Anorectal Disorders

Armando G. Santos, MD, FPCS

Anatomy of the Anorectal
Region
 Anal Canal
 Anatomic anal canal
 Dentate line separates canal from
margin
 Based on differences in histology and
lymphatic drainage
 Anal canal lies superior to dentate line
 Anal margin is inferior to dentate line
 Surgical anal canal
 Anal verge separates canal from margin
 Margin is perianal skin just outside the
verge
 Anatomic Significance of Dentate Line
Anatomy Above dentate line Below dentate line
Innervation Autonomic Somatic
Venous Superior rectal vein
Middle rectal vein
blood into inferior into internal iliac
supply mesenteric, portal vein; inferior rectal
system vein into internal
pudendal vein
Lymphatic Inferior mesenteric, Inguinal lymph
flow internal iliac lymph nodes
nodes
 Incontinence: Clinical
Evaluation
 Ample history
 Examination
 Inspection/palpation

 Endoscopy

 Diagnostic tests:
 Endoanal ultrasound

 Manometry

 Electromyography

 Defecography
 Causes of Fecal Incontinence
CATEGORY MECHANISM COMMON CAUSES
Functional Fecal impaction; dilated Difficulty relaxing sphincter when
internal anal sphincter defecating: drug side effect, idiopathic,
spinal cord injury
Diarrhea; rapid transit Irritable bowel syndrome; infectious and
and/or large volume metabolic causes of diarrhea
Cognitive or Dementia, psychosis, willful soiling
psychological defect
Sphincter Sphincter muscle injury Anal surgery/Obstetric/Foreign body trauma
weakness Pudendal nerve injury Obstetric trauma, diabetic peripheral
neuropathy, multiple sclerosis
CNS injury Spinal cord injury, CVA, multiple sclerosis
Sensory loss Afferent nerve injury: Diabetic neuropathy, spinal cord injury,
unable to detect rectal multiple sclerosis
filling
Investigation of Fecal
Incontinence
Incontinence: Management
 Medical
 Stool transit/consistency

modification
 Biofeedback training of anal

muscles
 Surgical

 Direct sphincter repair

 Artificial sphincter implantation


 Incontinence: Summary
 Dx, including severity, of
incontinence must be established
 Defect and underlying cause must be
identified
 Treatment must be based on the
confirmed pathology
Medical or surgical management of
incontinence produces much less
than 100% success rate
 Hemorrhoids: Essential
Features
 Vascularized “cushions” normally
present in anal canal
 “Cushions” contain blood vessels,
smooth muscle, elastic and
connective tissue
 “Cushions” located in left lateral,
right anterior, right posterior anal
quadrants
 “Hemorrhoids” denote symptom-
producing abnormal “cushions”
 Hemorrhoids: Essential
Features
 Hemorrhoids classified as internal,
external, or mixed
 Severity graded as:
 First-degree

 Second-degree

 Third-degree

 Fourth-degree
 Hemorrhoids: A.
Thrombosed
external; B. Grade 1
internal; C. Grade 2
internal; D. Grade 3
internal; E. Grade 4
strangulated
internal and
thrombosed
external 
 Hemorrhoids: Clinical
Diagnosis
 Dx based on history, P.E., and
endoscopy
 Manifestations: rectal bleeding, pain,
mucus/fecal leakage, pruritus,
prolapse associated with BM
 Complications: bleeding, thrombosis,
strangulation, necrosis, perianal
sepsis

Other anorectal pathologies must be

considered and excluded before
 Hemorrhoids: Diagnostic
Investigation
 CBC
 Anoscopy
 Proctosigmoidoscopy
 Defecography – if with obstruction/rectal
prolapse
 Colonoscopy – if hemorrhoids
unimpressive with regards to presentation
or colon CA risk significant
Hemorrhoids: Management
 Supportive Mx
 Definitive Mx:
 Non-operative

 Surgical
Hemorrhoids: Management
 Non-operative Mx
 Rubber band ligation

 Sclerotherapy

 Infrared coagulation

 Heater probe coagulation

 Electrocoagulation
Rubber Band Ligation of
Internal Hemorrhoids
Hemorrhoids: Management
 Surgical Mx
 Open hemorrhoidectomy

 Milligan-Morgan

 Ultrasonic: Harmonic scalpel

 Controlled electrical energy: Liga-

Sure
 Closed hemorrhoidectomy

 Stapled hemorrhoidectomy
Closed Hemorrhoidectomy
Excision of Thrombosed
External Hemorrhoid
Grade 4 Mixed Hemorrhoids:
Stapled Hemorrhoidectomy
Stapled Hemorrhoidectomy
 Stapling Device with
Circumferential Excision of
Anal Canal and Hemorrhoid
Mucosa
 Internal Hemorrhoids:
Grading/Mx
GRADE S/Sx MANAGEMENT
First degree Bleeding; no Dietary
Second prolapse
Prolapse with modifications
Rubber band
degree spontaneous ligation
reduction Coagulation
Third degree Bleeding, leakage
Prolapse requiring Dietary
Hemorrhoidectomy
digital reduction modifications
Rubber band
Bleeding, leakage ligation Dietary
modifications
Fourth Prolapsed, cannot Hemorrhoidectomy
degree be reduced Dietary
Strangulated modifications
 Hemorrhoids: Summary
 Symptom-producing abnormal anal
“cushions”
 Other diseases esp. CA must be ruled
out before instituting Tx
 Supportive measures key to Mx of all
cases
 Definitive Tx indicated for more
advanced cases
 Anal Fissure: Essential
Features
 Linear ulcer in lower half of anal canal
 Posterior midline most common site
 Anterior midline fissure relatively common
among females
 Pathogenesis possibly related to:
 Internal sphincter hypertonia

 Mucosal ischemia

Bizarre site/number likely due to

secondary fissures
 Anal Fissure: Clinical
Diagnosis
 History and P.E. are key to Dx
 Main Sx: Pain during and after
defecation
 Bleeding: Blood on stool or toilet
tissue
 Triad for chronic cases:
 Fissure
 Sentinel pile
 Hypertrophied papilla
 Digital exam may provoke sphincter
Posterior Anal Fissure
 Acute Anal Fissure (Left);
Chronic Anal Fissure (Right)
 Anal Fissure: Diagnostic
Investigation
 Hx and P.E. usually adequate basis
for Dx
 Endoscopy – to rule out malignant or
inflammatory disease
 Biopsy of ulcer – in suspected
secondary fissures
 Anal Fissure: Management
 Supportive Tx for acute fissures
 Tx options for chronic fissures or
failure of conservative measures:
 Non-operative

 Surgical
 Anal Fissure: Management
 Non-operative Tx:
 Topical nitroglycerin
 Topical calcium channel blocker

 Botulinum toxin injection

 Anal Fissure: Management
 Surgical Tx:
 Partial lateral internal
sphincterotomy
 Anorectal advancement flap

 Anal divulsion (Lord procedure)

Sphincterotomy, if improperly done,

may result in fecal incontinence
Partial Lateral Internal
Sphincterotomy
 Anal Fissure: Summary
 Primary fissures likely produced by
internal sphincter hypertonia and
subsequent mucosal ischemia
 Primary fissures mostly located in
posterior midline
 Partial lateral internal sphincterotomy
surgical Tx of choice for chronic fissures
 Ulcers being secondary fissures should be
considered and ruled out
Anorectal Abscess and Fistula:
Essential Features
 Primary suppuration and fistula result from
non-specific cryptoglandular infection
 Abscess represents acute phase; fistula
the chronic sequela
 Starts as anal gland infection in
intersphincteric space (intersphincteric
abscess)
 Secondary lesions may be due to
malignancy, Crohn’s disease, hidradenitis
suppurativa, TB, etc
Anorectal Abscess and
Fistula
Anorectal Abscess and Fistula:
Essential Features
 Types of abscess according to space
invaded
 Intersphincteric

 Perianal

 Intermuscular

 Supralevator

 Ischiorectal
Modes of Spread from Primary
Locus in Intersphincteric Zone
Classification of Anorectal
Abscesses
Formation of Acute Pararectal
Abscess and Recommended
Drainage
 Planes for Circumferential
Spread or “Horseshoeing” of
Abscess
Anorectal Abscess and Fistula:
Clinical Diagnosis
 Anal/perianal pain
 Perianal/rectal induration and
swelling
 Purulent or bloody drainage
 Perineal sepsis
 External opening with mucopurulent
or bloody drainage in anal fistula
 Palpable firm fistulous tract
Anorectal Abscess
External Opening of Anal
Fistula
 Classification of Anorectal
Fistulas
1. Intersphincteric
2. Trans-sphincteric
3. Suprasphincteric
4. Extrasphincteric
Main Anatomic Types of
Fistulas
Intersphincteric Fistula
Transsphincteric Fistula: High
Type
Anorectal Abscess and Fistula:
Diagnostic Investigation
 Imaging studies not needed for
uncomplicated abscesses and fistulas
 Imaging studies for complex or
recurrent fistulas:
 Fistulogram
 Endoanal/endorectal ultrasound
 CT scan
 MRI
Endoanal UTZ of a Complex
Fistula
MRI Fistulogram of a
Supralevator Fistula
 Anorectal Abscess:
Management
 Antibiotics not necessary for the
average patient
 Surgical drainage – Tx of choice
 Prompt drainage and antibiotics
indicated in diabetic or
immunocompromised patients
 Fistulotomy may be delayed if
internal opening not readily identified
Incision and Drainage of an
Ischiorectal Abscess
 Anal Fistula: Management
 Fistulotomy
 Seton placement
 Injection of fibrin glue
 Insertion of porcine small intestinal
submucosa (SIS) plug
 Goodsall Rule

Goodsall rule is of little use in complex or

recurrent fistulas
Fistulotomy
 Surgery of Transsphincteric
Fistula with Horseshoe Spread
Seton Placement in High Type
of Transsphincteric Fistula
Anal Fistula SIS Plug
Anorectal Abscess and Fistula:
Summary
 Primary lesions arise from
cryptoglandular infection
 Imaging studies helpful in complex
cases
 Surgical drainage primary Tx for
abscesses
 Tx options for fistulas: fistulotomy,
seton placement, fibrin glue
injection, SIS plug
 Tx tailored so as to prevent fecal
 Cancer of the Anal Canal and
Anal Margin: Clinical
Features/Evaluation
 Canal cancers develop cephalad to
anal verge
 Most canal tumors share similar
behavior in clinical presentation,
response to treatment, and prognosis
 Margin cancers arise in perianal skin
adjacent to anal verge
 Viral infection (HPV, HIV) important
factor
 Cancer of the Anal Canal and
Anal Margin: Clinical
Features/Evaluation
 Local symptoms: mass, bleeding,
pruritus
 Distant manifestations: weight loss
 Perianal skin alterations
 DRE: tumor location/mobility/fixity;
integrity of sphincter mechanism
 Endoscopy: size and location of
tumor in relationship to dentate
line/anal verge/anorectal ring
 Cancer of the Anal Canal and
Anal Margin: Clinical
Features/Evaluation
 P.E. for spread: organomegaly, groin
adenopathy
 Tests for tumor extent and
metastasis
 Chest radiography
 Endoanal ultrasound
 CT
 MRI
 Anal Margin Tumors
 Anal squamous cell carcinoma in situ
(Bowen's disease) and anal
intraepithelial neoplasia (AIN)
 Paget's disease
 Basal cell carcinoma
 Squamous cell carcinoma
 Verrucous carcinoma (giant
condyloma acuminatum)
 Anal Canal Tumors
 Epidermoid carcinoma:
 Squamous
 Basaloid
 Cloacogenic
 Mucoepidermoid
 Melanoma
 Adenocarcinoma
 Mx of Anal Margin Tumors
Bowen's Disease
Accurate lesion mapping

Wide local excision with flap repair as

indicated
Exclude locally invasive component or

associated gynecologic malignancy

Paget's Disease
Accurate lesion mapping

Wide local excision with flap repair as

indicated
Exclude underlying malignancy

APR and chemotherapy/radiotherapy if

 Mx of Anal Margin Tumors
Basal Cell and Anal Margin
Squamous Cell Carcinoma
Local excision with clear margins

Radiation or chemotherapy in poor-

prognosis lesions or recurrence as indicated

Verrucous Carcinoma
Wide local excision; APR if extensive

Combined-modality Tx if transformation to

squamous cell cancer has occurred

 Mx of Anal Canal Tumors
Epidermoid Cancer
Combined-modality: external-beam radiation Tx
plus 5-FU plus mitomycin
APR if incontinent or local Tx failure or recurrence

after combined chemo and radiation therapy

Triple-modality therapy in bulky T3 and T4 lesions

(role of APR controversial)

Adenocarcinoma
APR with 5-FU and radiation therapy as

indicated
Melanoma
APR if potentially curable
Local excision if established metastases
Bowen's Disease
Paget's Disease
Basal Cell Carcinoma of Anal
Margin
Verrucous Carcinoma Arising
from Genital Warts
Anal Canal Amelanotic
Melanoma
Anal Margin Squamous Cell
Carcinoma
Have a nice day!