cause. Similarly, patients with generalised
disorders, such as diabetes and acquired immunodeficiency syndrome
(AIDS), may present with an anorectal abscess; in these patients,
abscesses may run an aggressive course.
Clinical features
• A perianal abscess is usually associated with a short (2–3days) history of
increasingly severe, well-localised pain and a palpable tender lump at the
anal margin.
• Examination reveals an indurated hot, tender perianal swelling. Patients
with infection in ischiorectal space, usually present later, with less well
localised symptoms but more constitutional upset and fever.
• On examination, the affected buttock is diffusely swollen with widespread
induration and deep tenderness. If sepsis is higher, deep rectal pain, fever
and sometimes disturbed micturition may be the only features, with
nothing evident on external examination but tender supralevator
induration palpable on digital examination above the anorectal junction.
• Anorectal abscess
• ●● Usually produces a painful, throbbing swelling in the anal
• region. The patient often has swinging pyrexia
• ●● Subdivided according to anatomical site into perianal,
• ischiorectal, submucous and pelvirectal
• ●● Underlying conditions include fistula-in-ano (most common),
• Crohn’s disease, diabetes, immunosuppression
• ●● Treatment is drainage of pus in first instance, together with
• appropriate antibiotics
• ●● Always look for a potential underlying problem
Management
Management of acute anorectal sepsis is primarily surgical, including
careful examination under anaesthesia, sigmoidoscopy and
proctoscopy, and adequate drainage of the pus. For perianal and
ischiorectal sepsis , drainage is through the perineal skin, usually
through a cruciate incision over the most fluctuant point, with excision
of the skin edges to deroof the abscess . Pus is sent for microbiological
culture and tissue from the wall is sent for histological appraisal to
exclude specific causes. After irrigation of the cavity, the wound is
lightly tucked; antibiotics are prescribed if there is surrounding cellulitis
and especially in those less resistant to infection, such as diabetics.
Incision of an ischiorectal abscess.
Pilonidal sinus in the natal cleft.
• Perianal pilonidal disease is a common disorder with a population
incidence of 20–30 per 100,000. It is more common in males than
females, and affects around 2% of the population between the ages
of 15 and 35 years. The disease is rare before puberty, when sex
hormones act on hair follicles and sebaceous glands, and after the age
of 40, suggesting that there is an aetiological relationship with age
and skin character.
• it seldom presents after the fourth decade
• Typical presentation comprises midline natal cleft pits discharging
mucopurulent material which may smell mildly offensive and may be
blood-stained. There is often tenderness on pressure and the patient
may avoid long periods of sitting.
• When a sinus becomes infected and the pus is loculated, the disease
presents as pilonidal abscess, with the abscess typically pointing just
off the midline. However, there is invariably a communication with a
midline sinus containing hair and granulation tissue.
FISTULA-IN-ANO
A fistula-in-ano, or anal fistula, is a chronic abnormal communication, usually
lined to some degree by granulation tissue, which runs outwards from the
anorectal lumen (the internal opening) to an external opening on the skin of
the perineum or buttock (or rarely, in women, to the vagina).
• Anal fistulae may be found in association with specific conditions, such as
Crohn’s disease, tuberculosis, lymphogranuloma venereum,actinomycosis,
rectal duplication, foreign body and malignancy.
• However, the majority are termed non-specific, idiopathic
cryptoglandular, and intersphincteric anal gland infection is deemed
central to them.
Presentation
• usually complain of intermittent purulent discharge (which may be
bloody) and pain (which increases until temporary relief occurs
when the pus discharges). There is often, but not invariably, a
previous episode of acute anorectal sepsis that settled (incompletely)
spontaneously or with antibiotics, or which was surgically drained.
The passage of flatus or faeces through the external opening is
suggestive of a rectal rather than an anal.
Classification
• The most widespread and useful classification of anal fistulae is that
proposed by Parks, based on the centrality of intersphincteric anal
gland sepsis (the internal opening is usually at the dentate line), which
results in a primary track whose relation to the external sphincter
defines the type of fistula and influences management .
Categories of fistula-in-ano. (A) Low intersphincteric and
transsphinteric. (B) Ischiorectal and suprasphincteric.
• Intersphincteric fistulae usually have an external opening close to the
anal verge.Goodsall’s rule, used to indicate the likely position of the
internal opening according to the position of the external opening(s),
is helpful.
• Goodsall’s Law is a rough rule of thumb as to the likely course of
fistulous tracts. Thus, when the fistula opens on the perianal skin of
the anterior anus, the tract usually passes radially directly to the anal
canal. However, when the opening is posterior to a line drawn
between the 3 o’clock and 9 o’clock positions, the tract usually passes
circumferentially backwards to enter the anal canal in the midline (6
o’clock position).
Coronal magnetic resonance imaging scan

•
Coronal magnetic resonance imaging scan of complex
pelvirectal fistula (arrow
Surgical management
• Fistulotomy
• Fistulectomy
• Ligation of intersphincteric fistula tract(LIFT)
• Setons
• Anal cancer
• Anal cancer accounts for less than 1% of all new cases (UK) and is rare in comparison with colorectal
cancer.
• Clinical features and assessment
• Anal cancer is frequently misdiagnosed in the early stages because of its rarity and because symptoms
of benign anal conditions are highly prevalent. Anal verge tumours often present earlier than canal
tumours because the patient becomes aware of a mass or irregular area at the anal margin. Early cancer
may be confused with fissures, piles and warts. Anal tumours are readily accessible and detectable by
careful clinical examination; anal pain/discomfort, bleeding or discharge into the underwear, and
pruritus ani should be sought. Advanced tumours that have spread to the anal sphincters may present
with incontinence. Clinical examination of anal cancer at the margin reveals an ulcerated discoid lesion
at the anal verge. Anal canal cancer may not be visible, although extensive lesions may protrude to the
anal verge by direct spread. Examination under anaesthetic allows tumour biopsy and sigmoidoscopy.
Biopsy is essential to confirm the diagnosis, but also to determine the tissue of origin, as the treatment
for squamous carcinoma varies from that for adenocarcinoma.
The most severe degree of anal intraepithelial neoplasia
(AIN3), the precursor of most anal squamous cancer.
Squamous carcinoma of the anal verge.
Malignant melanoma of the anal canal
Rectal Prolapse
• Mucosal prolapse
• The mucous membrane and submucosa of the rectum protrude outside
the anus for approximately 1–4 cm.
• Full-thickness prolapse
• Complete rectal prolapse (synonym: procidentia) is less common than
the mucosal variety. The protrusion consists of all layers of the rectal wall
and is usually associated with a weak pelvic floor and/or chronic
straining. The prolapse is thought to commence as an intussusception of
the rectum, which descends to protrude outside the anus. The process
starts with the anterior wall of the rectum, where the supporting tissues
are weakest, especially in women. It is more than 4 cm and commonly as
much as 10–15 cm in length.
Mucohaemorrhoidal prolapse of the
anorectum.
Full-thickness rectal prolapse. The whole
bowel wall protrudes through the anus.
Laparoscopic ventral mesh rectopexy: