Common Office Anorectal Common Office Anorectal ProblemsProblems

Sandra J. Beck, M.D., FACS, FASCRSAssociate Professor of Colon and Rectal Surgery

University of Kentucky Medical Center

DisclosuresDisclosures

None

Benign Anal Rectal DiseaseBenign Anal Rectal Disease

Anatomy of the anal canal and perianal spaces

Benign Anal Rectal Disease– Abscess and Fistula– Fissure– Hemorrhoids

Overview of AnatomyOverview of Anatomy

Anatomy

– Pelvic and Perirectal Spaces

– Anatomy of Anal Canal

Retrorectal Space

Waldeyer’s FasciaSupralevator Space

Levator Ani Muscle

Deep Postanal Space

Superficial PostanalSpace

Peritoneum

Levator Ani m.

Puborectalis m.

Deep External Sphincter m.

Internal Sphincter m.

Transverse Septum

SupralevatorSpace

Ischioanal Space

IntersphinctericSpace

Perianal Space

ANAL CANAL

ANAL CANAL

Anal TransitionalZone

Column ofMorgagni

Dentate Line

Anal Crypt

Anal Gland

Anoderm

Patient complaintsAnal PainBleedingDrainage

Time course

FissureKnifelike pain with BM

Passing Glass Brick, ThrobingPain with BM:minutes to hours

Blood on toilet paperNo drainage

Small tag or “hemorrhoid”

HemorrhoidAcute or Chronic

Bleeding itching burning Sudden swelling, +/- pain

ProlapseDifficulty with hygiene

Pain rarely knifelike

AbscessGenerally Acute Minimal bleeding

Pain Swelling over largearea not associated with BM

+/-Purulent DrainageRapid increase in size

Diagnosis and Treatment of Diagnosis and Treatment of Anorectal Abscess and Fistula-in-Anorectal Abscess and Fistula-in-

AnoAno

Anorectal Abscess Anorectal Abscess EtiologyEtiology

Cryptoglandular abscess– Most common– Infection in the glands at the dentate line

Other causes– Crohn’s and Ulcerative Colitis– Tuberculosis and Actinomycoses– Malignancy– Foreign Bodies, Prostate Surgery or Radiation

Fistula DescriptionFistula Description

Clock description– Does the anus tell time?– Relies on description of patient’s position:

supine, lateral, prone and relative landmarks

Anatomic description: more consistent– Pubic bone defines anterior– Coccyx define posterior– Right and left– *If terms be incorrect, then statements do not accord with

facts; and when statements and facts do not accord, then

business is not properly executed." Confucius 1

Tailbone

Right anterior

Right posterior

Left anterior

Left posterior

Right Left

Pubic bone

There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained

Abscess ClassificationAbscess Classification

Four Types Based on Space Involved

– Perianal - 19-54%

– Intersphincteric - 20-40%

– Ischioanal - 40-60%

– Supralevator 2% or less

Most Common

Rare

SupralevatorAbscess

Perianal AbscessIschioanal Abscess

IntersphinctericAbscess

SupralevatorSpace

IntersphinctericSpace

Ischioanal Space

HORSESHOE ABSCESS

Anorectal AbscessAnorectal AbscessTreatment of Perianal and Treatment of Perianal and

Ischiorectal AbscessesIschiorectal Abscesses Diagnosis - usually straightforward

– Erythema and Pain over affected area– Fluctuance

Treatment– Incision and Drainage– +/- Excision of small amount of overlying skin– Initial packing for hemostasis– Drainage catheter (Pezzer) or pack wound– Attention to good hygiene and control blood

sugar– Antibiotics if immunocompromised, obese or

diabetic

Small Radial incisionSmall Radial incisionShort distance from anus – feel for soft spotShort distance from anus – feel for soft spotPlace drain and trim – avoids packingPlace drain and trim – avoids packingFollow up in 7-10 days to remove drainFollow up in 7-10 days to remove drain

Catheter TypesCatheter Types

Pezzer catheter Solid mushroom

top so stays in Less tissue

ingrowth

Malecot Allows tissue

ingrowth More painful to

remove

Peri anal abscess - ? AntibioticsPeri anal abscess - ? Antibiotics

Not usually indicated if there is adequate drainage

Indicated for patients with:– Obesity– Diabetes– Imunocompromised– Extensive large abscess or recurrent

abscess

Fistula-in-AnoFistula-in-AnoDefinition

– abnormal connection between two epithelial surfaces.

Classification:– Parks: Defines fistula by course of tract– Goodsall’s rule

DiagnosisTreatment

– Goals– Options

How does patient present?How does patient present?

May have had a history of abscess History of Crohn’s disease May present at the same time as abscess Complain of intermittent increase in

pain/swelling followed by spontaneous drainage

Chronic localized area of irritation or ulcer “pimple near my anus keeps coming back”

Fistula-in-AnoFistula-in-AnoGoodsall’s RuleGoodsall’s Rule

Posterior

Anterior

Fistula in anoFistula in ano

Fistula in ano: Surgical diseaseFistula in ano: Surgical disease

Refer to Colon and Rectal Surgeon or General Surgeon

Reassure patient – rarely cancer, most do not need a colostomy

If suspect Crohns– Gain control of perianal sepsis– Then complete full workup and staging

Goals of therapy– Get rid of the fistula/connection– Preserve continence

Surgical OptionsSurgical Options

Primary fistulotomy– Mainly for low, superficial fistula– Risk of fecal incontinence

Fibrin Glue/Fistula Plug– Utilizes substrate as scaffold to fill tract– Does not involve cutting muscle

Cutting or draining setons– For deeper tracts that involve significant muscle– Risk of fecal incontinence

Rectal advancement flap Lateral internal fistula transection

– Newer procedure. No foreign substrate– Cuts fistula tract, not muscle

Fistula in anoFistula in ano

Fistula in anoFistula in ano

Fissure in AnoFissure in Ano

Definition – a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus– Overlie the lower half of the internal

sphincter– ~73.5% are posterior– ~16.4% are anterior– ~2.6% both anterior and posterior

Fissure in AnoFissure in AnoPathogenesisPathogenesis

Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus

Secondary changes of chronic fissure include– Sentinel pile or skin tag at the distal end– Hypertrophied anal papilla-swelling, edema

and fibrosis near the dentate line– Fibrosis of the internal sphincter at the base

Fissure with Sentinel TagFissure with Sentinel Tag

Fissure with Sentinel TagFissure with Sentinel Tag

Fissure in AnoFissure in AnoPathogenesisPathogenesis

Perpetuating factors in chronic fissure– Persistent hard bowel movement– Abnormal high resting pressure in the

internal anal sphincter– Increased pressure in the sphincter

causes a decrease in blood flow, preventing healing of the fissure

Fissure in AnoFissure in AnoSymptomsSymptoms

Pain is the main symptom– Sharp, cutting or tearing during

defecation– Duration is few minutes to hours

Bleeding – bright red and scantSkin Tag Mucous discharge resulting in

itching

Fissure in AnoFissure in AnoDiagnosisDiagnosis

Diagnosis often made on history alone Inspection – gently spread the buttocks

and the fissure becomes apparent Triad of chronic anal fissure

– Sentinel pile– Hypertrophied anal papilla– Anal ulcer

Fissure in AnoFissure in AnoDifferential DiagnosisDifferential Diagnosis

Intersphincteric abscessPruritus AniFissure from inflammatory bowel

diseaseCarcinoma of the anusInfectious Perianal conditionsLeukemic infiltration

Fissure in AnoFissure in AnoCrohn’s Anal FissuresCrohn’s Anal Fissures

Acute Fissure in AnoAcute Fissure in AnoTreatmentTreatment

Increase dietary fiberLocal anesthetic to prevent spasmNitroglycerin or Nifedepine Ointment

– Not commercially available– Must be mixed by pharmacist

Warm tub soaks4-6 weeks of treatment

Chronic Fissure in AnoChronic Fissure in AnoSurgical TreatmentSurgical Treatment

Indicated on Chronic non-healing anal fissure and fissure that is refractory to medical therapy– Lateral Internal Sphincterotomy

• Forces the muscle to relax

– V-Y Anoplasty flap• Allow coverage of fissure with healthy

tissue

HemorrhoidsHemorrhoids

What are they?Where are they?Why do they become symptomatic?Classification?How do you treat them?Can they be avoided?

HemorrhoidsHemorrhoidsWhat are they?What are they?

Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissue

Aid in anal continence

HemorrhoidsHemorrhoidsWhere are they?Where are they?

Internal Hemorrhoids– 3 major bundles – left lateral, right anterior and

right posterior– Above the dentate line– Blood drains into the superior rectal vessels

then into the portal circulation External Hemorrhoids

– Below the dentate line– Blood drains through the inferior rectal veins

to the pudendal veins on into the iliac veins

HemorrhoidsHemorrhoidsSymptoms? Symptoms?

Chronic constipation Diarrhea Trauma to the hemorrhoids during

defecation cause the most common symptoms– Pain – generally not “knife-like”– Itching– Burning– Bleeding

HemorrhoidsHemorrhoidsClassification- Internal HemorrhoidsClassification- Internal Hemorrhoids1st degree – bulge into the lumen 2nd degree – prolapse with bowel

movement but reduce spontaneously3rd degree – prolapse spontaneously

and require manual reduction4th degree – permanently prolapsed

hemorrhoids that cannot be reduced

44thth Degree Hemorrhoids Degree Hemorrhoids

HemorrhoidsHemorrhoidsTreatment PrinciplesTreatment Principles

Thorough physical exam to determine severity and rule out other pathology– Refer for surgical evaluation if white or

discolored, firm or fixedDetermine if the problem is internal,

external or bothAssess the symptom complex

TreatmentTreatment

Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream…

Conservative therapy– Bulk agents – i.e. high fiber

• Fruits, vegetables, oat bran, psyllium

– Increase water intake– Avoid caffeinated beverages– Avoid prolonged sitting on the commode– Warm tub soaks

TreatmentTreatmentOffice and Minor ProceduresOffice and Minor Procedures

Rubber band ligation– Performed in the office– Indicated for Grade 1 and 2 internal

hemorrhoids– Band is applied through an anoscope at the

top of an internal hemorrhoid– Severe perianal sepsis – Classic Triad

• Delayed anal pain• Urinary retention• Fever

TreatmentTreatmentOffice and Minor ProceduresOffice and Minor Procedures

Infrared Photocoagulation– Indicated in 1st degree hemorrhoids– Causes photocoagulation of small

vessels– Performed in office or “Hemorrhoid

Relief Center”– Minimal pain

Closed HemorrhoidectomyClosed HemorrhoidectomyIndicationIndication

Hemorrhoids are severely prolapsed and require manual replacement

Patients fail to improve after multiple applications of non-operative treatment

Hemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags

Closed HemorrhoidectomyClosed HemorrhoidectomyGeneral PrincipleGeneral Principle

Most can be performed with local and IV Sedation

Prone/Kraske position is the bestInfuse the area with local anesthetic

with epinephrine for hemostasisFleets enema 1-2 hours priorNo antibiotic prophylaxis is

necessary

Closed HemorrhoidectomyClosed Hemorrhoidectomy

Closed HemorrhoidectomyClosed Hemorrhoidectomy

Closed HemorrhoidectomyClosed HemorrhoidectomyPost op ResultPost op Result

PPH Stapling Procedure for PPH Stapling Procedure for HemorrhoidsHemorrhoids

Not for every hemorrhoidIdeal for Grade 2 and 3 with minimal

external componentPrevents prolapse and thus less

trauma to hemorrhoid with bowel movement

PPH Stapling Procedure for PPH Stapling Procedure for HemorrhoidsHemorrhoids

PPH Stapling Procedure for PPH Stapling Procedure for HemorrhoidsHemorrhoids

Benefits– Less pain as compared to traditional

closed hemorrhoidectomy– Less blood loss during the procedure– Less chance of anal stenosis

PPH Stapling Procedure for PPH Stapling Procedure for HemorrhoidsHemorrhoids

Risks– If staple placed too low – severe chronic

pain and incontinence– If staple line placed too high – failure to

relieve symptoms of hemorrhoids– Hemorrhoids are not removed so they

may continue to bleed– Perianal sepsis– Rectovaginal fistula

Perianal CondylomaPerianal Condyloma

Can sometimes be difficult to distinguish from hemorrhoids

Cauliflower type appearance History of HIV, History of abnormal pap

smear Homosexual males usually but can be

seen in the heterosexual population Caused by HPV virus Increased risk of anal cancer in the

immunocompromised patient

Treatment - TopicalsTreatment - Topicals

Aldara (Imiquinod) >50% initial responseTopical 5-FU – 90% initial responseCondylox (podofilox)

Each have high local toxicity Practice Parameters for Anal SquamousNeoplasms

www.fascrs.org

TreatmentTreatment

Photodynamic therapyWide Local ExcisionTargeted destruction with cautery

and/or Infrared coagulationObservation of AIN I/II with removal

of visualized lesionsExcision of AIN III

Anal Squamous AINAnal Squamous AIN

High recurrence rate with all techniques

Close follow up to detect progression to invasive carcinoma

Anal pap smear vs high resolution anoscopy

Optomize underlying conditions

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