Painful Anal Conditions
By
Dr. Saleh M AlSalamah
Associate Professor of Surgery
PAINFUL ANAL CONDITIONS
INTRODUCTION
SURGICAL ANATOMY
EXAMINATION OF THE ANUS
COMMON PAINFUL ANAL CONDITIONS
PRURITUS ANI
ACUTE ANAL FISSURE
ANORECTAL ABSCESSES
PROLAPSED HAEMORRHOID (Acute thrombosis)
THROMBOSED EXTERNAL HAEMORRHOID
(Perianal Haematoma)
RECTAL PROLAPSE
BENIGN STRICTURES
INJURIES AND FOREIGN BODIES
I
N Anal and perianal
T disorders makeup about
R 20% of all outpatient
O Surgical referrals. These
D conditions are extremely
U
distressing and embarrassing
C
T patient often put up with
I symptoms for long time,
O before seeking
N medical care.
The anal canal The mid of
1.5” (4 cm) long anal canal
and is directed represents
downward and the junction
backward from between
the rectum to end endoderm
at the anal and ectoderm
orifice.
The lower ½ is lined by squamous epithelium
and the upper ½ by columnar epithelium so
carcinoma of the upper ½ is adenocarcinoma.
Where as that arising from the lower part is
squamous tumour.
The blood supply of upper ½ of the anal canal
is from the superior rectal vessels. Where as
that of the lower ½ is supply of the
surrounding anal skin the inferior rectal vessels
which derives from the internal pudendal
ultimately from the internal iliac vessels.
The lymphatic above the muco cutaneous
junction drain along the superior rectal
vessels to the lumbar lymph nodes, where as
below this line drainage is to the inguinal
lymph nodes.
The nerve supply to the upper ½ via
autonomic plexus and the lower ½ is supplied
by the somatic inferior rectal nerves terminal
branch of the pudendal nerve. So the lower
½ is sensitive to the prick needle.
The anal sphincter:-
This comprises:-
The internal anal sphincter of involuntary
muscle, which is the continuation of the
circular muscles of the rectum
The external sphincter of the voluntary
muscles, which surrounds the internal
sphincter and comprises 3 parts (formerly)
subcutaneous the lower most portion of the
external sphincter
superficial part
deep part
(now considered to be one muscle)
This requires careful attention to circumstances (couch, light,
gloves). The Sims (left lateral position) is satisfactory. The
examination proceed by:
inspection
digital examination with index finger
proctoscopy
sigmoidoscopy
P Intractable itching around the anus may
R
U
occur at any age but commonly in adult,
R more in men than women and more
I common in summer than winter and is
T not in itself a specific clinical entity or
U
disease.
S
A
N
I
Aetiology
The causes are very numerous
and includes:
Poor hygiene due to lack of cleanliness.
Mucous soiling due to leukorrhoea or
anorectal
lesion.
Parasitic infections such as thread worms,
scabies
etc.
Dermatological diseases e.g. Psoriasis
Bacterial infections secondary due to
scratching.
Systemic diseases e.g. DM, liver diseases
etc.
Anal diseases e.g. Fistula in ano, sinus
etc.
Dietary e.g. Excessive consumption of
alcohol etc.
Psychogenic
DIAGNOSIS
Careful History: Duration, time, pattern of itching
and relation to defecation, bathing, ingestion of food and intake
of drugs etc.
Local Examination: The perineal skin inspected
for erythema, fissuring, fungal infections at the presence of
thread worm and rectal examination is carried out to look for
underlying associated lesion.
General Examination: Is performed to search for
manifestations of allergy or skin diseases elsewhere in the body.
Laboratory Investigations: Urine, stool, to
exclude diabetes and parasites. Direct microscopic and culture of
scraping may reveal yeast, fungi or parasites.
Local Secondary infections
Signs associated with loss of
sleep
Persistent severe discomfort
TREATMENT
Treatment any detectable cause is
specifically treated and the following
measures are employed particularly
when no obvious cause detected.
Hygienic
Diet
Bowels
Drugs
Dermatological & psychiatric
consultation
Defined as longitudinal tear in
the mucosa and skin of the anal
canal. Commonly posterior
midline more common in female
than male. Lateral fissures are
so rare there presence suggest
specific lesions such as, Crohn’s
disease, UC, TB or malignancy.
Aetiology may be due to:
Tearing of the anal lining by over
distension of the anal canal during
passage of large scybalous mass (stool).
Tearing of anal valve or fibrous polyps.
Laceration of the anal canal by sharp FB.
Excessive straining during child birth.
The acute anal fissure if not treated
becomes chronic anal fissures. As
result secondary pathological
changes may occurs:
Chronicity
A “sentinel” pile
Hypertrophied anal papilla
Contracture of the anus
Suppuration
Usually affect, young or middle aged adult,
common in female than male. Rare in old
age may occur in infancy and may cause
acquired mega colon.
Pain during and after defecation.
Constipation
Bleeding
Discharge
Fissure or ulcer distal to
dentate line.
Sentinel Tag
Hypertrophied papilla.
Spasms of the internal
sphincter
TREATMENT
A Conservative Treatment
Stool softeners (laxative)
Sitz baths (10 – 15 mins.)
Ointments & Suppository
B Surgical Treatment
Dilation under anaesthesia (Anal
Stretch)
Fissurotomy and dorsal
sphincterotomy
Lateral partial internal sphincterotomy
Anorectal Abscess
Pathology: The infection usually starts in one
of the crypts of Morgagni and extends along the
related anal gland to the inter sphincteric plane
where it forms as abscess. Soon it tracks in
various directions to produce different types of
abscesses which are classified as follows:
Perianal abscess (60%)
Ischiorectal abscess (30%)
Sub mucous abscess (5%)
Pelvirectal abscess
NOTE: Patient with recurrent anorectal abscess always
consider associated underlying diseases such as
crohn’s UC, rectal cancer and active TB.
Symptoms:- Acute pain
High fever
Signs:- Swelling
Tenderness with
induration
Treatment:-
Incision and drainage and if
complicated, covered by
antibiotics.
Fistula in ano
Recurrence
Inflammatory bowel
disease
ACUTE THROMBOSIS OF PROLAPSED HAEMORRHOID
This is one of the complications of the haemorrhoid when
acute thrombosis occur when one or more internal
haemorrhoids become prolapsed and strangulated by the
sphincter.
The piles become firm and
irreducible and there is oedema
of the anal margin the
conditions associated with
severe pain.
Consequent:
In some cases the oedema gradually subsided
and the thrombosis is absorbed.
Ulceration and infections and may lead to
formations of the submucous abscess.
The strangulated piles becomes
gangrenous and slough off.
TREATMENT
Conservative treatment than surgery
External Haemorrhoids: (Perianal Haematoma)
due to rupture of dilated anal vein as result of
sever straining.
sudden onset of painful lump at the anus.
O/E swelling tense & tender, bluish in colour covered with
smooth shining skin.
Treatment: LA evacuation if the patient come within
48h0, if patient come late conservative treatment.
if untreated the haematoma undergoes:
resolution
ulceration
supporation to forms in abscess
fibrosis which give rise to skin tag.
Rectal Prolapse:
Prolapse of the rectum mainly two types:
Partial or incomplete prolapse when the mucous
membrane lining the anal canal protrudes through
the anus only.
Complete prolapse in which the whole thickness of
the bowel protudes through the anus.
Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of
age and elderly people. More common in
female than male.
In children: the predisposing causes are:-
The vertical straight course of the
rectum.
Reduction of supporting fat in the
ischiorectal fossa.
Straining at stool.
Chronic cough.
In adult: the predisposing causes depend on
type of the prolapse.
Partial prolapse
Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.
Complete prolapse
is generally regarded as
sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
and from pregnancy, obesity.
Prolapse is first noted during defaecation.
Discomfort during defaecation.
Bleeding.
Mucous discharge.
Bowel habit irregular and may lead to
incontinence.
Complications of rectal prolapse:
Irreducibility
Infection
Ulceration
Severe haemorrhage from one
of the mucosal vein
Thrombosis and obstruction of
the venous returns leading to
oedema
Irreducibility and gangrene
prolapse tends to
Prolapse in children: the
disappear spontaneously by the age of 5
years. So conservative measures are
sufficient.
Conservative treatment: constipation and
straining at stool are avoided and the
buttocks may be strapped together to
discourage prolapse during defaecation.
Perirectal injection of alcohol/phenol may be
used to fix the lax mucosa to underlying
tissue.
Partial prolapse:
Provided sphincter tone is satisfactory can be
treated by ligature excision of prolapsed
mucosa.
Injections of 5% phenol in oil in submucosa.
10-15ml total.
Electrical stimulation with sphincteric exercises.
Complete prolapse:
Surgery always necessary, none are ideal
and divided into abdominal approach and
perineal approach.
Abdominal approach
Rectopexy (lock haurt)
Rectosigmoidectomy (Mikulicz’s op.)
Ivalon sponge rectopexy (Well’s op.)
Ripstein operation
Low anterior resection (minor)
Perineal approach
Thiersch’s operation
Delorme Operation
BENIGN STRICTURES
Aetiology: Stricture of the anus
and rectum may be:
Congenital
Postoperative
Inflammatory
1
Progressive difficulty in defaecation
2
In cases of inflammatory strictures
Bleeding
Discharge
Tenesmus
Late cases subacute int. obst.
Note: (Pipestem Stools)
Diagnosis:
Rectal examination reveals
the location type and degree
of the stenosis.
Investigations: Proctoscopy
Biopsy
Treatment: Dilation
Superficial external proctotomy
Internal proctotomy
Injuries:
Causes:
Open injuries may be due to falling
astride or spikes, gunshots wound
or surgical operations.
Closed injuries: May be due to fracture
of the pelvis or to instrumental injuries
during sigmoidoscopy or dilatation or the
administration of an enema.
Treatment:
Depend on the cause
Foreign Bodies:
May be due to swallowed objects
such as chicken bone or fish bone
of false teeth etc. Other F.B. inserted
through the anus such as bottle and
enema.
Treatment:
By removal of FB from below after
dilatation of the anal sphincters