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

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

Anatomy of the anal canal:

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

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)

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

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”

Do not bleed, may thrombose Types: Internal hemorrhoids External hemorrhoids Above the dentate line Below the dentate line Covered with mucosa Covered with anoderm Painless Painful & itchy May bleed or prolapse Do not bleed, may thrombose

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

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

Etiology: Constipation or straining Increased abdominal pressure Pregnancy Portal hypertension

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

Diagnosis: History Rectal examination Proctoscopy Sigmoidoscopy or colonoscopy

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

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

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

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

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

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

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

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

Diagnosis: History Rectal examination Proctoscopy

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

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

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

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

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%)

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, lymphogranuloma venereum, Crohn's disease, trauma, leukemia and lymphoma

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

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

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

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

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

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.

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, lymphogranuloma venereum, syphilis, tuberculosis, radiation exposure and HIV

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

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

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

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

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

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

Cutting seton Draining seton Fistulotomy Fistula plug Advancement flap

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

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

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

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

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

Thank you…