MANAGEMENT OF PERIANAL

PAIN AND CONDITIONS

DRC
A.P. DR. CHALLA VENKATA RAO
ANATOMY
ANAL FISSURE
 FISSURE IN ANO

Split in the lining of the distal anal canal and 90%

of fissures are acute and resolve spontaneously

Chronic fissures that failed to heal after 6 weeks

of conservative measures usually require
pharmacological or surgical intervention.
 PATHOPHYSIOLOGY

Traumatic tear to the anoderm.

Associated with an episode of constipation
Hypertonicity of the internal anal sphincter and
raised resting pressures.
Reduced blood supply, causing relative ischaemia
and preventing healing.
 CLINICAL SCENARIO

young adults give a history of sharp pain in the anus,

worse on defecation, that may last for several hours.
Associated with the passage of fresh blood.
Anal discharge, pruritus and urinary symptoms.
Anal pain leads to fear of defecation, the passage of
hard stools and further sphincter spasm.
 CLINICAL SCENARIO

The fissure can often be seen as a tear at the anal

margin on parting the buttocks.

A ‘sentinel pile’ (a skin tag, not a hemorrhoid) may

be present.

Per rectal examination or

Proctoscopy is contraindicated in
Acute fissure.
 CLINICAL SCENARIO

Painful perianal conditions include

 Intersphincteric abscess
 Fistulain ano.
 Acutely thrombosed hemorrhoid

Multiple fissures, or a fissure in an unusual

position (e.g. lateral) should alert the clinician
to the possibility of other diagnoses.
 MANAGEMENT

Stool softeners and increased dietary fibre.

Pharmacological, reversible ‘chemical
sphincterotomy’.
 Nitrates
 Calcium Channel Blockers
 Botulinum Toxin
 MANAGEMENT

Nitrates:
 nitric
oxide causes relaxation of smooth muscle by
increasing the concentration of cyclic guanosine
monophosphate via the guanylyl cyclase pathway.

 0.2%GTN is applied topically to the anus 2–3

times a day for eight weeks.

 Major
side effect of GTN in >50% of patients is
headache.
 Calcium channel blockers

Relax smooth muscle by blocking slow l-type

calcium channels.

2% topical diltiazem has shown most promise,

healing a similar percentage of fissures as
GTN, but with fewer side effects.

Diltiazem gel has been shown to heal about

50% of GTN-resistant fissures.
 Botulinum Toxin A

Botulinum is a neurotoxin that binds to presynaptic

nerve endings, preventing the release of acetylcholine
at the neuromuscular junction.
20 iu is injected into the internal sphincter in the 3 and
9 o’clock positions; the effects last for about three
months.
Complications are rare, and include transient
incontinence to flatus and perianal hematoma.
 SURGICAL TREATMENT

Lateral anal sphincterotomy, for the length of

the fissure results in 95% healing rates.

Continence can be disturbed in up to 30% of patients.

An anal advancement flap is done if a sphincter defect
is present and the resting pressure is not raised.
SPHINCTEROTOMY
 HAEMORRHOIDS
 Anal canal has a triradiate
lumen.
 3 lip-like structures or
cushions in the left lateral,
right anterior and right
posterior positions

Suspended in the anal canal by smooth

muscle fibres. Contains a network of blood
vessels, mostly veins fed by arteriovenous
vessels. Contribute to resting anal
pressure and form a compliant seal
HAEMORRHOIDS
 CLINICAL FEATURES

Increase in prevalence with age until the seventh

decade of life and common in men.
Women usually present during pregnancy and
after childbirth.
It is believed that inadequate intake of fibre,
prolonged sitting on the toilet and straining lead to
the development of symptomatic haemorrhoids.
PATHOPHYSIOLOGY

The vascular
The varicose
hyperplasia
vein theory
theory

The sliding
anal lining
theory
 SYMPTOMS

Bleeding(bright red;on wiping;in toilet

bowl)
Prolapse
Soiling
Discharge
Itching
Pain(if thrombosed)
 SIGNS

Examination: assessment begins with careful

inspection of the perianal area for skin tags,
fissures, fistulas, polyps and tumours.
Digital Rectal Examination and anoscopy in the
left lateral position.
Haemorrhoids are usually seen at 3, 7 and 11
o’clock positions.
NON SURGICAL MANAGEMENT

• Lifestyle modification
1

• Medical treatment
2

• Outpatient treatment
3

• Rubber band ligation

4

• Injection sclerotherapy
5
• Other treatment methods include cryotherapy and
6 infrared coagulation
RUBBER BAND LIGATION
 SURGICAL MANAGEMENT

Haemorrhoidectomy

Milligan–Morgan procedure

Ferguson technique

Stapled haemorrhoidopexy

LiagatureTM haemorrhoidectomy

Diathermy haemorrhoidectomy
PERIANAL ABSCESS
 ANORECTAL ABSCESS

Suppurative condition of the anorectal region.

Men are affected more than women.
Risk factors include Crohn’s disease, ulcerative
colitis,diabetes and immunocompromised patients.
The anal glands, are located around the anal canal
and the intersphincteric plane.
 ANORECTAL ABSCESS

Skin organisms (e.g. Staphylococcus aureus) and gut

flora e.g. Escherichia coli, Bactericides species.
predominate in ano rectal abscess.

Mycobacterium tuberculosis and Actinomycoses sp.

should also be excluded.
 CLINICAL FEATURES

Perianal abscess- throbbing pain and swelling.

Dull in character in the case of intersphincteric,
submucous and pelvirectal abscesses.
Tender, hot, fluctuant swelling in the perianal or
ischiorectal region.
In intersphincteric, submucous or pelvirectal
abscesses, the swelling and tenderness can be
appreciated only on rectal examination.
CLASSIFICATION
 MANAGEMENT

Examination under anesthesia (EUA)

De roofing of the abscess through a cruciate, elliptical or
simple incision & the abscess cavity should be curetted
thoroughly and all necrotic tissues excised.

In ischiorectal abscesses the possibility of a horseshoe

extension should be considered and laid open when the
area of induration involves both sides of the perineum
Cruciate incision –
perianal abscess
FISTULA IN ANO
 FISTULA IN ANO

 Communication between the anal canal and the perianal skin

 CAUSES OF ANORECTAL FISTULA

Trauma,
Idiopathic Anal Crohn’s
including
carcinoma disease
surgery

Ulcerative Lymphogranulo Tuberculosis Actinomycosi

colitis ma venereum s

Perforated
Foreign body
diverticular
disease
GOODSALL'S RULE
 CLINICAL FEATURES

Intermittent discharge associated with itching and

soreness in the perineal region.

History of a previous perianal abscess.

Previous anal surgery (e.g. haemorrhoidectomy) or a

history of inflammatory bowel disease.
 EXAMINATION

Inspection of the perineal region usually reveals an

external opening.
External openings may be multiple.
On rectal examination, the site of the internal
opening may be located by an area of induration.
The track may be felt as subcutaneous induration
between the openings.
 TREATMENT

The aim is to achieve complete healing without

impairing the function of the anal sphincter.
The initial step is to determine whether the fistula is
superficial or deep to the sphincter.
The internal opening may be seen easily by injecting
methylene blue or hydrogen peroxide into the track.
 TREATMENT

Once the track and internal opening have been

found, a grooved director is passed and the track
is laid open excising the granulation tissue in the
case of superficial and intersphincteric fistula.
SETON STICH
SETON STITCH
 TAKE HOME MESSAGE

Please do Digital Rectal Examination (D.R.E.)

in all patients with perianal complaints except
for anal fissures
Haemorrhoid examination includes
proctoscopy, and is not diagnosed by D.R.E.
PR bleeding in patients > 40 year old should
be referred for colonoscopy evaluation
TERIMA KASIH

THANK YOU