The Rectum and You
Robert Theobald III, D.O.
Vein Associates P.A.
Napolean
Jimmy Carter
George Brett
Hemorrhoids
Cushions of tissue and varicose veins
located in and around the rectal area
Usually swollen and inflamed due to
precipitating factors
Factors include constipation, diarrhea,
pregnancy, straining, aging, and anal
intercourse
Hemorrhoids
Approximately 89% of all Americans at
some time in their lives
Over 2/3 of healthy people report having
hemorrhoids
Hemorrhoids tend to become worse
over the years, never better, unless
intervention ensues
Hemorrhoids
They are located both inside and above
the anus (internal) or under the skin
around the anus (external)
Hemorrhoids arise from congestion of
internal and/or external venous
plexuses around the anal canal
Are classified into four degrees
Hemorrhoids-Classifications
1st Degree: Bleeding occurs, but do not
prolapse outside the anal canal
2nd Degree: Prolapse outside the anal canal
upon defecation, but retract spontaneously
3rd Degree: Require manual reduction after
prolapse
4th Degree: Can not be reduced, because of
strangulation
This is a medical emergency!
Hemorrhoids
Hemorrhoids
The major drainage of the hemorrhoidal
plexus is through the superior
hemorrhoidal vein, which drains into
the inferior mesenteric vein and the
portal system
Hemorrhoidal veins have no valves
Valveless veins exert maximal pressure
at the lowest point
Hemorrhoids
Any process that impairs venous return
will promote stasis
Can be produced by either systemic or
by portal venous hypertension (CHF or
cirrhosis)
Intra-abdominal pressure also impairs
venous return (ascites, exercise,
pregnancy, straining, and tumors)
3 rd Degree Prolapse
4 th Degree Prolapse
Hemorrhoids
The most significant symptom is rectal
bleeding!
Usually bright red
Internal hemorrhoids are NOT painful
Bleeding can be significant because of an
arteriovenous fistula formation in plexus
Other symptoms are prolapse, pruritis, and
perianal edema
Perianal Edema
Hemorrhoid Treatment
Treatment starts conservatively
Hydrocortisone Cream 2.5%
Anusol HC Suppositories
Rubber-Band Ligation
Sclerotherapy (5% phenol)
Infra-Red Coagulation
Surgery
Hemorrhoidectomy
Thrombosed External
Hemorrhoids
Thrombosed hemorrhoids are an acute
and very painful problem that develops
rapidly
Typically a perianal mass develops
which is painful to palpate (and look at)
The lesion is due to sudden clot
formation in one of the subcutaneous or
submucosal veins
Thrombosed External
Hemorrhoids
Thrombosed External
Hemorrhoids
The diagnosis is easy to make by the violet
discoloration of the lesion
The overlying tissue is tense and shiney
Treatment is with excision of the clot
The body will eventually reabsorb the clot, but
might takes weeks
Easier to excise after a few days
Adherence may occur if not excised within a
few days
Abscesses
A perianal abscess is a collection of pus
in one of the anatomic spaces of the
anal region
The perianal anatomy is defined by the
sphincter and the levator ani muscles
The Iliococcygeus, Pubococcygeus, and
Puborectalis
Abscesses
Abscesses can be classified according
to location
Perianal, Supralevator, Intersphincteric
The most common location is perianal
It results from a blockage of the anal
glands located just outside the anus
Abscesses
According to the crypto-glandular theory, they
often develop from cryptitis which may be
associated with an enlarged papillae in the
anal canal
It starts as a cellulitis with only swelling and
erythema
Finally, the infecting organisms burrow in the
anal glands producing the abscess
Abscesses
The microorganisms are not specific or
unique
They are usually polymicrobial
More than 90% will include E. coli
Other organisms include streptococci,
staphylococci, and a variety of
anaerobic bacteria
Abscesses-Symptoms
The patient will present with fever, local
inflammation, and pain
The initial manifestation is fever followed by
pain
In 24-48 hours a fluctuant mass will appear
An abscess in the intramuscular space may
be difficult to diagnose and treat
Clinical assumption is needed to treat
appropriately
Abscess
Abscesses
Treatment consists of surgically draining
the infected cavity
A cruciate incision is made to allow pus
to drain for a few days
Sometimes a catheter is left in the
incision to assure adequate drainage
A fistulous tract can arise if the abscess
is not treated properly
Fistula
Most fistulas begin as an anorectal
abscess
Anal fistulas is an abnormal passage or
communication between the interior of
the anal canal or rectum and the skin
surface
Rarer forms may communicate with the
vagina, large bowel, and bladder
Fistula
Fistula-Symptoms
Are usually a purulent discharge and
drainage of pus or stool near the anus
Can irritate the outer tissues causing
itching and discomfort
Pain occurs when fistulas become
blocked and abscesses recur
Flatus may also escape from the tract
Fistula
Fistulas can be difficult to diagnosis
A probe must be passed between the
opening of the skin’s surface and the
interior opening
Goodsall’s Rule can be helpful
Other causes include tuberculosis,
inflammatory bowel disease, and cancer
Crohn’s Fistula
Fistula-Treatment
Fistulas last until surgically removed
Excision of the complete tract is called a
fistulectomy
Sometimes a seton is placed in the tract to
elicit an inflammatory reaction in the tissue
resulting in closure
80% success rate with surgery
Remicade (infliximab) for persistent disease
Fissures
An anal fissure is a tear causing a painful
linear ulcer at the margin of the anus
Can cause itching, pain, or bleeding
80% of fissures occur in the posterior midline
15% of fissures occur in the anterior midline
5% of fissures occur either right or left lateral
– Fissures that occur laterally think of Crohn’s,
tuberculosis, lymphoma, leukemia, anal cancer,
syphilis, and trauma
Fissures
When an anal fissure is suspected,
physical examination is diagnostic
The exam may be difficult due to pain
and sphincter spasm
The triad consists of a sentinel skin
tag, a fissure and a hypertrophied
papilla
Fissures
Fissures-Treatment
Treatment for superficial fissures includes
Anusol HC or Canasa (mesalamine)
suppositories
If suppositories don’t heal fissure, then
nitroglycerin cream 0.2% is used
(headaches are major side-effect)
If not responding to pharmacotherapy or
chronic fissure, then surgery is recommended
Fissures-Treatment
Surgery consists of a fissurectomy
and sphincterotomy
Helps the fissure to heal by preventing
pain and spasm which interferes with
healing
90% of patients will improve with the
surgery
Very small chance of anal incontinence
Auto-colonoscopy
Pilonidal Cysts
The term pilonidal was derived from the Latin
pilus meaning hair and nidus meaning nest
The pathogenesis is unknown, but the most
common theory is that they are a result of an
embryonic malformation and results in a
remnant of a neurocanal
Men are more likely than women to have the
cysts at a ratio of 4 to 1
Pilonidal Cysts
Infection of a pilonidal cyst is most commonly
seen between puberty and age 30
Hair growth and secretion of sebaceous
glands reach their peak
Some suggest that trauma to the gluteal area
to be an important predisposing factor
In WWI it was known as Jeep Rider’s
Disease
Pilonidal Cysts
Unless they become infected or inflamed,
they are asymptomatic
When a cyst becomes infected, an abscess
can develop, usually lateral or superior to the
gluteal cleft and over the coccyx
As the process becomes chronic, a fistula
develops and creates a sinus tract
Diagnosis can be made with pilonidal
pores which are 2 or more openings
located between the gluteal cleft
Pilonidal Cysts
Pilonidal Cysts
Pilonidal Cysts-Treatment
The only way to cure pilonidal cysts
is surgery
The first episode can be treated with
antibiotics (Keflex or Augmentin)
If recurrent, then surgery is performed
Open-technique is most successful
Other techniques include closed,
marsupialization, and Z-plasty
Condylomata Acuminata
Condylomata Acuminata (anal or perianal
warts) are the most common sexually
transmitted disease of the anus and rectum
Human papillomavirus (HPV) is responsible
Over 40 subtypes of HPV
Most common 6 and 11
16, 18, 31, and 32 are associated with
squamous cell carcinoma
Condylomata Acuminata
CDC reports a 500% increased in the
incidence from 1981; 1/7 Americans
Are epithelialized, raised wartlike lesions that
arise alone or more often in groups
They can range from a few millimeters to a
cauliflower-like lesion
Can occur in combination with genital lesions
Mode of transmission is sexual intercourse,
auto-inoculation may occur
Rarely bleed or painful, mostly pruritis
Condylomata Acuminata
Although perianal condylomata can be
seen in women and heterosexual men,
typically the patients are homosexual
males
CDC reports that 60-70% of
homosexual men have condylomata
Women have increased risk of cervical
carcinoma with HPV infection
Condylomata Acuminata
Condylomata Acuminata
Condylomata Acuminata
Condylomata Acuminata
Condylomata Acuminata
Successful therapy requires accurate
diagnosis and eradication of all warts
All patients undergo anoscopy and genital
examination
Once identified, there are many different
treatments depending on disease progression
Each treatment has advantages and
disadvantages
Condylomata Acuminata
The treatment options consist of excisional,
destructive, immunotherapy, and
chemotherapy
Condylomata can be excised either in the
office with local anesthesia or in the operating
room
Preservation of the anoderm and anal canal
mucosa to minimize pain and healing time
The rate of recurrance is less than 10%
Condylomata Acuminata
Podophyllin is a resin that is cytotoxic
to condylomas and very irritating to
normal skin
Can not be applied to anal canal lesions
Local complications include necrosis,
fistula, and anal stenosis
Electrocautery, Cryotherapy, and
Lasers are also used with frequency
Condylomata Acuminata
Two therapies that are more commonly
practiced today are interferon injections
and Aldara (imiquimod) cream
Both therapies are very potent with many
side-effects
LFT’s should be checked routinely with
interferon injections
Aldara should be used every other day,
because it can burn normal tissue and make
it necrotic
Pruritis Ani
Pruritis Ani
More common in males than females
Symptoms include itching, burning, and
irritation
Close examination of the perianal area is
required; ulcerations and excoriation
Can be associated with other diseases
– Infections (fungal, parasitic, bacterial)
– Irritants (soaps, coffee, ETOH, detergents)
– Dermatologic (psoriasis, dermatitis, pemphigus)
– Systemic disease (diabetes, SLE, liver dx)
Pruritis Ani
Treatment
– Avoiding the offending agents
– Creams (analpram lotion/cream 2.5%)
– Topical Steroids
– Corona ointment (lanolin/bees wax based)
Anal Cancer
Very uncommon cancer, accounting for
only 4% of all cancers of the lower GI
tract
Anal cancer is on the rise due to
individuals with HPV
The majority of patients are women in
their seventh decade who present with
bright red bleeding and pain
Anal Cancer
Anal cancer is often curable
3 major factors include site, size, and
differentiation
Squamous cell carcinomas make up the
majority of all primary cancers of the anus
The others are adenocarcinoma, verrucous
carcinoma, and malignant melanoma
Colorectal cancers are primarily
adenocarcinoma
Squamous Cell Carcinoma
Anal Cancer-Treatment
Surgery is a common way to diagnose and
treat anal cancer
Local resection takes out only the cancer, it
spares the internal anal sphincter muscle
Abdominoperineal resection (APR)
removes the anus and the lower part of the
rectum by cutting into the abdomen and the
perineum
With an APR, the patient will have a
colostomy
Anal Cancer-Treatment
Radiation therapy and Chemotherapy
are used together to shrink tumors
All anal cancers respond very well to
this combination therapy
APR is now an unnecessary surgery for
anal cancer, but still very common for
distal rectal carcinoma
Levator Syndrome
More commonly called Proctalgia fugax
It is episodic rectal pain caused by spasm of
the levator ani muscles
A spasm is situated in the rectum
approximately 10-15 cm above the anus
The pain or spasm is related to sitting for long
periods of time
Pain is described as a sharp, knife-like,
twisting inside the rectum
Levator Syndrome
Physical examination is usually normal
Emotional factors, sexual activity, or
fatigue can trigger an attack
Can also be triggered by an injury to
coccyx or lower back
Structural deviations of the lumbro-
sacral area, sacro-iliac, coccyx, and
supportive structures are also causes
OSTEOPATHIC
TREATMENT
A fracture or dislocation of the coccyx
should be reduced by bi-manual
manipulation
Levator ani tenderness will readily
respond to OMT
Digital stretching of the ischiococcygeus
tends to relax the entire structure,
usually on the left lateral side
Beach Bum
Questions?