Common Office Anorectal Problems Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center
l None Disclosures
Benign Anal Rectal Disease l Anatomy of the anal canal and perianal spaces l Benign Anal Rectal Disease Abscess and Fistula Fissure Hemorrhoids
Overview of Anatomy l Anatomy Pelvic and Perirectal Spaces Anatomy of Anal Canal
Retrorectal Space Waldeyer s Fascia Supralevator Space Levator Ani Muscle Deep Postanal Space Superficial Postanal Space
ANAL CANAL Peritoneum Levator Ani m. Puborectalis m. Deep External Sphincter m. Internal Sphincter m. Transverse Septum Supralevator Space Ischioanal Space Intersphincteric Space Perianal Space
ANAL CANAL Anal Transitional Zone Column of Morgagni Dentate Line Anal Crypt Anal Gland Anoderm
Patient complaints Anal Pain Bleeding Drainage Time course Fissure Knifelike pain with BM Passing Glass Brick, Throbing Pain with BM:minutes to hours Blood on toilet paper No drainage Small tag or hemorrhoid Hemorrhoid Acute or Chronic Bleeding itching burning Sudden swelling, +/- pain Prolapse Difficulty with hygiene Pain rarely knifelike Abscess Generally Acute Minimal bleeding Pain Swelling over large area not associated with BM +/-Purulent Drainage Rapid increase in size
Diagnosis and Treatment of Anorectal Abscess and Fistula-in- Ano
Anorectal Abscess Etiology l Cryptoglandular abscess Most common Infection in the glands at the dentate line l Other causes Crohn s and Ulcerative Colitis Tuberculosis and Actinomycoses Malignancy Foreign Bodies, Prostate Surgery or Radiation
Fistula Description l Clock description Does the anus tell time? Relies on description of patient s position: supine, lateral, prone and relative landmarks l Anatomic description: more consistent Pubic bone defines anterior Coccyx define posterior Right and left *If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed." Confucius 1
Pubic bone Right anterior Left anterior Right Left Right posterior Left posterior Tailbone
l There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained
Abscess Classification l Four Types Based on Space Involved Perianal - 19-54% Intersphincteric - 20-40% Ischioanal - 40-60% Supralevator 2% or less Most Common Rare
Supralevator Abscess Intersphincteric Abscess Perianal Abscess Ischioanal Abscess
HORSESHOE ABSCESS Supralevator Space Intersphincteric Space Ischioanal Space
Anorectal Abscess Treatment of Perianal and Ischiorectal Abscesses l Diagnosis - usually straightforward Erythema and Pain over affected area Fluctuance l Treatment Incision and Drainage +/- Excision of small amount of overlying skin Initial packing for hemostasis Drainage catheter (Pezzer) or pack wound Attention to good hygiene and control blood sugar Antibiotics if immunocompromised, obese or diabetic
Small Radial incision Short distance from anus feel for soft spot Place drain and trim avoids packing Follow up in 7-10 days to remove drain
Catheter Types l Pezzer catheter l Solid mushroom top so stays in l Less tissue ingrowth l Malecot l Allows tissue ingrowth l More painful to remove
Peri anal abscess -? Antibiotics l Not usually indicated if there is adequate drainage l Indicated for patients with: Obesity Diabetes Imunocompromised Extensive large abscess or recurrent abscess
l Definition Fistula-in-Ano abnormal connection between two epithelial surfaces. l Classification: Parks: Defines fistula by course of tract Goodsall s rule l Diagnosis l Treatment Goals Options
How does patient present? l May have had a history of abscess l History of Crohn s disease l May present at the same time as abscess l Complain of intermittent increase in pain/ swelling followed by spontaneous drainage l Chronic localized area of irritation or ulcer pimple near my anus keeps coming back
Fistula-in-Ano Goodsall s Rule Posterior Anterior
Fistula in ano
Fistula in ano: Surgical disease l Refer to Colon and Rectal Surgeon or General Surgeon l Reassure patient rarely cancer, most do not need a colostomy l If suspect Crohns Gain control of perianal sepsis Then complete full workup and staging l Goals of therapy Get rid of the fistula/connection Preserve continence
Surgical Options l Primary fistulotomy Mainly for low, superficial fistula Risk of fecal incontinence l Fibrin Glue/Fistula Plug Utilizes substrate as scaffold to fill tract Does not involve cutting muscle l Cutting or draining setons For deeper tracts that involve significant muscle Risk of fecal incontinence l Rectal advancement flap l Lateral internal fistula transection Newer procedure. No foreign substrate Cuts fistula tract, not muscle
Fistula in ano
Fistula in ano
Fissure in Ano l Definition a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus Overlie the lower half of the internal sphincter ~73.5% are posterior ~16.4% are anterior ~2.6% both anterior and posterior
Fissure in Ano Pathogenesis l Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus l Secondary changes of chronic fissure include Sentinel pile or skin tag at the distal end Hypertrophied anal papilla-swelling, edema and fibrosis near the dentate line Fibrosis of the internal sphincter at the base
Fissure with Sentinel Tag
Fissure with Sentinel Tag
Fissure in Ano Pathogenesis l Perpetuating factors in chronic fissure Persistent hard bowel movement Abnormal high resting pressure in the internal anal sphincter Increased pressure in the sphincter causes a decrease in blood flow, preventing healing of the fissure
Fissure in Ano Symptoms l Pain is the main symptom Sharp, cutting or tearing during defecation Duration is few minutes to hours l Bleeding bright red and scant l Skin Tag l Mucous discharge resulting in itching
Fissure in Ano Diagnosis l Diagnosis often made on history alone l Inspection gently spread the buttocks and the fissure becomes apparent l Triad of chronic anal fissure Sentinel pile Hypertrophied anal papilla Anal ulcer
Fissure in Ano Differential Diagnosis l Intersphincteric abscess l Pruritus Ani l Fissure from inflammatory bowel disease l Carcinoma of the anus l Infectious Perianal conditions l Leukemic infiltration
Fissure in Ano Crohn s Anal Fissures
Acute Fissure in Ano Treatment l Increase dietary fiber l Local anesthetic to prevent spasm l Nitroglycerin or Nifedepine Ointment Not commercially available Must be mixed by pharmacist l Warm tub soaks l 4-6 weeks of treatment
Chronic Fissure in Ano Surgical Treatment l Indicated on Chronic non-healing anal fissure and fissure that is refractory to medical therapy Lateral Internal Sphincterotomy Forces the muscle to relax V-Y Anoplasty flap Allow coverage of fissure with healthy tissue
Hemorrhoids l What are they? l Where are they? l Why do they become symptomatic? l Classification? l How do you treat them? l Can they be avoided?
Hemorrhoids What are they? l Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissue l Aid in anal continence
Hemorrhoids Where are they? l Internal Hemorrhoids 3 major bundles left lateral, right anterior and right posterior Above the dentate line Blood drains into the superior rectal vessels then into the portal circulation l External Hemorrhoids Below the dentate line Blood drains through the inferior rectal veins to the pudendal veins on into the iliac veins
Hemorrhoids Symptoms? l Chronic constipation l Diarrhea l Trauma to the hemorrhoids during defecation cause the most common symptoms Pain generally not knife-like Itching Burning Bleeding
Hemorrhoids Classification- Internal Hemorrhoids l 1 st degree bulge into the lumen l 2 nd degree prolapse with bowel movement but reduce spontaneously l 3 rd degree prolapse spontaneously and require manual reduction l 4 th degree permanently prolapsed hemorrhoids that cannot be reduced
4 th Degree Hemorrhoids
Hemorrhoids Treatment Principles l Thorough physical exam to determine severity and rule out other pathology Refer for surgical evaluation if white or discolored, firm or fixed l Determine if the problem is internal, external or both l Assess the symptom complex
Treatment l Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream l Conservative therapy Bulk agents i.e. high fiber Fruits, vegetables, oat bran, psyllium Increase water intake Avoid caffeinated beverages Avoid prolonged sitting on the commode Warm tub soaks
Treatment Office and Minor Procedures l Rubber band ligation Performed in the office Indicated for Grade 1 and 2 internal hemorrhoids Band is applied through an anoscope at the top of an internal hemorrhoid Severe perianal sepsis Classic Triad Delayed anal pain Urinary retention Fever
Treatment Office and Minor Procedures l Infrared Photocoagulation Indicated in 1 st degree hemorrhoids Causes photocoagulation of small vessels Performed in office or Hemorrhoid Relief Center Minimal pain
Closed Hemorrhoidectomy Indication l Hemorrhoids are severely prolapsed and require manual replacement l Patients fail to improve after multiple applications of non-operative treatment l Hemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags
Closed Hemorrhoidectomy General Principle l Most can be performed with local and IV Sedation l Prone/Kraske position is the best l Infuse the area with local anesthetic with epinephrine for hemostasis l Fleets enema 1-2 hours prior l No antibiotic prophylaxis is necessary
Closed Hemorrhoidectomy
Closed Hemorrhoidectomy
Closed Hemorrhoidectomy Post op Result
PPH Stapling Procedure for Hemorrhoids l Not for every hemorrhoid l Ideal for Grade 2 and 3 with minimal external component l Prevents prolapse and thus less trauma to hemorrhoid with bowel movement
PPH Stapling Procedure for Hemorrhoids
PPH Stapling Procedure for l Benefits Hemorrhoids Less pain as compared to traditional closed hemorrhoidectomy Less blood loss during the procedure Less chance of anal stenosis
PPH Stapling Procedure for Hemorrhoids l Risks If staple placed too low severe chronic pain and incontinence If staple line placed too high failure to relieve symptoms of hemorrhoids Hemorrhoids are not removed so they may continue to bleed Perianal sepsis Rectovaginal fistula
Perianal Condyloma l Can sometimes be difficult to distinguish from hemorrhoids l Cauliflower type appearance l History of HIV, History of abnormal pap smear l Homosexual males usually but can be seen in the heterosexual population l Caused by HPV virus l Increased risk of anal cancer in the immunocompromised patient
Treatment - Topicals l Aldara (Imiquinod) >50% initial response l Topical 5-FU 90% initial response l Condylox (podofilox) l Each have high local toxicity l Practice Parameters for Anal SquamousNeoplasms www.fascrs.org
Treatment l Photodynamic therapy l Wide Local Excision l Targeted destruction with cautery and/or Infrared coagulation l Observation of AIN I/II with removal of visualized lesions l Excision of AIN III
Anal Squamous AIN l High recurrence rate with all techniques l Close follow up to detect progression to invasive carcinoma l Anal pap smear vs high resolution anoscopy l Optomize underlying conditions
?