painful anal conditions

1. Painful Anal Conditions By Dr. Saleh M AlSalamah Associate Professor of Surgery

5. ? 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.

6. ? 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.

7. 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)

9. 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

11. Intractable itching around the anus may occur at any age but commonly in adult, more in men than women and more common in summer than winter and is not in itself a specific clinical entity or disease.

12. 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 ? Fungal infections e.g. Candidiasis

13. ? 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 ? Idiopathic

14. ? 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. DIAGNOSIS

15. ? 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.

16. Local Secondary infections Signs associated with loss of sleep Persistent severe discomfort

17. TREATMENT ? Treatment any detectable cause is specifically treated and the following measures are employed particularly when no obvious cause detected.

18. 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.

19. 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.

20. 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

21. 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

22. ? Fissure or ulcer distal to dentate line. ? Sentinel Tag ? Hypertrophied papilla. ? Spasms of the internal sphincter

23. Conservative Treatment ? Stool softeners (laxative) ? Sitz baths (10 – 15 mins.) ? Ointments & Suppository Surgical Treatment ? Dilation under anaesthesia (Anal Stretch) ? Fissurotomy and dorsal sphincterotomy ? Lateral partial internal sphincterotomy

24. Anorectal Abscess

25. 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:

26. ? Acute pain ? High fever ? Swelling ? Tenderness with induration Incision and drainage and if complicated, covered by antibiotics.

27. ? Fistula in ano ? Recurrence ? Inflammatory bowel disease

28. 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. ACUTE THROMBOSIS OF PROLAPSED HAEMORRHOID

29. The piles become firm and irreducible and there is oedema of the anal margin the conditions associated with severe pain.

30. 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.

31. (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.

32. 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.

33. the predisposing causes are:- ? The vertical straight course of the rectum. ? Reduction of supporting fat in the ischiorectal fossa. ? Straining at stool. ? Chronic cough.

34. the predisposing causes depend on type of the prolapse. ? Advance degree of prolapsing piles. ? Loss of sphincteric tone. ? Straining from urethral obstruction. ? Operations for fistula. is generally regarded as sliding hernia of the recto vesical or recto vaginal pouch due to stretching of the levator and from pregnancy, obesity.

35. ? Prolapse is first noted during defaecation. ? Discomfort during defaecation. ? Bleeding. ? Mucous discharge. ? Bowel habit irregular and may lead to incontinence.

36. ? Irreducibility ? Infection ? Ulceration ? Severe haemorrhage from one of the mucosal vein ? Thrombosis and obstruction of the venous returns leading to oedema ? Irreducibility and gangrene

37. the prolapse tends to 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.

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39. 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

40. Stricture of the anus and rectum may be: ? Congenital ? Postoperative ? Inflammatory

41. Progressive difficulty in defaecation In cases of inflammatory strictures ? Bleeding ? Discharge ? Tenesmus ? Late cases subacute int. obst. Note: (Pipestem Stools)

42. Rectal examination reveals the location type and degree of the stenosis. ? Proctoscopy ? Biopsy ? Dilation ? Superficial external proctotomy ? Internal proctotomy

43. 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.

44. 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:

45. ? By removal of FB from below after dilatation of the anal sphincters Treatment: