1. ‘A pain in the backside’
Kamal Patel

2. 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!).

3. Anatomy

4. 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

5. 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

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

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

8. 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.

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

10. 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.

11. 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.

12. 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