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Back to medical school -anorectal disorders Ian Botterill, Dept Colorectal Surgery Leeds General Infirmary Wide variety of pathologies • congenital / acquired • • • • benign / malignant traumatic infective / inflammatory gender / age related Common symptoms of ano-rectal disorders • • • • • • bleeding anal pain itch faecal leakage / hygiene problems swelling discharge Examination • abdomen • groins (lymph nodes) • dermatoses 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 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 Anatomy Haemorrhoids • Symptoms: - anal canal bleeding, pruritus, swelling, pain Haemorrhoids • Classification - 1y: bleed, do not prolapse - 2y: prolapse & reduce spontaeously - 3y: prolapse & require manual reduction - 4y: prolase, not reducible Cause of haemorrhoidal problems • altered bowel habit • raised intra-abdominal pressure • straining Treatment of haemorrhoids • Diet -five helpings fibre / d • Out-patient -injection sclerotherapy -banding -photocoagulation Surgical treatment • For 3rd / 4th degree haemorrhoids • Open haemorrhoidectomy • Closed haemorrhoidectomy • Ligasure haemorrhoidectomy • Stapled haemorrhoidopexy (PPH) 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 Complications of haemorrhoidectomy • Local - stenosis - faecal leakage - recurence - bleeding - retention of urine • severe perineal sepsis (esp IDDM & immunosuppressed) 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 Anal skin tags Sx: anal swelling / hygiene problems Diagnosis: perineal examination alone Differential: Crohn’s disease / anal warts Rx: reassurance / excision Rectal mucosal prolapse & full thickness rectal prolapse Rectal mucosal prolapse • result of straining • associated with pruritus ani / mucous discharge • diagnosis @ anoscopy • Rx - dietary correction - advised to avoid straining at stool - injection sclerotherapy 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 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 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 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 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 Management of fistula in ano Strike a balance between -cure of fistula -prevention of further anorectal abscess -preservation of continence 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 Anal fissure • ‘focal linear deficiency of anal mucosa’ • posterior > anterior • acute v. chronic -chronic: IAS exposed , > 6/52, keratinisation • simple v. complex Anal fissure Anal fissure management • stool softeners • dietary advice • topical LA • chemical sphincterotomy -topical -injected • surgical sphincterotomy Anal fissure surgery through the ages • anal stretch • lateral sphincterotomy • chemical sphincterotomy - topical - injectable Anal fissure treatment • GTN • Diltiazem • Botox • Sphincterotomy 40-50% successful s/e: severe headaches 60-80% successful s/e: nil generally 60-90% successful s/e transient minor leakage 98% successful s/e 2% passive leakage 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 Pilonidal sinus / & abscess Abscess often deep-seated – do not respond to antibiotics Pilonidal sinus disease Z plasty Uli Szymanovski Developed ‘Z’ plasty wound closure Rhomboid flap Healing by 1y intention ~90% of time as with Z plasty Healing by 2y intent Healing using Vac Therapy Perianal haematoma • Thromobosis of superficial haemorrhoidal veins • Discrete circular lump at / beyond anal verge • Incise & drain 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). 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 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 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 Assessment of faecal incontinence • History • Examination • Endoanal USS (sphincter injury) • Anorectal manometry (rest & squeeze strength) • Pudendal nerve terminal latency (sensation) 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 Treatment incontinence • dietary measures • treat diarrhoea / impaction / IBS • non-operative - collagen injections - anal plug • sacral nerve stimulation • sphincter repair • artificial sphincters • graciloplasty Anal stenosis • • • • Post-surgical Cancer Crohn’s Previous chronic anal fissure • Radiation • Systemic sclerosis • Need EUA to assess all these 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 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 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 Anal papillae Sx: nil (asymptomatic finding typically) Diagnosis: at anoscopy Biopsy: rarely required Treatment: leave alone 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 AIDS HSV Other perineal problems -pressure sores Post-sacral Over ischial tuberosity Normally have clear cut antecedant history summary • diverse pathology • high degree of overlap between 1y and 2y care • refer bleeding • refer ‘odd-looking’ lesions