Anal Pain and Discharge

1. Anal Pain and Discharge By: Mohammad Jamjoom Fahad Al-Sabhan Supervised by: Dr. Khayal Al-Khayal

2. Overview: • Anatomy of the anal canal • Hemorrhoids • Anal fissures • Anal abscesses • Anal fistulas

3. Anatomy of the anal canal:

4. The anal canal is 4 cm long • It extends from the anal verge to the anorectal junction • It is divided into upper and lower halves by the dentate (pectinate) line • Above Columnar epithelium • Below Squamous epithelium (anoderm) • Transitional zone Cuboidal epithelium

5. Internal (involuntary) and external (voluntary) sphincters • The internal sphincter is a thickened continuation of the circular smooth muscles of the rectum (autonomic nervous system) • It is responsible for anal continence • The external sphincter is a downward extension of the puborectalis muscle (internal pudendal nerve S2-S4)

6. Blood supply: • Arterial supply: • Upper half Superior rectal artery • Lower half Inferior rectal artery • Venous drainage: • Upper half Superior rectal vein Portal system • Lower half Inferior rectal vein Systemic circulation

7. Hemorrhoids: • They are engorgement of the venous plexi of the rectum, anus or both; with protrusion of the mucosa, anal margin or both • Also known as “Piles”

8. Types:

9. Sites: • Left lateral (3 o’clock) • Right posterior (7 o’clock) • Right anterior (11 o’clock)

10. Classification of internal hemorrhoids: • 1st degree: Do not prolapse • 2nd degree: Prolapse with straining, but are reduced spontaneously • 3rd degree: Prolapse with straining, but require manual reduction • 4th degree: Cannot be reduced

11. Etiology: • Constipation or straining • Increased abdominal pressure • Pregnancy • Portal hypertension

12. Signs and symptoms • Anal mass or prolapse • Bleeding • Pruritis • Pain or discomfort • Sensation of fullness • Mucoid discharge and soiling of underwear

13. Diagnosis: • History • Rectal examination • Proctoscopy • Sigmoidoscopy or colonoscopy

14. DDx: • Anal polyps • Anal fissures • Peri-anal hematoma • Rectal prolapse • IBD • Dermatitis • Anorectal carcinoma

15. Management: • Nonoperative (90%): • High fiber diet • Increase fluid intake • Laxatives • Avoid straining during defecation • Anal hygiene • Topical steroids • Sitz bath

16. Surgical (10%): • 1st degree: • Sclerotherapy • Infra-red photocoagulation • Liquid nitrogen cryotherapy • 2nd degree: • Rubber band ligation • 3rd and 4th degree: • Excisionalhemorrhoidectomy

17. Contraindications to surgery: • Anticoagulants • Portal hypertension and liver cirrhosis class C • Crohn's disease • Anorectal fissures • Anorectal infections • Anorectal tumors • Pregnancy • Rectal wall mucosal prolapse

18. Complications: • Exsanguination (bleeding may pool proximally in lumen of colon) • Pelvic infection (sepsis) • Urinary retention • Incontinence (sphincter injury) • Anal stricture • Abscess

19. Anal Fissures: • They are tears in squamous epithelium of the anus (anoderm) • Most common cause of anal pain • Most common site is the posterior midline

20. Etiology: • Hard stool or constipation • Hyperactive sphincter • Disease process (Crohn’s disease)

21. Signs and symptoms: • Tearing pain with defecation • Rectal bleeding (blood streaks on toilet paper) • Painful rectal examination • Sentinel pile (tag) • Hypertrophic papilla

22. Diagnosis: • History • Rectal examination • Proctoscopy

23. Management: • Nonoperative (80%): • High fiber diet • Increase fluid intake • Laxatives • Avoid straining during defecation • Anal hygiene • Topical nifedipine • Sitz bath • Botox

24. Surgical (20%): • Chronic fissures refractory to conservative treatment • Lateral internal sphincterotomy (LIS)

25. Anal Abscesses and Fistulas • They may present as acute or chronic manifestations of the same perirectal disease

26. Anal Abscess: • It’s an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity

27. Classification of anal abscesses: • Perianal (60%) • Ischiorectal (20%) • Intersphincteric (5%) • Supralevator (pelvirectal) (4%) (is very difficult to diagnose clinically and is very rare and caused by inflammation or a disease in the pelvis) • Submucosal (1%)

28. Etiology: • Blockage of anal glands which permits the growth of bacteria leading to an abscess formation • Common organisms: - Escherichia coli   - Enterococcus species - Bacteroides species • However, no specific bacterium has been identified as a unique cause of abscesses • Less common causes:Tuberculosis, squamous cell carcinoma, adenocarcinoma, actinomycosis, lymphogranulomavenereum, Crohn's disease, trauma, leukemia and lymphoma

29. Note: • most people have 8 to 10 glands , which are located circumferentially within the anal canal at the level of the dentate line, penetrate through the internal sphincter and end in the intersphincteric plane

30. Signs and symptoms: • Severe pain in the anal area (pain is constant and not necessarily associated with bowel movements) • Lump in the anal area • Lower abdominal pain (pelvirectal abscess) • Constitutional symptoms ( fever, malaise) • Drainage of pus

31. Management: • Early incision and surgical drainage of the purulent collection • Sitz bath • Anal hygiene • Laxatives • There is no role for antibiotics except for patients who are: - Immunocompromised - Diabetics - Diagnosed with valvular heart diseases - Diagnosed with cellulitis

32. Complications: • A potential complication of anorectal abscess drainage is the formation of fistulous tracts within 6 months in 50% of cases

33. Anal Fistulas: • They are abnormal connections between the epithelialized surface of the anal canal and the perianal skin

34. Classification of anal fistulas: • The 4 categories of fistulas according to Park’s classification, based on the relationship of fistula to sphincter muscles, are: • Intersphincteric • Transphincteric(most common) • Supra-sphincteric • Extra-sphincteric.

35. Etiology: • Opened perianal or ischiorectal abscesses, which drain spontaneously through these fistulous tracts • Fistulas can be found in patients with Inflammatory Bowel Disease (Crohn’s disease) • Diverticulitis, foreign body reactions, actinomycosis, chlamydia, lymphogranulomavenereum, syphilis, tuberculosis, radiation exposure and HIV

36. Signs and symptoms: • Recurrent malodorous perianal drainage • Pruritus • Recurrent abscesses • Fever • Perianal pain due to an occluded tract, may have pain during defecation

37. Physical examination: • Digital examination is usually all that is required, assessment of the anatomy of an anal fistula is very important • Digital examination in a patient with a fistula-in-ano may reveal an indurated tract or cord • Fistula can be identified by small circles of granulation tissue, which exudes pus when compressed if tissue is patent • A fistulous tract that opens internally can be visualized with aid of an anoscope • Inguinal lymph nodes may be enlarged and painful • In an acute fistulous abscess, cardinal signs of inflammation, (erythema, pain, increased temperature, edema) may be found

38. What to asses during physical examination: • Often done in the OR • External opening • Internal opening (Internal opening could be identified during fistula surgery, where we inject hydrogen peroxide (H2O2) & look for internal bubbling or inject methylene blue dye) • Course of the tract • Amount of sphincter muscle involved

39. Investigations: • CBC (number of WBC in significant infection), blood culture • Fistulogram • Transanal US • MRI • CT

40. Goodsall’s rule: • One of the most common used principles to assist in surgical management of fistulas • Fistulas originating anterior to a transverse line through the anus will course straight ahead and exit anteriorly • Whereas, fistulas exiting posteriorly have a curved tract

41. Management: • There are several stages to treating an anal fistula • Definitive treatment of a fistula aims to stop it from recurring • Treatment depends on where the fistula lies and which parts of the anal sphincter it crosses

42. Cutting seton • Draining seton • Fistulotomy • Fistula plug • Advancement flap

43. Cutting seton: • Is a thick suture placed through the fistula tract and staged pulling is done, so it will allow fibrosis and maintain continence • Draining seton: • A length of suture material looped through the fistula which keeps it open and allows pus to drain out • It only relieves symptoms, and can be used in patients with Crohn’s disease

44. Fistulotomy: • A surgical opening of a fistulous tract • Fistula plug: • Involves plugging the fistula with a device made from small intestinal submucosa

45. Advancement flap: • The internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place

46. Intersphincteric fistulae: Primary fistulotomy • Low Transsphincteric fistulae: Primary fistulotomy • High transsphincteric or anterior fistulae: In female patients should be treated with a more conservative approach, for example a cutting seton or a fistula plug as to avoid fistulotomy incontinence • Suprasphincteric fistulae: Advancement flaps, sphincter reconstruction or cutting setons. Fistulotomy should not be performed, to avoid incontinence • Extrasphincteric fistulae: Endorectal advancement flap

47. Contraindications of fistulotomy: • Anterior fistulas in females(perform a seton to avoid injuring the perineal body, due to it’s proximity) • A high level fistula • Patients diagnosed with Crohn’s disease

48. Thank you…