‘A pain in the backside’ Kamal Patel

Anorectal conditions in GP Aims Overview of the anatomy Common causes of anal pain and mx Functional anal pain Considerations A common problem. Source of embarrassment for patient (and GP in some cases!).

Anatomy

Anatomy Anal canal – 4 – 4.5cm Rectum – 13cm Dentate line – separates columnar epithelium of the upper 2/3 of anal canal for the squamous epthelium of the lower 1/3. Internal sphincter – involuntary External sphincter – levator ani

History Age of patient. Duration of symptoms. Associations Bleeding Discharge Timing of pain Defacation Sitting Related symptoms Change of bowel habit. Sinister features Weight loss

Causes of anorectal pain Organic Anal fissure Perianal abscess Perianal haematomas Carcinoma Strangulated haemorrhoids Pilonidal sinus Functional Levator ani syndrome Proctalgia fugax

Anal fissure Aetiology – constipation, Crohns o/e sentinel pile Mx – avoiding constipation. Topical GTN Botulinum toxin injection. Internal sphincterotomy

Perianal Abscess Arise from obstruction of perianal glands – intersphinctereric. Can track to the perineum or laterally to the ischiorectal fossa. Also associated with TB and actinomycetes. Mx – if early – tx with antibiotics. If presenting acutely – needs evacuation.

Perianal haematomas Due to ruptured anal vein. Onset after straining. Mx oral analgesia or evacuation.

Pilonidal Sinus Commonly in natal cleft, but can occur at other sites. Broken pieces of hair acting as foreign body ‘dark haired hirsuite men’ Recurrent episodes of pain and infection. Abx tx, lay open, complete excision, curettage with phenol injection.

Levator ani syndrome Prevalence 6.6% More common in women. PC: vague ache or pressure in rectum; worse on sitting. Diagnosis of exclusion. Mx: ‘digital massage of the levator ani’ Sitz baths Electrogalvanic stimulation Biofeedback training.

Proctalgia Fugax Severe cramp-like pain in the rectum Short duration Diagnosis of exclusion ‘Many patients are perfectionistic, anxious, and/or hypochondriacal’ Mx – reassurance. ?inhaled salbutamol