4 Anatomy Anal canal – 4 – 4.5cm Rectum – 13cm Dentate line – separates columnar epithelium of the upper 2/3 of anal canal for the squamous epthelium of the lower 1/3.Internal sphincter – involuntaryExternal sphincter – levator ani
5 History Age of patient. Duration of symptoms. Associations BleedingDischargeTiming of painDefacationSittingRelated symptomsChange of bowel habit.Sinister featuresWeight loss
6 Causes of anorectal pain OrganicAnal fissurePerianal abscessPerianal haematomasCarcinomaStrangulated haemorrhoidsPilonidal sinusFunctionalLevator ani syndromeProctalgia fugax
8 Perianal AbscessArise from obstruction of perianal glands – intersphinctereric. Can track to the perineum or laterally to the ischiorectal fossa. Also associated with TB and actinomycetes.Mx – if early – tx with antibiotics. If presenting acutely – needs evacuation.
9 Perianal haematomasDue to ruptured anal vein. Onset after straining. Mx oral analgesia or evacuation.
10 Pilonidal Sinus Commonly in natal cleft, but can occur at other sites. Broken pieces of hair acting as foreign body‘dark haired hirsuite men’Recurrent episodes of pain and infection.Abx tx, lay open, complete excision, curettage with phenol injection.
11 Levator ani syndrome Prevalence 6.6% More common in women. PC: vague ache or pressure in rectum; worse on sitting.Diagnosis of exclusion.Mx:‘digital massage of the levator ani’Sitz bathsElectrogalvanic stimulationBiofeedback training.
12 Proctalgia Fugax Severe cramp-like pain in the rectum Short duration Diagnosis of exclusion‘Many patients are perfectionistic, anxious, and/or hypochondriacal’Mx – reassurance. ?inhaled salbutamol