1. ANAL PAIN JAMES FRANCOMBE CONSULTANT COLORECTAL SURGEON WARWICK HOSPITAL

2. ANAL PAIN ANAL PAIN RELATIVELY COMMONRELATIVELY COMMON SEE OFTEN IN CLINICSSEE OFTEN IN CLINICS SEE OFTEN AS EMERGENCYSEE OFTEN AS EMERGENCY TREATMENT PERCEIVED EASYTREATMENT PERCEIVED EASY TREATMENT CAN BE DIFFICULTTREATMENT CAN BE DIFFICULT OUTCOME VARIABLEOUTCOME VARIABLE

3. ANAL PAIN AETIOLOGY FISSURE IN ANO ABSCESS/SEPSIS/FISTULA ABSCESS/SEPSIS/FISTULA TRAUMATIC TRAUMATIC NEOPLASTIC NEOPLASTIC THROMBOSED HAEMORRHOIDS THROMBOSED HAEMORRHOIDS THROMBOSED PERIANAL HAEMATOMA THROMBOSED PERIANAL HAEMATOMA RECTO-ANAL INTUSSUSCEPTION RECTO-ANAL INTUSSUSCEPTION

4. HAEMORRHOIDS DO NOT CAUSE PAIN....... UNLESS THROMBOSED THEY ITCH, FEEL SWOLLEN, UNCOMFORTABLE, ANGRY, FLARE UP BUT THEY DO NOT CAUSE PAIN UNLESS THROMBOSED

8. THROMBOSED HAEMORRHOIDS PAIN RELIEF LAXATIVES SPHINCTER RELAXATION ( ANOHEAL/GTN) ‘THE FROZEN FINGER ‘THE FROZEN FINGER ’ IF ALL ELSE FAILS SURGICAL EXCISION

9. THROMBOSED PERIANAL HAEMATOMA

11. THROMBOSED PERIANAL HAEMATOMA  PAINFUL  ACUTE ONSET  MAY HAVE BEEN STRAINING/COUGHING PROLONGED SITTING  SPONTANEOUS

12. THROMBOSED PERIANAL HAEMATOMA TREATMENT  ANALGESIA  ANOHEAL  LAXATIVES  ICE-PACK USUALLY RESOLVE SPONTANEOUSLY

13. THROMBOSED PERIANAL HAEMATOMA TREATMENT SURGICAL IF MEDICAL FAILS  INCISE AND DRAIN LA (SKIN TAGS)  EXCISE ?GA (NO TAGS)

14. FISSURE IN ANO COMMON PAINFUL DEFECATION ‘PASSING GLASS’ BLOOD SPOTS AND DRIPS INTERMITTENT PAIN  AFTER 1-2 HOURS OFTEN CONSTIPATED ‘HARD MOTION’

17. FISSURE IN ANO ISCHAEMIC ULCER -USUALLY POSTERIOR SPHINCTER SPASM - POOR BLOOD SUPPLY NATURALLY SLOW TO HEAL DUE TO ABOVE

18. FISSURE IN ANOTREATMENT DECREASE PAIN-LIGNOCAINE GEL REGULATE BOWELS-LAXATIVE SPHINCTEROTOMY-CHEMICAL -SURGICAL

19. FISSURE IN ANO SPHINCTEROTOMY-CHEMICAL DILTIAZEM 2% TOPICAL BD 6 WEEKS DILTIAZEM 2% TOPICAL BD 6 WEEKS RCT BETTER THAN GTN (LESS SIDE EFFECTS) RCT BETTER THAN GTN (LESS SIDE EFFECTS) BOTOX INJECTIONS BOTOX INJECTIONS HEALS 75% AT 6 WEEKS HEALS 75% AT 6 WEEKS RELAPSE MAY BE HIGH RELAPSE MAY BE HIGH

20. FISSURE IN ANO SPHINCTEROTOMY-SURGICAL BEWARE OF WOMEN POST CHILD BIRTH FAILED MEDICAL /BOTOX TREATMENT TAILORED SPHINCTEROTOMY OPEN IF POSSIBLE UPTO 10% GAS INCONTINENCE-USUALLY TEMPORARY.

21. FISSURE IN ANO POOR MEDICAL RESPONSE TO TREATMENT SENTINEL TAG LONG HISTORY >6 MONTHS FIBRES OF IAS EXPOSED

22. ABSCESS COMMONCOMMON EMERGENCYEMERGENCY CRYPTOGLANDULAR THEORY OF ORIGINCRYPTOGLANDULAR THEORY OF ORIGIN PERCEIVED ‘JUST AN ABSCESS’PERCEIVED ‘JUST AN ABSCESS’ USUALLY LEFT TO JUNIOR SURGEONUSUALLY LEFT TO JUNIOR SURGEON POOR OPERATIONPOOR OPERATION

24. ABSCESS ACUTE SITUATIONACUTE SITUATION INCISE AND DRAININCISE AND DRAIN BIOPSY SKIN (?CROHNS)BIOPSY SKIN (?CROHNS) RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA)RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA) PACK GENTLY (IF AT ALL –NEW EVIDENCE)PACK GENTLY (IF AT ALL –NEW EVIDENCE)

25. FISTULA ABNORMAL CONNECTION BETWEEN 2 EPITHELIASED SURFACES. A TUNNEL ABNORMAL CONNECTION BETWEEN 2 EPITHELIASED SURFACES. A TUNNEL DEVELOP FROM ABSCESS (25% FORM FISTULA) DEVELOP FROM ABSCESS (25% FORM FISTULA) DISCHARGE INTERMITTENTLY PRECEDED BY PAIN DISCHARGE INTERMITTENTLY PRECEDED BY PAIN

26. FISTULA CLASSIFICATION INTERSPHINTERICTRANS-SPHINCTERICSUPRALEVATOREXTRASPHINCTERIC +/- SECONDARY TRACTS/HORSESHOE

27. FISTULA TREATMENT INTER-SPHINTERIC LAY OPEN TRANS-SPHINCTERIC LOW-LAY OPEN HIGH-SETON/FLAP/PLUG

28. FISTULA TREATMENT TO CURE MEANS TO CUT OPEN TO CUT OPEN MEANS TO CUT SPHINCTER CUT SPHINCTER CUTS CONTINENCE MORE YOU CUT THE MORE THEY LOOSE CONTINENCE DECREASES WITH AGE FUNCTIONAL LENGTH OF FEMALE ANAL SPHINCTER APPROX 2 CM. CUT 6MM THEN 30% OF SPHINCTER CUT ----CHANCE INCONTINENCE APPROX 30%

29. ANAL ANATOMY

34. NEOPLASTIC USUALLY SQUAMOUS CELL CA HOWEVER VARIETY MELANOMA, LOW RECTAL CA CLEAR CELL CA RARIETIES

38. TRAUMATIC  SELF INDUCED-SEXUAL GAMES  INFLICTED- TRUE TRAUMA EITHER RTA, CHILDBIRTH, IMPALEMENT STUPIDITY-USUALLY WHILST UNDER THE INFLUENCE!!!!!!!

40. RECTOANAL INTUSSUSCEPTION  VERY EARLY PROLAPSE  RECTUM TELESCOPES INTO ANAL CANAL  MAY SEE ON SIGMOIDOSCOPY  SEEN ON DEF. PROCTOGRAM  MAY LEAD TO COMPLETE PROLAPSE  CAN CAUSE PAIN,OFTEN MULTIPLE INVESTIGATIONS-ALL NORMAL

42. RECTOANAL INTUSSUSCEPTION TREATMENT  BIOFEEDBACK  DEFECATORY DYNAMIC RETRAINING  LAPAROSCOPIC ANTERIOR RECTOPEXY