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Common Office Anorectal Problems

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Presentation on theme: "Common Office Anorectal Problems"— Presentation transcript:

1 Common Office Anorectal Problems
Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center

2 Disclosures None

3 Benign Anal Rectal Disease
Anatomy of the anal canal and perianal spaces Benign Anal Rectal Disease Abscess and Fistula Fissure Hemorrhoids

4 Overview of Anatomy Anatomy Pelvic and Perirectal Spaces
Anatomy of Anal Canal

5 Retrorectal Space Waldeyer’s Fascia Supralevator Space Levator Ani Muscle Deep Postanal Space Superficial Postanal Space

6 ANAL CANAL Peritoneum Supralevator Space Levator Ani m.
Puborectalis m. Ischioanal Space Deep External Sphincter m. Intersphincteric Space Internal Sphincter m. Perianal Space Transverse Septum

7 ANAL CANAL Column of Morgagni Dentate Line Anal Crypt Anal Gland
Transitional Zone Dentate Line Anal Crypt Anal Gland Anoderm


9 Diagnosis and Treatment of Anorectal Abscess and Fistula-in-Ano

10 Anorectal Abscess Etiology
Cryptoglandular abscess Most common Infection in the glands at the dentate line Other causes Crohn’s and Ulcerative Colitis Tuberculosis and Actinomycoses Malignancy Foreign Bodies, Prostate Surgery or Radiation

11 Fistula Description Clock description
Does the anus tell time? Relies on description of patient’s position: supine, lateral, prone and relative landmarks 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

12 Pubic bone Right anterior Left anterior Left Right Right posterior Left posterior Tailbone

13 There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained

14 Abscess Classification
Four Types Based on Space Involved Perianal % Intersphincteric % Ischioanal % Supralevator 2% or less Most Common Rare

15 Supralevator Abscess Intersphincteric Abscess Ischioanal Abscess Perianal Abscess

16 HORSESHOE ABSCESS Supralevator Space Intersphincteric Space
Ischioanal Space

17 Anorectal Abscess Treatment of Perianal and Ischiorectal Abscesses
Diagnosis - usually straightforward Erythema and Pain over affected area Fluctuance 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

18 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

19 Catheter Types Pezzer catheter Solid mushroom top so stays in
Less tissue ingrowth Malecot Allows tissue ingrowth More painful to remove

20 Peri anal abscess - ? Antibiotics
Not usually indicated if there is adequate drainage Indicated for patients with: Obesity Diabetes Imunocompromised Extensive large abscess or recurrent abscess

21 Fistula-in-Ano Definition Classification: Diagnosis Treatment
abnormal connection between two epithelial surfaces. Classification: Parks: Defines fistula by course of tract Goodsall’s rule Diagnosis Treatment Goals Options

22 How does patient present?
May have had a history of abscess History of Crohn’s disease May present at the same time as abscess Complain of intermittent increase in pain/swelling followed by spontaneous drainage Chronic localized area of irritation or ulcer “pimple near my anus keeps coming back”

23 Fistula-in-Ano Goodsall’s Rule
Posterior Anterior

24 Fistula in ano

25 Fistula in ano: Surgical disease
Refer to Colon and Rectal Surgeon or General Surgeon Reassure patient – rarely cancer, most do not need a colostomy If suspect Crohns Gain control of perianal sepsis Then complete full workup and staging Goals of therapy Get rid of the fistula/connection Preserve continence

26 Surgical Options Primary fistulotomy Fibrin Glue/Fistula Plug
Mainly for low, superficial fistula Risk of fecal incontinence Fibrin Glue/Fistula Plug Utilizes substrate as scaffold to fill tract Does not involve cutting muscle Cutting or draining setons For deeper tracts that involve significant muscle Rectal advancement flap Lateral internal fistula transection Newer procedure. No foreign substrate Cuts fistula tract, not muscle

27 Fistula in ano

28 Fistula in ano

29 Fissure in Ano 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

30 Fissure in Ano Pathogenesis
Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus 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

31 Fissure with Sentinel Tag

32 Fissure with Sentinel Tag

33 Fissure in Ano Pathogenesis
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

34 Fissure in Ano Symptoms
Pain is the main symptom Sharp, cutting or tearing during defecation Duration is few minutes to hours Bleeding – bright red and scant Skin Tag Mucous discharge resulting in itching

35 Fissure in Ano Diagnosis
Diagnosis often made on history alone Inspection – gently spread the buttocks and the fissure becomes apparent Triad of chronic anal fissure Sentinel pile Hypertrophied anal papilla Anal ulcer

36 Fissure in Ano Differential Diagnosis
Intersphincteric abscess Pruritus Ani Fissure from inflammatory bowel disease Carcinoma of the anus Infectious Perianal conditions Leukemic infiltration

37 Fissure in Ano Crohn’s Anal Fissures

38 Acute Fissure in Ano Treatment
Increase dietary fiber Local anesthetic to prevent spasm Nitroglycerin or Nifedepine Ointment Not commercially available Must be mixed by pharmacist Warm tub soaks 4-6 weeks of treatment

39 Chronic Fissure in Ano Surgical Treatment
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

40 Hemorrhoids What are they? Where are they?
Why do they become symptomatic? Classification? How do you treat them? Can they be avoided?

41 Hemorrhoids What are they?
Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissue Aid in anal continence

42 Hemorrhoids Where are they?
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 External Hemorrhoids Below the dentate line Blood drains through the inferior rectal veins to the pudendal veins on into the iliac veins

43 Hemorrhoids Symptoms? Chronic constipation Diarrhea
Trauma to the hemorrhoids during defecation cause the most common symptoms Pain – generally not “knife-like” Itching Burning Bleeding

44 Hemorrhoids Classification- Internal Hemorrhoids
1st degree – bulge into the lumen 2nd degree – prolapse with bowel movement but reduce spontaneously 3rd degree – prolapse spontaneously and require manual reduction 4th degree – permanently prolapsed hemorrhoids that cannot be reduced

45 4th Degree Hemorrhoids

46 Hemorrhoids Treatment Principles
Thorough physical exam to determine severity and rule out other pathology Refer for surgical evaluation if white or discolored, firm or fixed Determine if the problem is internal, external or both Assess the symptom complex

47 Treatment Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream… 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

48 Treatment Office and Minor Procedures
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

49 Treatment Office and Minor Procedures
Infrared Photocoagulation Indicated in 1st degree hemorrhoids Causes photocoagulation of small vessels Performed in office or “Hemorrhoid Relief Center” Minimal pain

50 Closed Hemorrhoidectomy Indication
Hemorrhoids are severely prolapsed and require manual replacement Patients fail to improve after multiple applications of non-operative treatment Hemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags

51 Closed Hemorrhoidectomy General Principle
Most can be performed with local and IV Sedation Prone/Kraske position is the best Infuse the area with local anesthetic with epinephrine for hemostasis Fleets enema 1-2 hours prior No antibiotic prophylaxis is necessary

52 Closed Hemorrhoidectomy

53 Closed Hemorrhoidectomy

54 Closed Hemorrhoidectomy Post op Result

55 PPH Stapling Procedure for Hemorrhoids
Not for every hemorrhoid Ideal for Grade 2 and 3 with minimal external component Prevents prolapse and thus less trauma to hemorrhoid with bowel movement


57 PPH Stapling Procedure for Hemorrhoids

58 PPH Stapling Procedure for Hemorrhoids
Benefits Less pain as compared to traditional closed hemorrhoidectomy Less blood loss during the procedure Less chance of anal stenosis

59 PPH Stapling Procedure for Hemorrhoids
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

60 Perianal Condyloma Can sometimes be difficult to distinguish from hemorrhoids Cauliflower type appearance History of HIV, History of abnormal pap smear Homosexual males usually but can be seen in the heterosexual population Caused by HPV virus Increased risk of anal cancer in the immunocompromised patient


62 Treatment - Topicals Aldara (Imiquinod) >50% initial response
Topical 5-FU – 90% initial response Condylox (podofilox) Each have high local toxicity Practice Parameters for Anal SquamousNeoplasms

63 Treatment Photodynamic therapy Wide Local Excision
Targeted destruction with cautery and/or Infrared coagulation Observation of AIN I/II with removal of visualized lesions Excision of AIN III

64 Anal Squamous AIN High recurrence rate with all techniques
Close follow up to detect progression to invasive carcinoma Anal pap smear vs high resolution anoscopy Optomize underlying conditions

65 Questions?? 65

66 ?

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