Benign Rectal, Anal, and Perineal Problems

1. Dr Ali Abuseini FRCS Ed Benign Rectal, Anal, and Perineal Problems

2. Benign Rectal, Anal, and Perineal Problems Anatomy • Dentate line divides the rectal mucosa, which is generally insensitive and is lined with columnar mucosa, from the anoderm, which is highly sensitive (because of somatic innervation) and lined with modified squamous mucosa.

3. Benign Rectal, Anal, and Perineal Problems Anatomy (continue) • The anal canal is surrounded by two muscles - Internal sphincter innervated by autonomic nervous system, maintaining resting anal tone and under involuntary control - External sphincter innervated by somatic nerve fibers, generates the voluntary anal squeeze and plays the key role in maintaining anal continence

4. Benign Rectal, Anal, and Perineal Problems Anatomy (continue) • The areas surrounding the anorectum is divided into four spaces - Peri-anal - Ischioanal - Supralevator - Intersphincteric (intermuscular)

5. Hemorrhoids • Fibro-muscular cushions that line the anal canal • Classically found in three locations - Right anterior - Right posterior - Left lateral - Small secondary cushions may be found lying between the main cushions

6. Hemorrhoids • They are part of normal anal anatomy • Play role in normal mechanism of fecal continence, they get engorged during straining or performance of Valsalva maneuver, which completes the occlusion of the anal canal and prevents stool loss with none defecatory straining

7. Hemorrhoids • Broadly classified as - Internal proximal to dentate - External distal to dentate, redundant folds of peri-anal skin, usually asymptomatic unless thromboses

8. Hemorrhoids

9. Hemorrhoids Internal Hemorrhoids Disease • Manifested by two main symptoms - Painless Bleeding - Protrusion (Pain is rare as they originate above dentate line) • Most popular etiologic theory states that Hemorrhoids result from chronic straining at defecation • Continued straining causes engorgement and bleeding, as well as hemorrhoidal prolapse

10. Hemorrhoids Internal Hemorrhoids Disease (continue) • Grades - Grade 1 Bleeding without prolapse - Grade 2 prolapse that spontaneously reduce -Grade 3 prolapse necessitating manual reduction - Grade 4 irreducible prolapse

11. Hemorrhoids Internal Hemorrhoids Disease • History - Bleeding - Protrusion - Chronic Constipation (extensive bathroom readers) • Physical examination - Visual inspection may reveal prolapsing hemorrhoidal tissue appearing as rosette of three distinct pink-purple hemorrhoidal groups - If no prolapse, anoscopy reveals redundant anorectal mucosa proximal to dentate line in the classic locations

12. Hemorrhoids Internal Hemorrhoids Disease Management • Ranges from (depending on hemorrhoid grade) Reassurance to operative hemorrhoidalexcision

13. Hemorrhoids Internal Hemorrhoids Disease / Management Therapies classified into three categories • Diet and lifestyle modification • None operative and office procedures • Operative hemorroidectomies

14. Hemorrhoids Internal Hemorrhoids Disease / Management (1)Diet and life style modification • All patients grade 1 or 2 and most patients with grade 3 • Correct constipation • High fiber diet • Liberal water intake • Fiber supplement • Sitz bath (soothing effect ability to relax anal sphincter) • Topical creams

15. Hemorrhoids Internal Hemorrhoids Disease / Management (2)None operative and office procedures • If diet and life style modification are not effective • Rubber band ligation • Ligation of hemorrhoid with elastic bands • Successful in 2/3 to 3/4 in patients with grade 1 or 2 - Complications - Bleeding - Pain - Thromboses - Perianal sepsis (pain, fever, difficult urination)

16. Hemorrhoids

17. Hemorrhoids Internal Hemorrhoids Disease / Management (2)None operative and office procedures • Infrared coagulation applied to apex of each hemorrhoid at top of anal canal • Infrared radiation coagulates tissue protein and evaporates water from cell • Extent of tissue destruction depends on intensity and duration of the application • Not effective in treating large amount of prolapsing tissue, most useful for grade 1 and small grade 2 hemorrhoids

18. hemorrhoids Internal Hemorrhoids Disease / Management (2)None operative and office procedures • Sclerotherapy • Less popular nowadays • Injection of sclerosant into anorectal submucosa to decrease vascularity and increase fibrosis (injection at apex of hemorrhoids at anorectal ring) • Agents used (phenol in oil, sodium morrhuate, and quinine urea)

19. Hemorrhoids Internal Hemorrhoids Disease / Management (3) Operative Hemorrhoidectomies • Reduction of blood flow to anorectal ring • Removal of redundant hemorrhoidal tissue • Fixation of redundant mucosa Procedures • Hemorrhoidectomy • Stapled Hemorrhoidectomy

20. Hemorrhoids External Hemorrhoids • Asymptomatic except when secondary thrombosed • Thrombosis may result from defecatory straining or extreme physical activity or may be random event • Patient presents with constant anal pain of acute onset • Physical examination identifies external thrombosis as purple mass at anal verge • Management - Depends on patients symptoms - In the first 24 – 72 hours after onset, pain increase and excision is warranted - After 72 hours, pain generally diminishes

21. Hemorrhoids External Hemorrhoids • If operative treatment is chosen, entire thrombosed hemorrhoid has to be excised • Incision and drainage of clot shouldn’t be done as this can lead to re-thrombosis and exacerbation of symptoms

22. Anal Fissure • Tears or splits in the anoderm just distal to dentate line • Acute or chronic • Acute fissures are caused by mechanical force generated by the passage of large bowel movement through an anal canal that is too small to accommodate it safely and easily (though they can be caused by diarrhea) • Posterior midline 90% of fissures in females, and 99% of those in males

23. Anal Fissure • Decreased blood flow or increased mechanical stress may account for the propensity of these fissures to occur at this location • Repeated injury (hard or watery bowel movement ) may result in development of chronic fissure

24. Anal Fissure Clinical Evaluation Symptoms • Pain (knife like or tearing sensation) • Bright red rectal bleeding after bowel movement, minor and seen on toilet paper • Associated with anal spasm that persist for several hours after each bowel movement

25. Anal Fissure Clinical Evaluation Physical Examination • Difficult , extremely tender anus • Split in anoderm, about 1 cm long, in posterior midline just distal to dentate line • In chronic fissure • Classic triad - Hypertrophy of anal papilla - Anal fissure - Sentinel skin tag (with exposed internal anal sphincter muscle at base of fissure)

26. Anal Fissure • Multiple fissures or fissures that occur away from anterior or posterior midline, should raise suspicions that other problems may be present

27. Anal Fissure Management Acute anal fissure • History less than 4 – 6 weeks • None operative - Fiber supplement - Stool softeners - Generous water intake - Sitz bath - Local anesthetic ointment Rapidly alleviate symptoms and bring about complete healing

28. Anal Fissure Management Chronic anal fissure • Longer than 4 – 6 weeks • Respond less to none-operative measures • Surgical procedure of choice lateral internal anal sphintrotomy • Cure in 95 -98% • Complications - Incontinence to flatus 0 – 18% - Soiling 0 – 7% - Fecal incontinence 0 – 0.17%

29. Anal Fissure Management Therapeutic alternatives • Topical Nitroglycerin (cause neurogenic relaxation of internal sphincter( • Nifedipine gel or ointment (reduce local demand for O2 and mechanical contraction of the muscle • Topical Diltiazem • Botulinum Toxins (from clostridium botulinum) eliminate spasm and contraction of sphincter

30. Anorectal Abscess Pathophysiology • Most anorectal abscesses are of cryptogenic • They begin as infections in the anal glands that surrounds the anal canal and empty in the anal crypts at the dentate line • The ducts leading to and from glands become obstructed by feces or traumatized tissue, the secondary infection develops and follow the path of least resistance

31. Anorectal Abscess Clinical Evaluation • Categorized according to space in which they occurPeri-anal, Ischioanal, Supralevator, Intersphincteric (intermuscular) • Perianal abscesses are the most common, together with ischioanal abscesses account for 90% of perianal infections • Presentation (Pain, fever, chills, malaise, s/t systemic toxicity)

32. Anorectal Abscess

33. Anorectal Abscess Clinical Evaluation Examination • Fluctuant, erythematous, tender area in the perineum or perianal area • In case of supralevater or intersphenteric abscesses, there may be no external manifestations, however, digital rectal examination may reveal tender mass above anal canal Management • Adequate Drainage

34. Fistula in Ano • Communication between anal canal and anal skin • Usually begins in a crypt at the dentate line and follows a course either between the internal and external sphincters (the most common location) resulting in ischioanal abscess, or above sphincter leading to supralevator abscess • After abscess drainage (one of three possibilities) - Fistula heals spontaneously OR - Abscess heals to recur in the future OR - Abscess heals but chronic draining fistula remains

35. Fistula in Ano Clinical Evaluation • After drainage of Abscess, fistula is usually associated with chronic serosanguinous to seropurulent discharge • As long as fistula remains open and draining, patient report little pain • If fistula close externally, abscess may develop • Physical Examination reveals 2 – 3 mm opening in the perianal skin, with surrounding induration • Fistula tract can be palpated as firm cord between external opening and anal canal

36. Fistula in Ano Clinical Evaluation • The relation ship between external opening to internal opening is suggested by Googsall’s rule

37. Fistula In Ano Clinical Evaluation • Fistulas are classified into four categories according to their relation to anal sphincter - Intersphincteric - Trans-sphincteric - Supra-sphincteric - Extra-sphincteric

38. Fistula In Ano Management • Chronic fistulas call for surgical treatment • Unroofing entire fistula tract (fistulotomy) and leaving wound open to heal secondarily • Fistula that course through significant amount of sphincter muscle, can’t be opened entirely because incontinence will result. In this condition the fistula is partially open with the musculature left intact and encircled with seton (tight (cutting seton) or un-tight) • OR close internal opening with advancement flap

39. Pilonidal Sinus Disease • Derived from Latin words pilus (hair) and nidus (nest) • It denotes a chronic subcutaneous infection and foreign body reaction to hairs imbedded in the skin or to abnormalities of follicles in the natal cleft • Most common in men between the onset of puberty and 40 years of age, and in obese persons • Clinical evaluation - most patient experience an episode of acute abscess formation - After abscess resolves, sinus tract develops - Later in most cases sinus tract resolve, however, in the minority chronic disease or recurrent disease develops

40. Pilonidal Sinus Disease Physical examination • One or more small dermal pits at the base of intergluteal cleft • Tracking from the pits (usually proceeding in a cranial and lateral direction) appears as areas of induration • If there is abscess, the area will be erythematous, tender and draining pus may be evident

41. Pilonidal Sinus Disease

42. Pilonidal Sinus Disease Management • Abscess must be drained (incision & drainage) • 40% of acute pilonidal abscesses treated with incision and drainage develop into chronic sinuses • Operations for sinus tract - Closed techniques (coring out follicles and brushing the tracts), very high recurrence rate - Laying open (un-roofing) the tract with healing by granulation, healing time 48 days, recurrence rate 13% - Wide and deep excision of the sinus alone, healing time 72 days, recurrence rate 13% - Excision and primary closure, healing time two weeks, recurrence rate 15%

43. Pilonidal Sinus Disease Management • None operative conservative approach - Meticulous hair control (natal cleft shaving) - improved perineal hygiene - Limited lateral incision and drainage for treatment of abscess

44. Hydradenitis Suppurativa • Chronic recurrent inflammatory process involving the apocrine glands of the axilla, the groin, and peri-anal region • Occlusion of follicles and abnormalities of apocrine ducts are believed to be the causative factors • Disease can result in chronically draining wounds and sinus tracts and can become quite painful and debilitating

45. Hydradenitis Suppurativa Management • Medical may afford temporary relief of symptoms • Most patients eventually require surgical therapy • Incision and drainage or un-roofing of sinus reserved for early and acute disease • Local excision provides adequate control of symptoms, recurrence rate higher than 50% • Wedge excision with secondary granulation

46. Pruritus Ani • Dermatologic condition of the perianal skin characterized by uneasiness or itching in the area around anus • Predisposing factors - Poor peri-anal hygiene (related to incontinence, diarrhea, or excessive hair) - Over hygiene - Excessive moisture - Irregularities of peri-anal skin (from hemorrhoids, fistulas, or previous surgery) - Skin hypersensitivity - Diet - Decreased resistance to infection - Injury to peri-anal skin

47. Pruritus Ani Clinical Evaluation • History and physical examination to suggest possible causes of pruritus • Inspection of peri-anal skin with gentle retraction of buttocks under bright lighting • Characteristic finding is erythematous or thickened skin which result in whitish appearance with accentuation of the radial anal skin creases • Skin may be excoriated or ulcerated (with thickening process called Lichenification) • Large excoriations can coalesce forming weeping ulcers

48. Pruritus Ani Clinical Evaluation • Digital rectal examination to assess competence of anal sphincter at rest and at maximal squeeze • Anoscopy and proctoscopy should be performed Management • Cause has to be eliminated • Keep peri-anal area dry • Avoid trauma to area • Peri-anal area should be gently washed, never scrubbed • Avoid irritating foods (tomatoes, pepper, citrus fruits and juices, coffee, colas, beer, milk , nuts and any food stuff found to be associated with increased gas, indigestion and diarrhea • Maintain regular bowel habbits

49. Pruritus Ani Management (continue) • Avoid creams, lotions and emollients • Hydrocortisone cream may be applied for one week • If candidal yeast infection is found, try antifungal lotion, solution or powder • If standard measures fail to elicit improvement, fungal and viral cultures and even biopsy may be necessary to exclude an infectious or neoplastic cause

50. Solitary Rectal Ulcer Syndrome • Clinical condition characterized by rectal bleeding, copious mucous discharge, anorectal pain and difficult evacuation • SRUS can have single rectal ulcer, multiple ulcers or even no ulcers • When present, ulcers usually occur on the anterior rectal wall just above the anorectal ring • Ulcers usually appear as shallow lesions with punched out gray-white base that is surrounded by hyperemia • Cause unclear, associated with chronic inflammation or trauma (internal intussception or prolapse of the rectum, direct digital trauma, or forces to evacuate hard stool)