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

2. Disclosures
None

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

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

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

6. 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

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

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

10. 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

11. 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

12. Pubic bone
Right anterior
Left anterior
Left
Right
Right posterior
Left posterior
Tailbone

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

14. Abscess Classification
Four Types Based on Space Involved
Perianal %
Intersphincteric %
Ischioanal %
Supralevator 2% or less
Most
Common
Rare

15. Supralevator
Abscess
Intersphincteric
Abscess
Ischioanal Abscess
Perianal Abscess

16. HORSESHOE ABSCESS Supralevator Space Intersphincteric Space
Ischioanal Space

17. 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

18. 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

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

20. 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

21. 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

22. 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”

23. Fistula-in-Ano Goodsall’s Rule
Posterior
Anterior

24. Fistula in ano

25. 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

26. 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

27. Fistula in ano

28. Fistula in ano

29. 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

30. 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

31. Fissure with Sentinel Tag

32. Fissure with Sentinel Tag

33. 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

34. 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

35. 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

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

37. Fissure in Ano Crohn’s Anal Fissures

38. 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

39. 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

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

41. 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

42. 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

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

44. 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

45. 4th Degree Hemorrhoids

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. Closed Hemorrhoidectomy

53. Closed Hemorrhoidectomy

54. Closed Hemorrhoidectomy Post op Result

55. 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

57. PPH Stapling Procedure for Hemorrhoids

58. 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

59. 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

60. 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

62. 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

63. 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

64. 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

65. Questions?? 65

66. ?