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Anorectal Procedures. Dr Justin Bailey MD, FAAFP AAPCE Nov 2015. Procedural treatment of …. Thrombosed Hemorrhoids Internal and External Hemorrhoids Anal fissures Anal/perianal condyloma Pilonidal cysts. Thrombosed External Hemorrhoid.
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Anorectal Procedures Dr Justin Bailey MD, FAAFP AAPCE Nov 2015
Procedural treatment of … • Thrombosed Hemorrhoids • Internal and External Hemorrhoids • Anal fissures • Anal/perianal condyloma • Pilonidal cysts
Thrombosed External Hemorrhoid 45 y/o male with extreme pain, difficulty sitting down Symptoms started 24 hours ago
External treatment • Incision and Drainage • Excision • Timing 48-72 hours,
External Hemorrhoid Tags 34 y/o MSM would like a cosmetically concerning anal skin tag to be removed
External Hemorrhoid Tags • Symptomatic treatment • Cleaning • “1 soft, easy-to-pass bowel movement a day” • Fiber, Miralax, Colace • Topicals- Analgesics, Anti-inflammatory, Antispasmodics, Sitz • Excision • Don’t take off things that don’t need to come off.
Excision of External Tag • Lidocaine with Epi 3-5 cc • 27-30 gauge needle • Ligation • Excision
Internal Hemorrhoids 29 y/o male painless bleeding -especially after his wife had a baby and he ate a lot of ramen and cheese quesadillas Blood on toilet paper and stool. Can sometimes feel something coming out that usually goes back in.
Internal Hemorrhoid TX • Rubber banding • Infrared Coagulator • Sclerotherapy • Laser, Cryo • Complications
Anal Fissure 42 y/o male with rectal bleeding and pain with every bowel movement “like crapping a piece of glass” Frequent Constipation Pain lasts for 1-2 hours after bowel movement
Anal Fissure • Relaxation of internal sphincter • Atraumatic passage of stool • Pain Relief • Sitz baths, Fiber, topical anesthetic creams
Anal Fissures • Topical • Nitroglycerin (58-70%), Diltiazem (70%), Bethanecol • Orals • Nifedipine (60%), Diltiazem (38%) • Injectable • Botox injection (73%-95) • Surgical • Lateral Sphincterotomy (95% healing, 45% with transient incontinence, 6-30% long term) • Dilation • Lords
The Anal Pap 21 y/o HIV + MSM who presents with anal condyloma.
Anal Pap • Anal carcinoma 100/100,000 • High Risk • MSM, HIV +, Immunosuppressed, Women with High Grade CIN, or Cancer, Anal warts • Progression 1/377/ yr in HIV +, HPV+ • LGSIL regression common, HGSIL rare regression
Anal Pap • 3 forms • Subclinical HPV+ • HGSIL on High Resolution Anoscopy • Anal Condyloma • 20% of HIV+ MSM males + path (15% lgsil, 5% hgsil), 50% of MSM are +HPV • HIV+ women, with anal receptive intercourse similar rates • Progression HIV, Low CD4, high risk HPV • HGSIL low rate of regression • HGSIL to anal carcinoma 5 years
anal pap • Usually asymptomatic • Screening suggestions • >30 in HIV+ • >40 in immunocomopent • ? HG vaginal SIL, Anal Condyloma • No USPSTF • HIV Medical Association of the Infectious Diseases Society of America • Weak recommendation based on moderate quality evidence for screening with anal cytology in MSM, women with a history of receptive anal intercourse or abnormal cervical Pap test results and those with genital warts
How to • Left Lateral Side- damp non-cotton swab inserted to resistance. • Standard vs liquid prep • If positive then • High Resolution Anoscopy
HRA • Anascope • Colposcope • 4x4 acetowhite • Biopsy
IF postive Tx • Chemical- Immiqimod, Flourouracil (20-30% effective) • Ablation • Infrared coagulation (40-60%) • Anoscopy lesion ablation (30-50%)
Perianal Warts 45 y/o female with large volume perianal wart Hygiene difficult Can be painful
Anal Condyloma • Topical- • Irritants -Podophylin (20-50%), TCA( 20-50%), 5FU+epinephrine (50%) • Immunomodulators- Immiquimod 40-70%, Interferon Alpha (25-80%) Sinecatechins (55%) • Surgery • Cryo (63%-92%) • Infrared Coagulation (61%-74%) • Laser Therapy (100%, reoccurrence 45%) • Excision (36%)
Pilonidal Cysts 24 y/o overweight male presents to the ER with painful abscess at the top of his gluteal fold. Has had once before.
Pilonidal Cysts • Cause • Basic Treatment • I&D • Currette • Advanced?
