Common Office Anorectal Problems Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center

Disclosures None

Benign Anal Rectal Disease Anatomy of the anal canal and perianal spaces Benign Anal Rectal Disease Abscess and Fistula Fissure Hemorrhoids

Overview of Anatomy Anatomy Pelvic and Perirectal Spaces Anatomy of Anal Canal

Retrorectal Space Waldeyer’s Fascia Supralevator Space Levator Ani Muscle Deep Postanal Space Superficial Postanal Space

ANAL CANAL Peritoneum Supralevator Space Levator Ani m. Puborectalis m. Ischioanal Space Deep External Sphincter m. Intersphincteric Space Internal Sphincter m. Perianal Space Transverse Septum

ANAL CANAL Column of Morgagni Dentate Line Anal Crypt Anal Gland Transitional Zone Dentate Line Anal Crypt Anal Gland Anoderm

Diagnosis and Treatment of Anorectal Abscess and Fistula-in-Ano

Anorectal Abscess Etiology Cryptoglandular abscess Most common Infection in the glands at the dentate line Other causes Crohn’s and Ulcerative Colitis Tuberculosis and Actinomycoses Malignancy Foreign Bodies, Prostate Surgery or Radiation

Fistula Description Clock description Does the anus tell time? Relies on description of patient’s position: supine, lateral, prone and relative landmarks Anatomic description: more consistent Pubic bone defines anterior Coccyx define posterior Right and left *If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed." Confucius 1

Pubic bone Right anterior Left anterior Left Right Right posterior Left posterior Tailbone

There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained

Abscess Classification Four Types Based on Space Involved Perianal - 19-54% Intersphincteric - 20-40% Ischioanal - 40-60% Supralevator 2% or less Most Common Rare

Supralevator Abscess Intersphincteric Abscess Ischioanal Abscess Perianal Abscess

HORSESHOE ABSCESS Supralevator Space Intersphincteric Space Ischioanal Space

Anorectal Abscess Treatment of Perianal and Ischiorectal Abscesses Diagnosis - usually straightforward Erythema and Pain over affected area Fluctuance Treatment Incision and Drainage +/- Excision of small amount of overlying skin Initial packing for hemostasis Drainage catheter (Pezzer) or pack wound Attention to good hygiene and control blood sugar Antibiotics if immunocompromised, obese or diabetic

Small Radial incision Short distance from anus – feel for soft spot Place drain and trim – avoids packing Follow up in 7-10 days to remove drain

Catheter Types Pezzer catheter Solid mushroom top so stays in Less tissue ingrowth Malecot Allows tissue ingrowth More painful to remove

Peri anal abscess - ? Antibiotics Not usually indicated if there is adequate drainage Indicated for patients with: Obesity Diabetes Imunocompromised Extensive large abscess or recurrent abscess

Fistula-in-Ano Definition Classification: Diagnosis Treatment abnormal connection between two epithelial surfaces. Classification: Parks: Defines fistula by course of tract Goodsall’s rule Diagnosis Treatment Goals Options

How does patient present? May have had a history of abscess History of Crohn’s disease May present at the same time as abscess Complain of intermittent increase in pain/swelling followed by spontaneous drainage Chronic localized area of irritation or ulcer “pimple near my anus keeps coming back”

Fistula-in-Ano Goodsall’s Rule Posterior Anterior

Fistula in ano

Fistula in ano: Surgical disease Refer to Colon and Rectal Surgeon or General Surgeon Reassure patient – rarely cancer, most do not need a colostomy If suspect Crohns Gain control of perianal sepsis Then complete full workup and staging Goals of therapy Get rid of the fistula/connection Preserve continence

Surgical Options Primary fistulotomy Fibrin Glue/Fistula Plug Mainly for low, superficial fistula Risk of fecal incontinence Fibrin Glue/Fistula Plug Utilizes substrate as scaffold to fill tract Does not involve cutting muscle Cutting or draining setons For deeper tracts that involve significant muscle Rectal advancement flap Lateral internal fistula transection Newer procedure. No foreign substrate Cuts fistula tract, not muscle

Fistula in ano

Fistula in ano

Fissure in Ano Definition – a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus Overlie the lower half of the internal sphincter ~73.5% are posterior ~16.4% are anterior ~2.6% both anterior and posterior

Fissure in Ano Pathogenesis Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus Secondary changes of chronic fissure include Sentinel pile or skin tag at the distal end Hypertrophied anal papilla-swelling, edema and fibrosis near the dentate line Fibrosis of the internal sphincter at the base

Fissure with Sentinel Tag

Fissure with Sentinel Tag

Fissure in Ano Pathogenesis Perpetuating factors in chronic fissure Persistent hard bowel movement Abnormal high resting pressure in the internal anal sphincter Increased pressure in the sphincter causes a decrease in blood flow, preventing healing of the fissure

Fissure in Ano Symptoms Pain is the main symptom Sharp, cutting or tearing during defecation Duration is few minutes to hours Bleeding – bright red and scant Skin Tag Mucous discharge resulting in itching

Fissure in Ano Diagnosis Diagnosis often made on history alone Inspection – gently spread the buttocks and the fissure becomes apparent Triad of chronic anal fissure Sentinel pile Hypertrophied anal papilla Anal ulcer

Fissure in Ano Differential Diagnosis Intersphincteric abscess Pruritus Ani Fissure from inflammatory bowel disease Carcinoma of the anus Infectious Perianal conditions Leukemic infiltration

Fissure in Ano Crohn’s Anal Fissures

Acute Fissure in Ano Treatment Increase dietary fiber Local anesthetic to prevent spasm Nitroglycerin or Nifedepine Ointment Not commercially available Must be mixed by pharmacist Warm tub soaks 4-6 weeks of treatment

Chronic Fissure in Ano Surgical Treatment Indicated on Chronic non-healing anal fissure and fissure that is refractory to medical therapy Lateral Internal Sphincterotomy Forces the muscle to relax V-Y Anoplasty flap Allow coverage of fissure with healthy tissue

Hemorrhoids What are they? Where are they? Why do they become symptomatic? Classification? How do you treat them? Can they be avoided?

Hemorrhoids What are they? Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissue Aid in anal continence

Hemorrhoids Where are they? Internal Hemorrhoids 3 major bundles – left lateral, right anterior and right posterior Above the dentate line Blood drains into the superior rectal vessels then into the portal circulation External Hemorrhoids Below the dentate line Blood drains through the inferior rectal veins to the pudendal veins on into the iliac veins

Hemorrhoids Symptoms? Chronic constipation Diarrhea Trauma to the hemorrhoids during defecation cause the most common symptoms Pain – generally not “knife-like” Itching Burning Bleeding

Hemorrhoids Classification- Internal Hemorrhoids 1st degree – bulge into the lumen 2nd degree – prolapse with bowel movement but reduce spontaneously 3rd degree – prolapse spontaneously and require manual reduction 4th degree – permanently prolapsed hemorrhoids that cannot be reduced

4th Degree Hemorrhoids

Hemorrhoids Treatment Principles Thorough physical exam to determine severity and rule out other pathology Refer for surgical evaluation if white or discolored, firm or fixed Determine if the problem is internal, external or both Assess the symptom complex

Treatment Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream… Conservative therapy Bulk agents – i.e. high fiber Fruits, vegetables, oat bran, psyllium Increase water intake Avoid caffeinated beverages Avoid prolonged sitting on the commode Warm tub soaks

Treatment Office and Minor Procedures Rubber band ligation Performed in the office Indicated for Grade 1 and 2 internal hemorrhoids Band is applied through an anoscope at the top of an internal hemorrhoid Severe perianal sepsis – Classic Triad Delayed anal pain Urinary retention Fever

Treatment Office and Minor Procedures Infrared Photocoagulation Indicated in 1st degree hemorrhoids Causes photocoagulation of small vessels Performed in office or “Hemorrhoid Relief Center” Minimal pain

Closed Hemorrhoidectomy Indication Hemorrhoids are severely prolapsed and require manual replacement Patients fail to improve after multiple applications of non-operative treatment Hemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags

Closed Hemorrhoidectomy General Principle Most can be performed with local and IV Sedation Prone/Kraske position is the best Infuse the area with local anesthetic with epinephrine for hemostasis Fleets enema 1-2 hours prior No antibiotic prophylaxis is necessary

Closed Hemorrhoidectomy

Closed Hemorrhoidectomy

Closed Hemorrhoidectomy Post op Result

PPH Stapling Procedure for Hemorrhoids Not for every hemorrhoid Ideal for Grade 2 and 3 with minimal external component Prevents prolapse and thus less trauma to hemorrhoid with bowel movement

PPH Stapling Procedure for Hemorrhoids

PPH Stapling Procedure for Hemorrhoids Benefits Less pain as compared to traditional closed hemorrhoidectomy Less blood loss during the procedure Less chance of anal stenosis

PPH Stapling Procedure for Hemorrhoids Risks If staple placed too low – severe chronic pain and incontinence If staple line placed too high – failure to relieve symptoms of hemorrhoids Hemorrhoids are not removed so they may continue to bleed Perianal sepsis Rectovaginal fistula

Perianal Condyloma Can sometimes be difficult to distinguish from hemorrhoids Cauliflower type appearance History of HIV, History of abnormal pap smear Homosexual males usually but can be seen in the heterosexual population Caused by HPV virus Increased risk of anal cancer in the immunocompromised patient

Treatment - Topicals Aldara (Imiquinod) >50% initial response Topical 5-FU – 90% initial response Condylox (podofilox) Each have high local toxicity Practice Parameters for Anal SquamousNeoplasms www.fascrs.org

Treatment Photodynamic therapy Wide Local Excision Targeted destruction with cautery and/or Infrared coagulation Observation of AIN I/II with removal of visualized lesions Excision of AIN III

Anal Squamous AIN High recurrence rate with all techniques Close follow up to detect progression to invasive carcinoma Anal pap smear vs high resolution anoscopy Optomize underlying conditions

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