1. Back to medical school -anorectal disorders
Ian Botterill, Dept Colorectal Surgery
Leeds General Infirmary

2. Wide variety of pathologies
congenital / acquired
benign / malignant
traumatic
infective / inflammatory
gender / age related

3. Common symptoms of ano-rectal disorders
bleeding
anal pain
itch
faecal leakage / hygiene problems
swelling
discharge

4. Examination
abdomen
groins (lymph nodes)
dermatoses

5. Ano-rectal examination
chaperoned
relaxed patient
left lateral
good light
knee elbow position
use pt’s hand to elevate right buttock
+/- anoscopy in 1y care

6. Ano-rectal examination
External appearance -skin condition -swellings -soiling / discharge -perineal descent -scars
Digital examination -sphincter tone -squeeze pressure -cervix / prostate -coccyx -retrorectal space -rectocoele

7. Anatomy

8. Haemorrhoids
Symptoms: anal canal bleeding, pruritus, swelling, pain

9. Haemorrhoids
Classification y: bleed, do not prolapse y: prolapse & reduce spontaeously - 3y: prolapse & require manual reduction - 4y: prolase, not reducible

10. Cause of haemorrhoidal problems
altered bowel habit
raised intra-abdominal pressure
straining

11. Treatment of haemorrhoids
Diet five helpings fibre / d
Out-patient injection sclerotherapy -banding photocoagulation

12. Surgical treatment For 3rd / 4th degree haemorrhoids
Open haemorrhoidectomy
Closed haemorrhoidectomy
Ligasure haemorrhoidectomy
Stapled haemorrhoidopexy (PPH)

13. Results of haemorrhoidectomy
>90% daycase
least initial pain stapled haemorrhoidopexy -Ligasure haemorrhoiodectomy
quickest return to work: stapled haemorrhoidopexy -Ligasure haemorrhoidectomy
most costly: PPH / ligasure
lowest recurrence (prolapse) ; conventional

14. Complications of haemorrhoidectomy
Local stenosis faecal leakage recurence bleeding retention of urine
severe perineal sepsis (esp IDDM & immunosuppressed)

15. Painful prolapsed haemorrhoids
natural history (worst pain days ~ 3-7, then settles)
most resolve with conservative Rx - lactulose / topical anaesthetic creams / ice / paracetamol & NSAIDs / relief of anal spasm (GTN or diltiazem) failure to resolve > haemorrhoidectomy - refer gangrenous or those that fail to settle
interval haemorrhoidectomy if still problematic

16. Anal skin tags Sx: anal swelling / hygiene problems
Diagnosis: perineal examination alone
Differential: Crohn’s disease / anal warts
Rx: reassurance / excision

17. Rectal mucosal prolapse & full thickness rectal prolapse

18. Rectal mucosal prolapse
result of straining
associated with pruritus ani / mucous discharge
anoscopy
Rx dietary correction advised to avoid straining at stool - injection sclerotherapy

19. Ano-rectal sepsis
Sx: perineal pain (throbbing), possible prior history of similar
Exam: tender fluctuant mass +/- discharge, may be toxic
Beware: diabetics (risk of rapidly progressive infection & Fournier’s gangrene)
skin necrosis (possible Fournier’s gangrene)
anal spasm & throbbing pain (inter-sphincteric abscess)
Treatment: I&D

20. Fistula in ano
~ 30-40% of all perineal sepsis once drained goes on to develop a fistula
~ 80-90% of perineal sepsis that yielded enteric organisms will develop a fistula

21. Fistula in ano
95% cryptoglandular ie origin in ano-rectal crypts at dentate line
5% rarities Crohn’s TB hidradenitis suppurativa - traumatic malignancy complicated diverticular disease - radiation anastomotic leakage

22. Classification Inter-sphincteric 70% Trans-sphincteric 25%
Supra-sphincteric ~5%
Extra-sphincteric <1%
Simple v. complex
‘Complex’:
-branching tracts / 2y tracts
-associated abscess
-associated pathology

23. Goodsall’s rule
External opening posterior to 3-9 oclock position open in posterior midline of the anal canal
External opening anterior to 3-9 oclock position open radially in the anal canal
~80-90% accurate

24. Management of fistula in ano
Strike a balance between
-cure of fistula
-prevention of further anorectal abscess
-preservation of continence

25. Management of fistula in ano
Divide tissues overlying track ( to allow healing by 2y intent) lay open cutting seton
Occlude internal opening & provide external drainage anal fistula plug rectal or anal advancement flap
Prevention of further ano-rectal sepsis - draining seton

26. Anal fissure ‘focal linear deficiency of anal mucosa’
posterior > anterior
acute v. chronic chronic: IAS exposed , > 6/52, keratinisation
simple v. complex

27. Anal fissure

28. Anal fissure management
stool softeners
dietary advice
topical LA
chemical sphincterotomy -topical injected
surgical sphincterotomy

29. Anal fissure surgery through the ages
anal stretch
lateral sphincterotomy
chemical sphincterotomy - topical injectable

30. Anal fissure treatment
GTN % successful s/e: severe headaches
Diltiazem % successful s/e: nil generally
Botox % successful s/e transient minor leakage
Sphincterotomy 98% successful s/e 2% passive leakage

31. Proctitis
Biopsy mandatory (with exception of prior prosate / cervical brachytherapy)
UC / Crohn’s / indeterminate / infective
Stool culture
Biopsy prior to starting suppositories
Suppositories often preferable to oral therapy

32. Pilonidal sinus / & abscess
Abscess often deep-seated – do not respond to antibiotics

33. Pilonidal sinus disease

34. Z plasty
Uli Szymanovski
Developed ‘Z’ plasty wound closure

35. Rhomboid flap
Healing by 1y intention ~90% of time as with Z plasty

36. Healing by 2y intent

37. Healing using Vac Therapy

38. Perianal haematoma Thromobosis of superficial haemorrhoidal veins
Discrete circular lump at / beyond anal verge
Incise & drain

39. Pruritus ani Night > day
Rule out coexistent dermatoses / renal failure / liver disease
If fungal disease suspected > skin scrapings
Ano-rectal examination & proctoscopy.
Treat ano-rectal pathology (haemorrhoids / faecal incontinence / anal tags etc).

40. Pruritus treatment Avoid synthetic / tight underwear
Avoid perfumed soaps etc
Avoid scratching
Use hairdryer to dry skin
Avoid steroid creams
Treat anal pathology / diarrhoea
Dermatology involvement
Methylene blue injections > ~80% successful - s/e occasional cellulitis / ulcer / incontinence

41. Faecal incontinence - understand continence first!
Brain / higher centres
Spinal cord
Reflex arcs
Pudendal nerves
Ano-rectal sensation ‘sampling’
Stool consistency
Rectal compliance
Anal sphincter complex

42. Faecal incontinence Causation
Obstetric injury (8-30% sphincter injury rate at childbirth)
Post-surgical
Faecal impaction
Neuropathy / MS / Parkinson’s
Poor mobility / impaired cognition
Diarrhoea
IBS / rectal non-compliance

43. Assessment of faecal incontinence
History
Examination
Endoanal USS (sphincter injury)
Anorectal manometry (rest & squeeze strength)
Pudendal nerve terminal latency (sensation)

44. Assessment of incontinence
Cleveland clinic score severity of soiling frequency of soiling use of pads lifestyle disruption
History of back injury / neurolgical disorder
Urinary incontinence
Saddle anaesthesia

45. Treatment incontinence
dietary measures
treat diarrhoea / impaction / IBS
non-operative collagen injections anal plug
sacral nerve stimulation
sphincter repair
artificial sphincters
graciloplasty

46. Anal stenosis Post-surgical Cancer Crohn’s
Previous chronic anal fissure
Radiation
Systemic sclerosis
Need EUA to assess all these

47. Anal cancer
Sx: itch, bleeding, pain (if below dentate line), swelling, ulcer, groin node
Exam: hard, irregular, friable area. Groin nodes possible. ? Coexists with anal warts
Differential: haemorrhoids, anal fissure, anal warts, STD
Diagnosis: EUA & biopsy

48. Anal cancer -treatment
Chemo-radiotherapy
Ongoing perineal surveillance
Average local control ~ 70%
Average cure ~ 70%
Salvage surgery for recurrence - APER with rectus flap to perineum
Rarely is local excision alone sufficient

49. Hidradenitis suppurativa
Superficial fistulating condition ass’d with chronic skin sepsis
Axillae > groins > perineum
Clinical diagnosis (+/- biopsy) – typically have disease elsewhere
Rx: drain sepsis / rotating antibiotics / infliximab / stop smokng

50. Anal papillae Sx: nil (asymptomatic finding typically)
Diagnosis: at anoscopy
Biopsy: rarely required
Treatment: leave alone

51. AIDS & the perineum
Wide variety of pathology fissures / abscesses / fistulae / infections / anal cancer / cutaneous lymphoma - florid warts pruritus incontience
General principle suspect immunocompromise culture / biopsy avoid agresssive surgery treat in conjunction with Infectious Diseases / Sexual Health

52. AIDS
HSV

53. Other perineal problems -pressure sores
Post-sacral
Over ischial tuberosity
Normally have clear cut antecedant history

54. summary diverse pathology
high degree of overlap between 1y and 2y care
refer bleeding
refer ‘odd-looking’ lesions