CPC/PMQ:

ANORECTAL
CONDITION
Anatomy of Anal Canal
 Anal canal: Location
■ Is the terminal part of
alimentary canal
■ Extends from the ano-
rectal junction to the Rectum
anus
■ Begins when the rectal Pelvic
diaphragm
ampulla narrows at the
level of puborectalis
sling
Ano-rectal
junction
■ Anus: surface opening
of anal canal

Anal canal
Anterior view
 Anal canal

■ Is directed
downwards &
backwards
■ About 3.8cm
long
■ Guarded by
sphincters
■ Canal is Rectum
collapsed except
during passage Posterior
of feces
Anterior
■ Most of anal canal
lies below the Anal
pelvic diaphragm
canal
Anus
Lateral view
 Anal canal: Internal
Features
4) Intersphincteric groove
(Hilton’s white line)

■ Corresponds to junction
between internal &
external anal sphincter
beneath it

■ A groove that is palpable

at physical examination
Inter-
sphincteric
groove
 Anal canal: Internal Features
Pectinate line
Anorectal
■ An imagenary transverse junction
line formed by anal
valves
■ Situated opposite to the
middle of internal anal
sphincter Superior
part
■ An important clinical
landmark
Pectinate
■ Pectinate line divides the line
anal canal into 2 parts:
Inferior
1) Superior part of anal part
canal

2) Inferior part of anal

canal Anterior view
 Anal canal: Internal Features
Superior part of anal
canal
■ Derived from hindgut
endoderm (visceral part)
Superior
part
Inferior part of anal
canal
■ Derived from
ectoderm (somatic part)
Inferior
part

Anterior view
 Anal Canal

■ The superior & inferior

parts of anal canal has
different
embryological origins,
therefore they differ in Superior
their: part

1) Innervation
2) Arterial supply
3) Venous drainage Inferior
part
4) Lymphatic drainage

Anterior view
 BLOOD SUPPLY &
INNERVATION OF ANO-
RECTAL CANAL
 Arterial Supply of Anal Canal
Superior Rectal a.
■ Supplied by:

1) Superior part of
anal canal
■ Supplied by
superior rectal
artery

2) Inferior part of
anal canal
• Supplied by inferior
rectal artery
Inferior
rectal a.
Venous Drainage
Blood drain into

Rectum 1) Superior rectal vein → inferior mesenteric

vein → hepatic portal vein

2) Middle & inferior rectal vein → internal

iliac vein

Sup. Superior rectal vein → inferior mesenteric vein

part → hepatic portal vein
Anal
canal Inf. part Inferior rectal vein → internal iliac vein
Venous Drainage: systemic venous system
IVC

■ Middle & inferior

rectal veins drain
into internal iliac
vein → common
iliac vein →
inferior vena cava Internal
(systemic venous iliac v.
system)
Middle
rectal v.

Internal
pudendal v.

Inferior rectal v.
Venous Drainage:
anastomosis

■ In wall of anal canal, Sup.

rectal v.
anastomoses occur
between:

1) Superior rectal vein

(portal venous system) Anastomosis

Middle
rectal v.
2) Middle and inferior
rectal veins (systemic
venous system)
Inferior rectal
v.
■ This is one of the area
of portal-systemic
(portal caval)
anastomosis
 Innervation: rectum & superior part of
anal canal
Rectum & superior part of anal
canal are innervated by visceral
innervation (autonomic nervous
system)
Pelvic
splanchni
■ Thus, they are innervated by: c n.

1) Sympathetic fibres
2) Parasympathetic fibres
3) Visceral afferent fibres (sensory)
• Sensitive to stretching (eg:
distension)
• Not sensitive to pain, Inferior
touch & temperature hypogastric
plexus

Anterior Posterior
Lateral view
 Innervation – Inferior Part of Anal Canal
■ Inferior part of anal
canal has somatic
innervation

■ It is supplied by the
inferior anal (rectal)
nerves, branch of
pudendal nerve

■ Inferior part of anal Pudendal

canal is sensitive to n.
pain, temperature &
touch
Inferior anal n.

Anterior Posterior
Lateral view
Innervation
Sympathetic Parasympatheti Afferent nerve
nerve fibres c nerve fibres fibres (sensory)
Rectum & From L1&L2 S2-S4 → pelvic follow
superior → splanchnic splanchnic parasympathetic
part of anal nerve → nerves → fibres retrogradely to
canal Hypogastric hypogastric the S2 – S4
(visceral plexus plexus
innervation)

Inferior
part of anal Inferior anal (rectal) nerves, branch of pudendal nerve
canal
(somatic Sensory - sensitive to pain, temperature & touch
innervation)
 Lymphatic Drainage of ano-rectal canal
Drain into Inferior
mesenteric
LN
1 Superior ½ Inferior
rectum mesenteric
LNs

2 Inferior ½ Inferior Internal

rectum mesenteric iliac LN
3 Superior & internal
part of anal iliac LNs
canal
Inguinal
4 Inferior part Inguinal LN
of anal LNs
canal
Differences between Superior & Inferior Parts of
Anal Canal
Features Superior part Inferior part

1 Mucosa Has anal column No anal column

2 Arterial Superior rectal artery Inferior rectal artery

supply
3 Venous Superior rectal vein Inferior rectal vein
drainage
4 Lymphatic Internal iliac nodes Superficial inguinal
drainage nodes
5 Nerve Visceral innervation Somatic innervation
supply (autonomic nervous (inferior anal nerve)
system)
References
1. Clinically Oriented Anatomy. 6th edition. 2010. Keith L. Moore, Anne M. R. Agur
& Arthur F. Dally. Lippincott Williams & Wilkins.
2. Atlas of Human Anatomy. 5th edition. 2011. Frank H. Netter. Saunders Elsevier.
3. Clinical Anatomy by Regions. 9th edition. 2012. Richard S. Snell. Lippincott
Williams & Wilkins.
 Anal cancer

Name: Nurul Ainie binti Ideris

Introduction
• Anal cancer accounts for less than 1% of all new cases
• rare in comparison with colorectal cancer.
• Most patients present in the sixth or seventh decade,
• but younger cases are well recognised, particularly in those with HIV
and high risk activities.
 Histological Types of Anal Cancer
• Over 85% of anal cancers are squamous = Those arising below the dentate line are usually squamous.
• those above are variously termed basaloid, cloacogenic or transitional. Collectively they are known as epidermoid
carcinomas, and account for >70% of anal malignancies; management and prognosis is similar for this group.
• Around 5% of tumours are adenocarcinomas arising from the glandular epithelium of the upper anal canal or rarely from
the intersphincteric space anal glands.
• Other rarer tumours include melanoma, lymphoma and sarcoma.
Risk factor
1. Human papilloma virus (HPV) infection - strongly associated with
HPV types 16 and 18.
2. Smoking
3. Anogenital warts
4. Immunosuppressive state - HIV infection , organ transplantation
5. The premalignant lesion= anal intraepithelialneoplasia (AIN) ; the
precursor of most anal carcinomas
Clinical features
• Pain
• Bleeding
• Mass
• Pruritus
• Discharge

• Anal cancer is frequently misdiagnosed in the early stages due to:

• Its rarity
• symptoms of benign anal conditions are highly prevalent.

• Early cancer may be confused with fissures, piles and warts.

• Advanced tumours may cause:

• Faecal incontinence by invasion of the sphincters
• Anovaginal fistulation - anterior extension (in women)
Clinical assessment
• Anal margin cancer may reveals an ulcerated discoid lesion
at the anal verge.
• Anal canal cancer
• may not be visible, but extensive lesions may protrude to the
anal verge by direct spread.
• palpable as irregular indurated tender ulceration.
• There may be associated HPV lesions.

• Examination under anaesthetic allows tumour biopsy and

sigmoidoscopy.
• Essential to confirm the diagnosis, to determine the tissue of
origin, as the treatment for squamous carcinoma varies from
that for adenocarcinoma.
Staging
• Initial staging involves
• clinical examination
• biopsy of the primary tumour
• examination of inguinal nodes

• Local staging - to assess lungs and abdomen for metastatic spread.

• MRI scanning and CT

• Important for both prognosis and guiding treatment approaches

(TNM staging)
Management

1. Chemoradiotherapy

• Current primary treatment (combined modality therapy (CMT); Nigro)

• Chemotherapy usually include a combination of 5-fluorouracil (5-FU)
with mitomycin C or cisplatin.
• Newer radiotherapy regimens, combined with capecitabine and
cisplatinum, are being introduced
• In case of metastases are rare at presentation (5%) and treatment is
aimed at local control.
• Initial staging involves a clinical examination and biopsy of the primary tumour as well as
examination of inguinal nodes.
• Local staging is by MRI scanning and CT isused to assess lungs and abdomen for
metastatic spread.
2. Surgery
Considered if :
• tumor is small and can be easily removed - local excision
• chemoradiation is not favorable - abdominoperineal excision of
the rectum
Other anal malignancies
• Adenocarcinomata - usually extensions of distal rectal cancers.
• Rarely, adenocarcinoma may arise from
• anal glandular epithelium
• develop within a longstanding (usually complex) anal fistula;

• Treatment is as for low rectal cancers :

• (i.e. abdominoperineal excision of the rectum (APER) with or without
previous radiotherapy or chemoradiotherapy)
• but prognosis is less good.
Reference
 ANAL WARTS
(CONDYLOMATA
ACCUMINATA )

SHAHIRA ISMAIL
046503
 INTRODUCTION
• Also known as condylomata acuminata or venereal warts,
is one of the most common types of sexually transmitted
infection.
• The disease usually cause by human papilloma virus,
genotypes 6 or 11, which normally are not involved with
cancers but can cause abnormal pap smear.
• Associated warts on the penis and along the female genital
tract are common.
• In women, they can appear on the vulva, walls of vagina, perianal area and cervix.
• In men, may be found at tip or shaft of penis, scrotum or anus,
• There are over 170 subtypes of HPV, but certain subtypes (16, 18, 31, 33) are
associated with a greater risk of progression to dysplasia and malignancy.
• Squamous cell carcinoma (SCC) is associated with HPV (especially subtypes 16, 18,
31 or 33).
CLINICAL
CLINICAL
FEATURES
PRESENTATION
AND
Normally can be asymptomatic
SYMPTOM
Pruritus, discharge, bleeding and pain are usual presenting complaints
S Bumps near or inside the anal opening that are usually light brown or skin-colored
Growths resembling small cauliflowers around the anus
Mucus-like discharge from the bumps
Sores
The sensation of having a lump or something similar in the anal area
 ON EXAMINATION
• Anoscope used to view the anal canal and see if any warts are present.
• During early stages, examination reveals separate pinkish-white warts
close to the anal margin and also often on the anoderm within the distal
anal canal.
• Later, the warts enlarge, coalesce and carpet the skin.
• The diagnosis is aided by aceto-whitening upon application of acetic
acid but confirmed by biopsy, which will also indicate the presence or
absence of dysplasia.
 TREATMENT
• Treatment options for anal warts depending on their number, size and any
symptoms
• If symptoms such as rectal bleeding or sores are mild or if the warts are relatively
small, a doctor may prescribe a topical medication to kill the warts.
• Examples of these treatments:
• Imiquimod 3.75% (Zyclara) or 5% (Aldara) cream
• Podofilox 0.5% solution or gel (Condylox)
• Sinecatechins 15% ointment (Veregen)
• Careful serial application of 25% podophyllin to discrete warts on the perianal
skin .
• However, it cannot be used intra-anally
• Surgical excision under local, regional or general anaesthesia
• Effective for larger warts that don’t respond to treatment or for anal warts inside
anal
• Cryotherapy
• Electrocautery
• Laser treatments
PREVENTION
• HPV vaccine
• Using barrier methods such as condom
• Limiting number sex of partners
43

RECTAL PROPLASE
 44

INTRODUCTION
• Distressing condition that can affect both children and adults.
• The term rectal prolapse encompasses three types:
1. Full-thickness rectal prolapse (procidentia) includes the mucosa and the muscular
layers.
2. Mucosal prolapse: involves only the mucosal lining of the rectum.
3. Occult rectal prolapse : rectal wall intussusception but without the prolapse protruding
through the anus.
• This also refers to the much rarer condition of solitary rectal ulcer syndrome characterized by
a full-thickness prolapse of the anterior rectal wall only.
 45

PATHOGENESIS
• The majority of cases of full-thickness rectal prolapse occur
in elderly women, with no obvious etiological basis.
• Weight loss in the elderly with loss of fat supporting the
rectum, combined with degeneration of collagen fibers
and weakness of the musculature of the pelvic floor 🡪 in
loss of the anorectal angle and laxity of the rectal wall.
• In many cases, there is a deep rectovaginal pouch with a
long loop of sigmoid colon that pushes down into the
rectovaginal pouch and contributes to the prolapse.
46

PREDISPOSING FACTOR
• Chronic constipation and straining at stool are the commonest etiological
factors in young adults
• Spinal injury, psychiatric illness, multiple sclerosis and spinal tumor can
predispose.
• In children, the lack of a sacral hollow, combined with constipation and
excessive straining at stool 🡪 evagination of the rectum and prolapse
protrusion through the anus.
• In children with cystic fibrosis, excessive coughing increases intraabdominal
pressure
 CLINICAL FEATURES
47

• Sensation of ‘something coming down’ the back passage (Initially on

defecation🡪 constant prolapsed of rectum 🡪 not reduce spontaneously).
• The patient may be able to reduce the prolapse digitally.
• Constipation is usually an accompanying feature.
• There is often fecal incontinence and mucous discharge.
• Blood-stained mucus is common when the rectum remains prolapsed.
• The prolapse may become ulcerated and strangulated.
• In extreme cases🡪 associated uterine prolapse, alluding to the underlying
etiology relating to weakness of the entire pelvic floor.
 48

CLINICAL ASSESSMENT
• Digital examination: patulous anus, poor sphincter tone and
evidence of a weak pelvic floor on straining.
• Rigid sigmoidoscopy will reveal cases of occult prolapse.
• If the history is short, consideration should be given to the
presence of a spinal tumour, a spinal stenosis or a prolapsed
intervertebral disc.
• In occult rectal prolapse, radiological assessment using a
defaecating proctogram or dynamic MRI may secure the
diagnosis.
• Conditions that might be mistaken for a rectal prolapse:
large fourth-degree hemorrhoids, prolapsing rectal neoplasia,
anal warts, skin tags, inflammatory bowel disease and
MANAGEMENT
49

1. Childhood rectal prolapse:

• Maintaining a regular bowel habit with stool softeners, combined with digital reduction
of the prolapse by the parents.
• The condition is self-limiting and surgery is rarely indicated.
2. Mucosal rectal prolapse:
• Submucosal injection of sclerosant, by photocoagulation or by applying Barron’s bands
to the prolapsed area.
• In resistant cases, a limited excision of the area, similar to a hemorrhoidectomy, is
effective.
• Stapled anorectal rectopexy has gained favor in some centers
3. Full thickness rectal prolapse:
• Perineal
50 approaches : to fixate or excise the prolapse surgically
from below.
- Delorme’s procedure involves the excision of the mucosa lining
the prolapse, with plication of the muscle tube.
- Perineal proctosigmoidectomy entails excision through the anus
of the prolapsed rectum and lower part of the sigmoid.
- The latter may be combined with a repair of the pelvic floor
(Altmeier procedure).
• Abdominal approaches: to mobilize the rectum to the pelvic floor
safe-guarding the pelvic nerves and blood vessels and to fix the
rectum to the bony pelvis using sutures or foreign material (mesh).
- Include resection of the redundant sigmoid colon, particularly
when constipation is a predominant feature, because rectal
fixation usually aggravates the constipation.
51
PILONIDA
L SINUS
MUHD IZZAT
046426
 INTRODUCTION

A condition found in the natal cleft overlying the coccyx, consisting 1

or more, non-infected (usually), midline openings which communicate
with a fibrous track (lined by granulation tissue) and containing hair
(lying loosely within the lumen).
Common affliction amongst the military, referred to as ‘Jeep disease’
 AETIOLOGY AND PATHOLOGY
Evidence to supports the theory of the origin of pilonidal sinuses as acquired (compared
to congenital theories):
o Interdigital pilonidal sinus – an occupational disease of hairdressers (the hair
within the interdigital cleft being the customers.
• Pilonidal sinuses of axilla and umbilicus has also been reported.
o The age incidence of the appearance of pilonidal sinus (82% occur between the
ages of 20-29 years)
o Hair follicles have almost never been demonstrated in the walls of the sinus
o The hairs projecting from the sinus are dead hairs 🡪 their pointed ends directed
towards the blind end of the sinus
o Recurrence is common
• The combination of buttock friction and shearing
forces – allows shed hair or broken hairs which
have collected there to drill through the midline
skin.
• Or that infection in relation to a hair follicle allows
hair to enter the skin by the suction (created by
movement of the buttocks) – creating a
subcutaneous, chronically infected, midline tract.
• From this primary sinus – secondary tracks may
spread laterally 🡪 may emerge at the skin as
discharging openings (granulation tissue-lined).
 CLINICAL FEATURES
▪ More frequently in men,
usually after puberty and before
the fourth decade of life
▪ Seen in dark-haired individuals
rather than those with softer
blond hair
▪ Patient complain of intermittent
pain (finds some relief by lying
prone), swelling and discharge
at the base of the spine
▪ Often a history of repeated
abscess – burst
spontaneously or which have
been incised
▪ The primary sinus may have
1 or many openings – strictly
in the midline between the
level of the sacrococcygeal
joint and the tip of the
coccyx
▪ Commonest site:
Interbuttock sacral region.
 CONSERVATIVE TREATMENT

As the natural history of the condition is usually one of

regression – in those whose symptoms are minor 🡪 a simple
cleaning out of the tracks and removal of all hairs (regular
shaving of the area) and strict hygiene are recommended
 DEFINITIVE TREATMENT
▪ In acute phase initially – drainage of the abscess and antibiotic; later definitive
treatment is undertaken
▪ Definitive treatment:
o In prone position (jack knife position) – excision and primary closure is
done under GA or LA. All sinus tracks, unhealthy granulation tissues with
hairs are removed completely. Methylene blue is injected to demonstrate
the multiple tracks properly
o Excision and skin grafting – has got high recurrent rate
o Excision with Z plasty – good result
o Excision with multiple Z plasty
o Karydakis excision through a semilateral incision and lateralized suturing
of the wound away from the midline gives good result
▪ Definitive treatment:
o Excision with closure using Limberg (Rhomboid)
buttock flap (single or double rhomboid flaps) –
good result
o V-Y gluteal advancement flap
o Bascom technique of excision through lateral
approach (good method)
o Lahey and Cattell’s relaxing skin incisions on one
buttock to relieve tension on main wound sutures
with later closure of secondary wound s by sutures
or advancement
▪ Definitive treatment:
o Davies and Starr buttock skin flap rotation into the defect and secondary
defect is closed at a later period
o After excision of entire sinus completely, wound is left open to granulate and
heal by epithelialisation with regular dressings
o Buie’s marsupialisation of the sinus track – after making incision on the sinus
track, edge of the laid opened area is sutured to the skin edge all round using
silk or vicryl. This reduces healing time and promotes healing
o Lord and Millar’s limited excision of primary track for 0.5cm depth with
removal of tuft of hairs, debris and unhealthy granulation tissue using tiny
brush and nylon bristle
o Injection of phenol to the track destroys the epithelium after removal of the
tufted hairs
• Irrespective of procedure,
postoperative wound care is
important and centres around
elimination of hair (ingrown,
local or other) from the wound
 RECURRENT PILONIDAL SINUS
▪ Three possibilities for this recurrent:
o Part of the sinus complex has been overlooked at the primary
operation
o New hairs enter the skin or the scar
o There is persistence of a midline wound cause by shearing forces and
scarring

▪ In this situation - revisional surgery may include re-excision followed by

wound closure and obliteration of the natal cleft (either by
myocutaneous rotational buttock flap or cleft closure (Bascom)).