Benign Anorectal Conditions

Ahmed Badrek-Amoudi FRCS

 Anorectal Anatomy
Arterial Supply Nerve Supply

Inferior rectal A Sympathetic: Superior

middle rectal A hypogastric plexus

Venous drainage
:Parasympathetic
Inferior rectal V
S234 (nerviergentis
middle rectal V

:Pudendal Nerve
hemorrhoidal 3
complexes Motor and sensory
L lateral
R antero-lateral
R posterolateral Anal canal

Lymphatic drainage
Above dentate: Inf. Mesenteric Anal verge
Below dentate: internal iliac
Haemorrhoids
Back Ground
• They are part of the normal
anoderm cushions
• They are areas of vascular
anastamosis in a supporting stroma
of subepithelial smooth muscles.
• The contribute 15-20% of the normal
resting pressure and feed vital
sensory information .
• 3 main cushions are found
• L lateral
• This combination
R anterior
is only in 19%
• R posterior
• But can be found anywhere in anus
• Prevalence is 4%
• Miss labelling by referring
physicians and patients is common
Haemorrhoids
Pathogensis
Abnormal haemorrhoids are dilated cushions of arteriovenous
plexus with stretched suspesory fibromuscular stroma with
prolapsed rectal mucosa
3 main processes: 1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone
Risk Factors
Pathological Habitual
1. Chronic diarrhea (IBD) 1. Constipation and straining
2. Colon malignancy 2. Low fibre high fat/spicy diet
3. Portal hypertension 3. Prolonged sitting in toilet
4. Spinal cord injury 4. Pregnancy
5. Rectal surgery 5. Aging
6. Episiotomy 6. Obesity
7. Anal intercourse 7. Office work
8. Family tendency
Haemorrhoids
:Classification
Degree of prolapse through anus Origin in relation to Dentate line
•1st: bleed but no prolapse 1. Internal: above DL
•2nd: spontaneous reduction 2. External: below DL
•3rd: manual reduction 3. Mixed
•4th: not reducable
Haemorrhoids
Clinical assessment
Examination History ( Full history required)
Local Haemorrhoid directed:
•Inspect for: •Pain acute/chronic/
–Lumps, note colour and cutaneous
reducability •Lump acute/ sub-acute
–Fissures •Prolapse define grade
–Fistulae •Bleeding fresh, post defecation
–Abscess •Pruritis and mucus
•Digital: General GI:
–Masses •Change in bowel habit
–Character of blood and mucus •Mucus discharge
•Perform proctoscopy and •Tenasmus/ back pain
sigmoidoscopy •Weight loss
•Anorexia
•Other system inquiry
General abdominal examination
Haemorrhoids
:Investigations
The diagnosis of haemorrhoids is based on
clinical assessment and proctoscopy

Further investigations should be based on a

clinical index of suspicion
• Lab: CBC / Clotting profile/ Group and save
• Proctography: if rectal prolpse is suspected
• Colonoscopy: if higher colonic or sinister pathology is
suspected
 Complications
1. Ulceration
2. Thrombosis
3. Sepsis and abscess formation
4. Incontinence

Thrombosed Thrombosed
internal external
haemorrhoids haemorrhoids
Haemorrhoids
: Internal H. Treatment
Grade 1&2 Conservative
• Dietary modification: high fibre diet Measures
• Stool softeners
• Bathing in warm water
• Topical creams NOT MUCH VALUE

Indicated in failed medical treatment and grades 3&4 Minimally

• injection sclerotherapy invasive
• Rubber band ligation
• Laser photocoagulation
• Cryotherapy freezing
• Stapled haemorrhoidectomy
Indications: Surgical
1. Failed other treatments
2. Severely painful grade 3&4
3. Concurrent other anal conditions
4. Patient preference
Haemorrhoids
: External H. Treatment
• If presentation less than 72 hours:
• Enucleate under LA or GA
• Leave wound open to close by secondary intension
• Apply pressure dressing for 24 hours post op

• If more than 72 hours:

• Conservative measures
Perianal Fistula and Abscess
Perianal abscess almost always arise 5%
from a fistulous tract. It is an infection of
the soft tissue surrounding the anus.

Aetiology & Pathogenesis:

•4-10 glands at dentate line.
•Infection of the cryptglandular epithelium
resulting from obstruction of the glands.
•Ascending infection into the intersphincteric
space and other potential spaces.
•Bacteria implicated:
E.Coli., Enterococci, bacteroides

Other causes:
•Crohn
•TB 60% 5% Ischiorectal
20%
•Carcinoma, Lymphoma and Leukaemia
•Trauma Intersphincteric suprasphincteric

•Inflammatory pelvic conditions (appendicitis) Trans-sphincteric extrasphincteric

Perianal Abscess
Clinical presentation

Clinical presentation Abscess

•Perianal pain, discharge (pus) and fever Perianal
•Tender, fluctuant, erythematous subcutaneous
lump
•Chills, fever, ischiorectal pain Ischio-rectal
•Indurated, erythematous mss, tender
•Rectal pain, chills and fever, discharge Intersphincteric
•PR tender. Difficult to identify are. EUA needed Supralevator
Peri-anal Fistula
Clinical presentation
• Follow 40-60% of perianal Godsalls law
abscess and cryptgland
Anterior: drain straight
infections
Posterior: drain curved to anorectal
midline
• Presentation:
– External openings
– Purulent discharge
– Blood
– Perianal pain

Also associated with:

•IBD
•Malignancy
•TB/ Actinomycosis
•Diverticular disease
Perianal Abscess
Management
Aim: adequate drainage of abscess
preservation of sphincter function

Treatment Abscess
•Incision and drainge de-roof cavity Perianal
•pack with gauze and iodine
•IV AB, sitz bath tid, laxitives and anlgesia Ischio-rectal
•F/U for fistula

•I&D through interspgincteric plane. Intersphincteric

•Treat the underlying cause Supralevator

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.
Perianal fistula
Managment
Aim: Define anatomy
Eliminate tract
preservation of sphincter function

Treatment Fistula
•Fistulotomy vs fistulectomy Perianal
•Complex treatments using seton Trans/Extra/Supra
sphincteric

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.
Anal Fissure
• Linear tears in the anal mucosa exposing the internal sphincter
• 90% are posterior
• Caused mainly by trauma ( hard Stool). Followed by increased
sphincter tone and ischemia.
• Other causes: IBD, Ca, Chronic infections
Anal Fissure
Clinical Assessment
Chronic Acute

•Pain mild to •Sever acute

moderate pain
•More than 6 •Fresh blood
weeks spotting
•Hypertrophied •Clean linear
Int.sphincter tear.
•Skin tag
•Granulation
around the
edge
Anal Fissure
Treatment

Surgical Conservative
Lateral sphincterotomy •High fibre diet
•Medical
sphincterotomy:
–GTN
–Ca channel blockers
–Butulinum toxins
Pilonidal Sinus
Pathogenesis:
A sinus tract at natal cleft resulting from:
• Blockage of hair follicle
• Folliculitis
• Abscess followed by sinus formation.
• Hair trapping
• Foreign body reaction
• The sinus tract is cephald

Associated with:
• Caucasians
• Hirsute
• Sedentary occupations
• Obese
• Poor hygeine
Presentation & Treatment
Incision and drainage abscess Acute

Recurrence: 40%

Wide local excision Pain and Chronic

• with primary closure or discharge
• closure by secondary
intension

Recurrence: 8-15%
• Also found: umbilicus, finger webs, perianal area