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Anorectal Pain Andy Ramwell Consultant General and Colorectal Surgeon St George’s Hospital and Parkside Anatomy Cause • Anal fissure • Infection – Skin – fungal, bacterial, STI – Perianal abscess/fistula • • • • • Skin problem – dermatitis, psoriasis Malignancy Anal ulcer Haemorrhoids Pain syndromes Anal fissure • Commonest cause of pain • Sharp pain during defeacation • Dull ache afterwards – Can last for hours • May be able to localise • Bleeding • May have abnormal bowel habit Anal Fissure • Chronic fissure – 6/52 + – Sentinel pile/tag – Intra-anal fibroepithelial polyp • Multiple fissure – Consider other causes – IBD, TB, HIV • Post partum Anal fissure - Treatment • Conservative – Soften bowels – Topical lignocaine – Oral analgesia • • • • GTN 0.4% (Rectogesic) Diltiazem 2% (Anoheal) Botulinum toxin Surgery – Lateral sphincterotomy – Fissurectomy – Advancement flaps • Low pressure fissures Infection - Skin • • • • • Fungal Bacterial Viral/STI Often with pruritus Treat with steroid cream +/antibiotic/antifungal • Skin swab? • GU clinic? Dermatology • • • • • Dermatitis Psoriasis Lichen sclerosis Very itchy Dermatology review Infection - abscess • • • • Severe, constant pain Cannot sit Usually obvious signs of inflammation Intersphinteric abscess Anal fistula Abscess - treatment • Antibiotics – Early stages – If induration • Incision and drainage • Treat fistula – Lay open – Seton – Glue/plug – LIFT procedure Malignancy • • • • Can present with pain Usually constant Progressive Lump Anal Cancer Anal Cancer - Introduction • • • • • 4% of large bowel malignancies 350-400 new cases per year in Eng/Wales Increasing incidence 80% are squamous Anal receptive intercourse relative risk by 33 times • More common x30 in HIV+ve • Anal warts relative risk by x27♂ and x22♀ Anal cancer - treatment • • • • • Local excision Chemoradiotherapy Nodal treatment Salvage surgery Extralevator abdominoperineal excision and reconstruction Anal Ulcers • Crohn’s • Nicorandil • Malignant Haemorrhoids • • • • • Not usually painful Uncomfortable Irritate/itch Bleed Prolapse Painful haemorrhoids Thrombosed haemorrhoids • Perianal haematoma – Can be incised and squeezed under LA • True thrombosed haemorrhoids – Conservative Rx • May not need other intervention • Investigate other symptoms eg bleeding Haemorrhoids - treatment • Conservative – Diet – Stool softener – Topical treatments • Outpatients – Injection sclerotherapy – Banding Haemorrhoids – treatment • Operative – Haemorrhoidectomy – Stapled haemorrhoidopexy – Ligasure – Haemorrhoidal ligation procedures • THD • HALO Transanal Haemorrhoidal Dearterialisation Pain syndromes • Proctalgia fugax • Chronic idiopathic anal pain (levator ani syndrome) • Coccydynia Proctalgia Fugax • Sudden, short lived, severe, self limiting bursts of anorectal pain • Only lasts longer than 5 mins in 10% • Max 30 mins • Variable pattern, M=F, 30% at night • <5 times per year in 51% • Lifetime prevalence 8-18% • 90% anal pain • PR is normal Chronic Idiopathic anal pain • • • • • • • “Bearing down pain” Worse sitting Prevalence 6-7% Declines after 45yrs F>M Major psychological overlay Frequently have puborectalis tenderness on PR Coccydynia • • • • • • Severe rectal, perineal and sacrococcygeal pain Continuous, burning pain Radiates buttocks/thighs Mainly female Worse sitting down Pain can be reproduced by manipulation of the coccyx • Very difficult treatment History • When? – During defeacation – usually a fissure – With wiping – skin issue – Constant – thrombosed pile, abscess, malignancy • Timescale – Acute, sudden – thrombosed pile, fissure – Over a few days – abscess – Over months – malignancy, skin problem History • Is there rectal bleeding? • Alarm symptoms – Weight loss – Bowel habit Examination • • • • • • Is there anything to see? A fissure may be hidden Is the skin warm and/or swollen? Is there a lump? What colour is it? Is the anus moist or dry? Is a PR possible? Don’t attempt if there is a fissure Summary • Anal fissure is the commonest cause of anal pain • No obvious cause needs EUA • Often conservative measures will work
