MANAGEMENT OF

PERI-ANAL
CONDITIONS :
HEMORRHOIDS
Abscess
FISTULA-IN-ANO ,
FISSURE AND
RECTAL PROLAPSE
 Anatomy of anal canal
Anal canal :pelvic diaphragm to anal verge
Mucus membrane
Dentate line: an important landmark
Anal canal musculature
Internal sphincter fissure pathogenesis
External sphincter
Longitudinal muscle pathways for spread of infections
Anorectal ring (circular lower border of puborectalis)
Anal glands
Anal crypts
Hemorrhoidal tissue / anal cushions
Arterial ,venous , lymphatic and nervous systems
Anatomy of anal canal
 Hemorrhoids
Definition :
Cushions of sub mucosal tissues ( two Rt vs one Lt)
Normal part of anorectal anatomy & assists
continence
Pathologic if symptomatic or complicated
Some define as descent of anal cushion
Different from rectal varices

Classification :
Internal :above the dentate line
External :below the dentate line
Intero-external
Pathogenesis :
intra abdominal pressure during
straining ,lifting or standing engorgement
of veins dilate ,stretch enlargement and
distal displacement of anal cushions
abnormal Hemorrhoidal tissue

Increased resting anal tone incomplete

relaxation during defecation increased
shearing forces on the anal cushions
 Hemorrhoids

Internal hemorrhoids
Incidence :4 % to 80 % ,age 45-65
Arranged in three groups (3, 7 ,11 oclock)

Classification
First degree
Second degree
Third degree
Fourth degree
Clinical feature

Painless bleeding
Prolapse
Mucus discharge
Itching
Under normal circumstance, pain is not feature of
internal hemorrhoids
Pain signify that complication (thrombosis or necrosis)
 Diagnosis
High index of suspension

Clinical feature

Prolapsed /thrombosed

DRE

Anoscopy/proctoscopy
 Hemorrhoids

Complications
Bleeding
Strangulation
Thrombosis
Gangrene
Suppuration
pylephlebitis
Ulceration
Fibrosis
 Hemorrhoids

Treatment
Non-operative : avoidance of straining
stool softeners ,creams,suppositories
Active medicaltreatment
Scelerotherapy :3 sessions/6wks

First & second degree

Banding Rx :second degree

2 hemorrhoids/session
Complications
Pain, urinary retention
Slippage of the band
Bleeding at 7th day
 Hemorrhoids

Infrared photocoagulation & Direct current coagulation

Operations
Open (Milligan-Morgan)
Closed (Ferguson)
Stappled hemorroidectomy
White head hemorroidectomy

Indications
Third and fourth degree
Failure of non-operative Rx
Interoexternal hemorrhoids
Acute thrombosis and incarceration
 Hemorrhoids

Hemorroidectomy
Preop preparation :enema & laxatives
Anesthesia : LA ,spinal or GA
Postoperative care
o Warm sitz bath
o Bulk laxatives
o Analgesics
o DRE after 3-4 weeks to check for stenosis
Hemorrhoids
 Hemorrhoids

Postoperative complications

Early
Late
Pain
Hemorrhage
Urinary retention
Anal stenosis
Fecal impaction
Ana fissure
Hemorrhage
Sphincter injury
Infection

Stapled Hemorroidectomy :less postop pain

 Hemorrhoids

Thrombosed External hemorrhoids

Clinical feature
Sudden onset severe pain
Tense & tender swelling in the anal verge
Pain is characteristics of external hemorroids
Natural course
Resolution is common
Suppuration
Fibrosis skin tag is common
 Hemorrhoids

Treatment
Early (with in 36-72 hrs)
o Excision under LA

Late
o Conservative mx
o Recurrence rate is 50 %
 Anorectal abscess

> 90 % originates from infection of

anal glands
Other causes
o Hematogenous
o Extension of boil
o Neoplasm
o Inflammatory bowel disease
o Immunosuppression :AIDS and DM
 Anorectal abscess

Classification
o Perianal (60 %)

o Ischiorectal (30 %)

o Submucus (5 %)

o Pelvirectal (<5 %)

Intersphincteric (difficult to diagnosis other

wise rare)
 Anorectal abscess

Clinical features
Severe & continuous anal pain (throbing pain)
May be Constitutional (systemic) symptoms
Tender mass with/without flactuation

Treatment of perianal abscess

Drainage (cure rate is 50 %)
o Perianal & ischiorectal :incision over the
perianal skin overlying the abscess
o Pelvirectal : trans anal incision over the
abscess
Antibiotics( for immuno compromized pts
,high risk or patients with systemic
manifestation)
 Treatment of ischerectal abscess

Simple ones may be drain through an incision

on the overlying skin
Horseshoe abscesses require drainage of the
deep postanal space and often require
counterincisions over one or both ischiorectal
spaces
 Fistula in ano
Def: A track lined by granulation tissue that
connects the anal canal or rectum to skin
around the anus

Causes
Anorectal abscess which bursts spontaneously or was
opened inadequately
Granulomatous lesions :Tb, Crohns dis.,
actinomycosis (multiple external openings)
Carcinoma

Chronic fistula may be complicated by colloid

Fistula in ano
 Fistula in ano

Types
Low level :internal opening below/ distal to
the

anorectal ring
High level : internal opening above the

anorectal ring
 Fistula in ano

Standard Parks
classification classification
Subcutaneous Intersphinicteric
Submucus Transsphinicteric
Low anal Suprasphinicteric
High anal Extrasphinctric
pelvirectal
Fistula in ano
 Fistula in ano

Diagnosis
o Persistent purulent drainage
o Palpable indurated tract & external openings
o Internal opening detected by palpation or
proctoscopy
Goodsalla rule as a guide to locate the
internal opening
Probing
Injections of methylene blue/hydrogen
peroxide
Fistula in ano
 Fistula in ano

Investigation
Fistulography

Endoluminal ultrasound

MRI

CXR (pulmonary Tb)

 Fistula in ano

Treatment of low level fistula

Preop care :cleansing enema ,laxatives
Intraoperative :bidigital examination
,probing ,injection of hydrogen
peroxide
Technique
Fistulotomy ,curettage
Biopsy from the track
 Fistula in ano

Treatment of High level fistula

Staged operations with primary colostomy
Seton method ( a ligature of silk, nylon,
silastic or linen)
Types
cutting :drain, cuts the muscle to allow
fibrosis with no muscle defect
non-cutting (loose) :drain
 Fistula in ano

Newer treatment modalities

Fibrin glue success rate is 8%

(surgery today,2006 ,Turkey)

Sliding endorectal flap
 Anal fissure
Elongated ulcer in lower anal canal below dentate
line
Location
o Midline posterior (90 %)
o Midline anterior (10 %)
Etiology
Pressure of a hard fecal mass on posterior anal
tissues stretching of epithelium
Ischemia
Other causes
 Anal fissure

Pathology
Acute anal fissure (< 6 weeks)
o Little indurations or edema of its edges
o Spasm of internal sphincter
Chronic anal fissure (>6 weeks)
o Indurated margins ,a base consisting of either
scar or internal sphincter
o Skin tag at lower end
o Spasm of anal sphincter
 Anal fissure

Common in women in middle age

D/dx
Anal cancer
Tuberculosis
STDS (Herpes ,HIV)
 Anal fissure

Clinical features
Pain on defecation
Constipation
Minimal bright red bleeding
Mucus discharge
Skin tag
Ulcer may be seen
 Anal fissure

Treatment
Conservative treatment
o Stool softeners ,local anesthetic jelly and anal
dilators

Nitrates ointments
o Healing in 70-90 % of patients
o Advantage :increase blood flow and no permanent
incontinence

Injection of botulinium toxin

 Anal fissure

Operative treatment
Anal dilatation under GA (Lords
procedure)
Risk :minor incontinence in 50 %
Recurrence is 40 %
CI :pts with weak sphincters
Lateral anal sphincterotomy (LA , GA)
Healing in 90 to 95 %,minor
Anal fissure
 Rectal prolapse
Predisposing factors
Infants
Absent sacral curve
Reduced anal tone
Children
Diarrhea
Severe whooping cough
Decreased ischiorectal fat due to malnutrition
Adults
 Rectal prolapse

Types
Partial

Complete

Partial rectal prolapse

The mucus membrane & submucosa of the
rectum protrude outside the anus for ~1-4 cm
Age :the extremes of age
 Rectal prolapse

Treatment

Infants & children

Digital reposition
Submucus injection with phenol 5 %
Thierschs operation
Adults
Submucus injection
Excision of prolapsed mucosa
 Rectal prolapse

Complete rectal prolapse

All layers of rectal wall protrude through the
anus > 4 cm

Epidemiology
Common in elderly

M:F = 1:6
 Rectal prolapse

Clinical feature
Prolapsed mass reduced by itself or
manually
Mucus discharge ,bleeding and
anorectal pain
Irreducible mass
Associated with prolapse of uterus or
past gynecologic operations
Patulous anal sphincter
Incontinence in 50 % of cases
Rectal prolapse
 Rectal prolapse

Investigation
defecography

Colonoscopy & barium enema

Manometry & electromyography

 Rectal prolapse

Treatment
Surgery is a must
Two approaches
Perineal
Abdominal
Perineal approach
Elderly and very weak pt
Very early life
 Rectal prolapse

Perineal procedures
Delormes operation
Effect
Reducing the prolapse
Narrowing of the anal orifice & prevents
recurrence
Thierisch operation
Obsolete in adults
Others
Postanal repair by Parks :strengthening the
Rectal prolapse
 Rectal prolapse

Abdominal approaches
Lower recurrence rate
High morbidity
Principle
To reduce & hold the rectum in its proper
position (rectopexy)
To reduce redundant colon by anterior
resection
More than 50 different operations
Rectal prolapse
THANKS A LOT
 REFERENCES
Principles of surgery ,Schwartz ,9th Ed.

Short Practice of surgery ,Bailey & Loves ,25th

Ed.
Current diagnosis & treatment 13th edition

ACS SURGERY, 6th edition

Surgery International ,1998 ,Vol. 44

E-Medicine ,internet ,2006