Benign anorectal

conditions

By Ibrahim M.
 Benign anorectal conditions refer to non-cancerous issues affecting the anus
and the rectum and common examples may include hemorrhoids, anal fissures,
anal fistulas and rectal prolapse.
 Understanding benign anorectal conditions is important for accurate diagnosis
and differentiating between the different benign anorectal conditions to provide
effective treatment strategies.
 Different diagnostic methods for benign anorectal conditions may include:
 Physical examination for example digital rectal examination to assess the
rectum for fissures, prolapse or tenderness.
 Colonoscopy
 Imaging studies such as Endoanal ultrasound which provides detailed images
of the anal sphincters and surrounding tissues which is useful in detecting
fistulas.
 Surgical anatomy
 Rectum begins where the taenia coli of the sigmoid colon join
to form a continuous outer longitudinal muscle layer at the
level of the sacral promontory.
 The rectum follows the curve of the sacrum
 Ends at the anorectal junction.
 Puborectalis muscle encircles the posterior and lateral aspects
of the junction
 Has 3 lateral curvatures: the upper and lower are convex to the
right, and the middle is convex to the left.
 These curves are marked by semicircular folds (Houston’s
valves)
 Ampulla of the rectum. part of the rectum below the middle valve has wider diameter than
the upper third
 The adult rectum is 12–18 cm in length
 Divided into 3 equal parts:
 Upper third; mobile and has a peritoneal coat
 Middle third; peritoneum covers only the anterior and part of the lateral surfaces
 Lowest third; which lies deep in the pelvis
 The lower third of the rectum is separated by a fascial condensation
 Denonvilliers’ fascia; from the prostate/vagina in front
 Waldeyer’s fascia; from the coccyx and lower two sacral vertebrae
 These fascial layers are surgically important as they are a barrier to malignant invasion
 Blood supply
 Superior rectal artery branch of inferior mesenteric artery main arterial supply of the rectum.
 Middle rectal artery branch of internal iliac artery
 Inferior rectal branch of internal pudendal artery
 Venous drainage
 Superior haemorrhoidal veins drain the upper half of the anal canal above the dentate line
pass upwards to become the rectal veins: these unite to form the superior rectal vein..
 Main symptoms of rectal  Examination of the rectum
disease ■ Visual inspection of the
■ Bleeding per rectum perineum
■ Altered bowel habit ■ Digital examination
■ Mucus discharge ■ Proctoscopy
■ Tenesmus ■ Sigmoidoscopy – rigid or
flexible
■ Prolapse
 PROLAPSE

 Mucosal prolapse
 The mucous membrane and submucosa of the rectum protrude outside the anus for approximately
1–4 cm.
 In infants
 Predisposing factors;
 The direct downward course of the rectum
 undeveloped sacral curve- the absence of a normal sacral curve predisposes to rectal prolapse in an infant
 And reduced resting anal tone
 which offers diminished support to the mucosal lining of the anal canal
 In children
 Follows an attack of diarrhoea
 Loss of weight and consequent loss of fat in the ischiorectal fossae.
 Fibrocystic disease
 Neurological causes
 Maldevelopment of the pelvis.
In adults

 Often associated with third-degree hemorrhoids.

 In the female a torn perineum
 In the male straining from urethral obstruction
 In old age, both mucosal and full-thickness prolapse are associated with atony of the
sphincter mechanism
 Partial prolapse
 follows fistulectomy.
 localised to the damaged quadrant
 progressive.
 Prolapsed mucous membrane is pink;
 prolapsed internal hemorrhoids are plum coloured and more pedunculated.
 Treatment
 In infants and young children
 Digital repositioning and treatment of the underlying causes
 Submucosal injections
 Failure of repositioning after 6 weeks
 Injections of 5% phenol in almond oil are carried out under general anaesthestic.
 As a result of the aseptic inflammation following these injections, the mucous membrane becomes
tethered to the muscle coat.
 Surgery; Rectopexy
 In adults
 Local treatments
 Submucosal injections of phenol in almond oil
 Application of rubber band
 Excision of the prolapsed mucosa
 When the prolapse is unilateral, the redundant mucosa can be excised or, if circumferential, an
endoluminal stapling technique can be used.
Full-thickness prolapse
 Procidentia
 Less common than the mucosal variety.
 The protrusion consists of all layers of the rectal wall
 associated with a weak pelvic floor.
 Commence as an intussusception of the rectum, which descends to protrude outside the anus.
 Starts with the anterior wall of the rectum, where the supporting tissues are weakest, especially in
women.
 It is commonly as much as 10–15 cm in length
 prolapse over 5 cm in length contains anteriorly between its layers a pouch of
peritoneum
 When large, the peritoneal pouch contains small intestine,
 The anal sphincter is patulous and gapes widely on straining to allow the rectum to
prolapse.
 Common in the elderly.
 Women are affected more than men, and it is commonly associated with prolapse
of the uterus.
 In approximately 50% of adults, faecal incontinence is also a feature.
 Differential diagnosis
 Ileocaecal intussusception
 In rectosigmoid intussusception, there is a deep groove between the emerging
protruding mass and the margin of the anus, into which the finger can be placed.
Treatment

 Surgery is the mainstay of treatment

 Perineal or the abdominal approaches.
 Perineal approach
 Thiersch operation
 steel wire or, a silastic or nylon suture is pressed around the anal canal.
 Problems; breakage of the suture, chronic perineal sepsis, or the anal stenosis

Delorme’s operation
 Altemeier’s procedure
 Excision of the prolapsed rectum and associated sigmoid colon from
below, and construction of a coloanal anastomosis

Abdominal approach
 Principle; Replacement and holding the rectum in its proper
position.
 Indication; complete prolapse who are otherwise in good
health.
 Wells’operation, the rectum is fixed firmly to the sacrum
using a sheet of polypropylene mesh
 Ripstein’s operation involves hitching up the rectosigmoid
junction by a Teflon sling to the front of the sacrum
 Rectopexy; Suturing the mobilised rectum to the sacrum
using four to six interrupted non-absorbable sutures
 PROCTITIS
Inflammation of the rectal mucosa; can be acute or chronic.
It can be associated with involvement of the colon
(proctocolitis)

 Symptoms  Investigations
 passage of blood and mucus  Proctoscopy
 Pus in severe cases  Sigmoidoscopy
 Tenesmus  colonoscopy
 malaise and pyrexia.  Pathological
 mucosa feels swollen and is often  bacteriological examination
tender.  culture of the stools
Treatment; usually self-limiting, but treatment with topical 5-
aminosalicylic acid compounds (5-ASA) (Asacol, Penasa) in
the form of suppositories or foam enemas is effective.

 Proctitis due to specific infections

 Ulcerative proctocolitis
 Chron’s proctitis
 Clostridium difficile
 Bacillary dysentry
 Amoebic dysentry
 Amoebic granuloma
 Tuberculous proctitis
 Gonococcal proctitis
 Lymphogranuloma venerum
 Acquired Immunodeficiency syndrome
 Strawberry lesion of the rectosigmoid
 Rectal bilharzias
 Proctitis due to herbal enemas
 ANAL FISSURE

 A longitudinal split in the anoderm of the distal anal canal which extends from the anal
verge proximally towards, but not beyond, the dentate line.
 Aetiology
 Not completely understood.
 Strained evacuation of a hard stool
 Repeated passage of diarrhoea.
 Symptoms:
 Pain on defecation
 Bright-red bleeding
 Mucous discharge
 Constipation
 Itching/irritation
 Discharge
 NOTE; Chronic fissures are characterised by a hypertrophied anal papilla internally and a
sentinel tag externally
 Treatment
 Conservative mgt is the mainstay of treatment of acute and the majority of
chronic fissures.
 Addition of fibre to the diet to bulk up the stool,
 stool softeners
 Adequate water intake
 Warm baths
 Topical local anaesthestic agents relieve pain
 Anal dilatation
 Mainstay of conservative management is the topical application of pharmacological
agents that relax the internal sphincter
 nitric oxide
 glyceryl trinitrate (GTN) 0.2% applied four times per day
 diltiazem 2% applied twice daily.

 Operative measures
 Forceful manual sphincter dilatation to reduce sphincter tone
 There is a risk of incontinence
 HAEMORRHOIDS
 Haemorrhoids or piles are symptomatic anal cushions
 Cushions; highly vascularized discrete masses of thick submucosa containing
blood vessels, smooth muscle, and elastic and connective tissue.
 located in the left lateral, right anterior, and right posterior quadrants of the
canal to aid in anal continence
 They are more common when intra-abdominal pressure is raised, e.g. in
obesity, constipation and pregnancy
 Classically, they occur in the 3, 7 and 11 o’clock positions with the patient in
the lithotomy position
 Internal haemorrhoids; Are symptomatic anal cushions and characteristically lie
in the 3, 7 and 11 o’clock positions
 External haemorrhoids
 External haemorrhoids associated with internal haemorrhoids (‘interoexternal
piles’)
 Secondary internal haemorrhoids; Arise as a result of an underlying condition
or caused by factors such as chronic constipation, straining during bowel
movements or other medical conditions.
 Etiology
 Local; anorectal deformity, hypotonic anal sphincter;
 Abdominal; ascites;
 Pelvic; gravid uterus, uterine neoplasm (fibroid, carcinoma of the uterus or cervix),
ovarian neoplasm, bladder carcinoma
 Neurological; paraplegia, multiple sclerosis.
 Primary internal haemorrhoids
 Portal hypertension
 Vascular diseases
 Anal infection
 Diet and stool consistency
 Anal hypertonia
 Ageing
 Symptoms of haemorrhoids:
– bright-red, painless bleeding
– mucus discharge
– prolapse
– pain only on prolapse
Four degrees of haemorrhoids
 First degree; bleed only, no prolapse
 Second degree; prolapse but reduce spontaneously
 Third degree; prolapse and have to be manually reduced
 Fourth degree; permanently prolapsed
 Treatment of haemorrhoids
 Symptomatic – advice about defaecatory habits, stool softeners and bulking agents
 Injection of sclerosant
 Banding
 Haemorrhoidectomy
 Indications for Haemorrhoidectomy include:
 Third- and fourth-degree haemorrhoids;
 Second-degree haemorrhoids that have not been cured by non-operative treatments;
 fibrosed haemorrhoids
 Bleeding haemorrhoids
 Intero-external haemorrhoids when the external haemorrhoids is well defined
 Haemorrhoidectomy

 Preoperative preparation
 Stool softeners
 Pre-operative enema
 General or regional anaesthesia
 Lithotomy or prone jack-knife position.
 Perianal skin is shaved and a formal examination performed.
 Haemorrhoidectomy; open or closed
 Ligation and excision of the haemorrhoids
 Open; the anal mucosa and skin are left open to heal by secondary intention
 Closed; the wound is sutured
 Complications of haemorrhoids
 Strangulation and thrombosis
 Ulceration
 Gangrene
 Portal pyaemia
 Fibrosis
ANORECTAL ABSCESSES
 Painful, throbbing swelling in the anal region.
 The patient often has swinging pyrexia
 Underlying conditions include
 Fistula-in-ano (most common)
 Crohn’s disease
 Diabates
 Immunosuppression
 Treatment; Drainage of pus and antibiotics
 Presentation
 Increasingly severe, well-localised pain
 Palpable tender lump at the anal margin.
 indurated hot tender perianal swelling.
 fever.
 Diffusely swollen affected buttock with
 Widespread induration
 Deep tenderness.
 Deep rectal pain
 Differential diagnosis;
 Abscesses connected with a pilonidal sinus, Bartholin’s gland or Cowper’s gland.
 Management
 Careful examination under anaesthesia, sigmoidoscopy and proctoscopy, and adequate
drainage of the pus.
 Perianal and ischiorectal
 Drainage is through the perineal skin
 Through a cruciate incision over the most fluctuant point,
 Excision of the skin edges to de-roof the abscess
 Pus is sent for microbiological culture and tissue from the wall is sent for histological appraisal to
exclude specific causes
 FISTULA-IN-ANO
 A chronic abnormal communication, from the anorectal lumen (the internal opening) to
an external opening on the skin of the perineum or buttock (or rarely, in women, to the
vagina).
 Associated specific conditions;
 Crohn’s disease,
 Tuberculosis
 Lymphogranuloma venereum,
 Actinomycosis
 Rectal duplication
 Foreign body
 Malignancy
 Presentation
 Fistulae are more common in men than women.
 The overall incidence is about 9 cases per 100 000 population per year
 Common in the third, fourth and fifth decades of life
 Purulent discharge; which may be blood stained
 Pain; increases until temporary relief occurs when the pus discharges
 Previous episode of acute anorectal Sepsis
 Passage of flatus or faeces through the external opening is suggestive of a rectal rather than an
anal internal opening.

 Classification
 Based on the fistula track in relation to the internal and external sphincter
 High or Low
 High, indicating a high risk of incontinence if laid open
 low, with a lower risk of incontinence
 Complexity of treatment;

 Clinical assessment
 Medical history (obstetric, gastrointestinal, anal surgical and continence)
 Proctosigmoidoscopy to determine
 the site of the internal opening
 the site of the external opening
 the course of the primary track
 the presence of secondary extensions
 the presence of other conditions complicating the fistula.
 Examination under anaesthesia
 Use of probes
 Endoanal ultrasound; with hydrogen peroxide, can also be used to delineate fistulae
 MRI
 ‘gold standard’ for fistula imaging; limited by availability and cost
 It can demonstrate secondary extensions, which may be missed at surgery and which are the cause of
persistence
 Fistulography
Goodsall’s rule
 Surgical management

 Fistulotomy; The fistulous track is laid open from its termination to its source
 Fistulectomy; This involves coring out of the fistula by diathermy cautery
 Setons
 Advancement flaps
 Glues

 Useful preventive measures for benign anorectal

conditions
 Consuming a fiber rich diet to prevent constipation, a common factor in anorectal conditions
 Adequate hydration to soften stool to reduce the risk of anal fissures or hemorrhoids
 Regular exercises to promote overall health