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

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

3. Anatomy of the anal canal:

4. 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

5. 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)

6. 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

7. 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”

8. 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

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

10. 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

11. Etiology: Constipation or straining Increased abdominal pressure
Pregnancy
Portal hypertension

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

13. Diagnosis: History Rectal examination Proctoscopy
Sigmoidoscopy or colonoscopy

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

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

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

17. 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

18. 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

19. 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

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

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

22. Diagnosis:
History
Rectal examination
Proctoscopy

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

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

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

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

27. 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%)

28. 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

29. 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

30. 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

31. 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

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

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

34. 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.

35. 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

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

37. 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

38. 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

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

40. 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

41. 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

42. Cutting seton
Draining seton
Fistulotomy
Fistula plug
Advancement flap

43. 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

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

45. 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

46. 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

47. 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

48. Thank you…