4Any patient with anal/perianal symptoms requires a careful history and physical, including a digital rectal examinationdefecography, manometry, CT scan, MRI, contrast enema, endoscopy, endoanal ultrasound, or examination under anesthesia may be required to arrive at an accurate diagnosis
5HemorrhoidsHemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth-muscle fibers .Three hemorrhoidal cushions :left lateralright anteriorright posterior
6Hemorrhoidal Function continence mechanismaid in complete closure of the anal canal at restBecause hemorrhoids are a normal part of anorectal anatomy, treatment is only indicated if they become symptomatic.
8TypesExternal hemorrhoids are located distal to the dentate line and are covered with anodermInternal hemorrhoids are located proximal to the dentate line and covered by insensate anorectal mucosa
9Internal hemorrhoids Graded according to the extent of prolapse: First-degree hemorrhoids bulge into the anal canal and may prolapse beyond the dentate line on straining.Second-degree hemorrhoids prolapse through the anus but reduce spontaneously
10Third-degree hemorrhoids prolapse through the anal canal and require manual reduction. Fourth-degree hemorrhoids prolapse but cannot be reduced and are at risk for strangulation
11Combined internal and external hemorrhoids Combined internal and external hemorrhoids straddle the dentate line and have characteristics of both internal and external hemorrhoidsHemorrhoidectomy often is required for large, symptomatic, combined hemorrhoids.
12Postpartum hemorrhoids result from straining during labor, which results in edema, thrombosis, and/or strangulation.Hemorrhoidectomy is often the treatment of choice, especially if the patient has had chronic hemorrhoidal symptoms
13Treatment Medical Therapy: Bleeding from first- and second-degree hemorrhoids often improves with the addition of dietary fiber, stool softeners, increased fluid intake, and avoidance of strainingAssociated pruritus may often improve with improved hygiene
14Treatment Rubber Band Ligation Infrared Photocoagulation Sclerotherapy Excision of Thrombosed External Hemorrhoids
15Operative Hemorrhoidectomy Closed Submucosal HemorrhoidectomyOpen HemorrhoidectomyWhitehead's HemorrhoidectomyProcedure for Prolapse and Hemorrhoids/Stapled Hemorrhoidectomy(PPH)
16Complications of Hemorrhoidectomy Postoperative painUrinary retentionfecal impactionBleedingInfectionIncontinenceanal stenosisectropion (Whitehead's deformity)
17Anal FissureA fissure in ano is a tear in the anoderm distal to the dentate line.The vast majority of anal fissures occur in the posterior midline. Ten to 15% occur in the anterior midline.Less than 1% of fissures occur off midline
18pathophysiology of anal fissure trauma from either the passage of hard stool or prolonged diarrhea.This cycle of pain, spasm, and ischemia contributes to development of a poorly healing wound that becomes a chronic fissure.
19Symptoms and Findings extremely common tearing pain with defecation and hematochezia (usually described as blood on the toilet paper)painful anal spasm lasting for several hours after a bowel movement
20physical examinationcan be seen in the anoderm by gently separating the buttocksPatients are often too tender to tolerate digital rectal examination
21TypesAn acute fissure is a superficial tear of the distal anoderm and almost always heals with medical managementChronic fissures develop ulceration and heaped-up edges with the white fibers of the internal anal sphincter visible at the base of the ulcer.There often is an associated external skin tag and/or a hypertrophied anal papilla internally.
22A lateral location of a chronic anal fissure may be evidence of an underlying disease such as Crohn's disease, HIV, syphilis, tuberculosis, or leukemia.If the diagnosis is in doubt or there is suspicion of another cause for the perianal pain, such as abscess or fistula, an examination under anesthesia may be necessary
23TreatmentTherapy focuses on breaking the cycle of pain, spasm, and ischemiaFirst-line therapy to minimize anal trauma includes bulk agents, stool softeners, and warm sitz bathsThe addition of 2% lidocaine jelly or other analgesic creams can provide additional symptomatic relief.
24Treatment Nitroglycerin ointment (0.2%) Both oral and topical calcium channel blockers (diltiazem and nifedipine)arginine (a nitric oxide donor)topical bethanechol (a muscarinic agonist)Medical therapy is effective in most acute fissures, but will heal only approximately 50 to 60% of chronic fissures.
25Botulinum toxin (Botox) Surgical therapy: traditionally has been recommended for chronic fissures that have failed medical therapyApproximately 30% of the internal sphincter fibers are divided laterallyHealing is achieved in more than 95% of patients by using this technique
26Anorectal Sepsis and Cryptoglandular Abscess The majority of anorectal suppurative disease results from infections of the anal glands (cryptoglandular infection)Their ducts traverse the internal sphincter and empty into the anal crypts at the level of the dentate line
27perianal and perirectal spaces perianal spaceintersphincteric spaceischiorectal space (ischiorectal fossa)supralevator spaces
31Pathways of anorectal infection in perianal spaces
32Diagnosis Severe anal pain Walking, coughing, or straining can aggravate the painPalpable massfeverurinary retentionlife-threatening sepsis
33Treatment Drainage as soon as the diagnosis is established diagnosis is in question:an examination under anesthesiaAntibiotics :extensive overlying cellulitisImmunocompromiseddiabetes mellitusvalvular heart disease
35Fistula in AnoDrainage of an anorectal abscess results in cure for about 50% of patients.The fistula usually originates in the infected crypt (internal opening) and tracks to the external opening, usually the site of prior drainage.
36DiagnosisPatients present with persistent drainage from the internal and/or external openings.An indurated tract often is palpableGoodsall's rule can be used as a guide in determining the location of the internal opening .
38intersphincteric fistula tracks through the distal internal sphincter and intersphincteric space to an external opening near the anal verge
39transsphincteric fistula often results from an ischiorectal abscess and extends through both the internal and external sphincters
40suprasphincteric fistula originates in the intersphincteric plane and tracks up and around the entire external sphincter
41extrasphincteric fistula originates in the rectal wall and tracks around both sphincters to exit laterally, usually in the ischiorectal fossa
42TreatmentThe goal of treatment of fistula in ano is eradication of sepsis without sacrificing continence.Simple intersphincteric fistulas often can be treated by fistulotomy (opening the fistulous tract), curettage, and healing by secondary intention