Common Office Anorectal Problems

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

Disclosures l None Benign Anal Rectal Disease

l Anatomy of the anal canal and perianal spaces l Benign Anal Rectal Disease – Abscess and Fistula – Fissure – Hemorrhoids Overview of Anatomy

l Anatomy – Pelvic and Perirectal Spaces – Anatomy of Anal Canal Retrorectal Space Waldeyer’s SupralevatorFascia Space Levator Ani Muscle Deep Postanal Space Superficial Postanal Space ANAL CANAL

Peritoneum Supralevator Levator Ani m. Space Puborectalis m. Ischioanal Space Deep External Sphincter m. Intersphincteric Internal Space Sphincter m. Perianal Space Transverse Septum ANAL CANAL

Column of Anal Transitional Morgagni Zone Dentate Line Anal Crypt Anal Gland Anoderm Patient complaints Anal Pain Bleeding Drainage Time course

Fissure Hemorrhoid Abscess Knifelike pain with BM Acute or Chronic Generally Acute Passing Glass Brick, Throbing Bleeding itching burning Minimal bleeding Pain with BM:minutes to hours Sudden swelling, +/- pain Pain Swelling over large Blood on toilet paper Prolapse area not associated with BM No drainage Difficulty with hygiene +/-Purulent Drainage Small tag or “hemorrhoid” Pain rarely knifelike Rapid increase in size

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

Anorectal Abscess Etiology l Cryptoglandular abscess – Most common – Infection in the glands at the dentate line l Other causes – Crohn’s and Ulcerative Colitis – Tuberculosis and Actinomycoses – Malignancy – Foreign Bodies, Prostate Surgery or Radiation Fistula Description l Clock description – Does the anus tell time? – Relies on description of patient’s position: supine, lateral, prone and relative landmarks l 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 Pubic bone

Right anterior Left anterior

Right Left

Right posterior Left posterior

Tailbone l There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained Abscess Classification

l Four Types Based on Space Involved – Perianal - 19-54% Most – Intersphincteric - 20-40% Common – Ischioanal - 40-60% – Supralevator 2% or less Rare Supralevator Abscess

Intersphincteric Abscess

Ischioanal Abscess Perianal Abscess HORSESHOE ABSCESS

Supralevator Space Intersphincteric Space

Ischioanal Space Anorectal Abscess Treatment of Perianal and Ischiorectal Abscesses l Diagnosis - usually straightforward – Erythema and Pain over affected area – Fluctuance l 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 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 Catheter Types l Pezzer catheter l Malecot l Solid mushroom l Allows tissue top so stays in ingrowth l Less tissue l More painful to ingrowth remove Peri anal abscess - ? Antibiotics l Not usually indicated if there is adequate drainage l Indicated for patients with: – Obesity – Diabetes – Imunocompromised – Extensive large abscess or recurrent abscess Fistula-in-Ano l Definition – abnormal connection between two epithelial surfaces. l Classification: – Parks: Defines fistula by course of tract – Goodsall’s rule l Diagnosis l Treatment – Goals – Options How does patient present? l May have had a history of abscess l History of Crohn’s disease l May present at the same time as abscess l Complain of intermittent increase in pain/ swelling followed by spontaneous drainage l Chronic localized area of irritation or ulcer “pimple near my anus keeps coming back” Fistula-in-Ano Goodsall’s Rule

Posterior

Anterior Fistula in ano Fistula in ano: Surgical disease l Refer to Colon and Rectal Surgeon or General Surgeon l Reassure patient – rarely cancer, most do not need a colostomy l If suspect Crohns – Gain control of perianal sepsis – Then complete full workup and staging l Goals of therapy – Get rid of the fistula/connection – Preserve continence Surgical Options l Primary fistulotomy – Mainly for low, superficial fistula – Risk of fecal incontinence l Fibrin Glue/Fistula Plug – Utilizes substrate as scaffold to fill tract – Does not involve cutting muscle l Cutting or draining setons – For deeper tracts that involve significant muscle – Risk of fecal incontinence l Rectal advancement flap l Lateral internal fistula transection – Newer procedure. No foreign substrate – Cuts fistula tract, not muscle Fistula in ano Fistula in ano Fissure in Ano l 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 Fissure in Ano Pathogenesis l Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus l 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 Fissure with Sentinel Tag Fissure with Sentinel Tag Fissure in Ano Pathogenesis l 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 Fissure in Ano Symptoms l Pain is the main symptom – Sharp, cutting or tearing during defecation – Duration is few minutes to hours l Bleeding – bright red and scant l Skin Tag l Mucous discharge resulting in itching Fissure in Ano Diagnosis l Diagnosis often made on history alone l Inspection – gently spread the buttocks and the fissure becomes apparent l Triad of chronic anal fissure – Sentinel pile – Hypertrophied anal papilla – Anal ulcer Fissure in Ano Differential Diagnosis l Intersphincteric abscess l Pruritus Ani l Fissure from inflammatory bowel disease l Carcinoma of the anus l Infectious Perianal conditions l Leukemic infiltration Fissure in Ano Crohn’s Anal Fissures Acute Fissure in Ano Treatment l Increase dietary fiber l Local anesthetic to prevent spasm l Nitroglycerin or Nifedepine Ointment – Not commercially available – Must be mixed by pharmacist l Warm tub soaks l 4-6 weeks of treatment Chronic Fissure in Ano Surgical Treatment l 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

Hemorrhoids l What are they? l Where are they? l Why do they become symptomatic? l Classification? l How do you treat them? l Can they be avoided? Hemorrhoids What are they? l Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissue l Aid in anal continence Hemorrhoids Where are they? l 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 l External Hemorrhoids – Below the dentate line – Blood drains through the inferior rectal veins to the pudendal veins on into the iliac veins Hemorrhoids Symptoms? l Chronic constipation l Diarrhea l Trauma to the hemorrhoids during defecation cause the most common symptoms – Pain – generally not “knife-like” – Itching – Burning – Bleeding Hemorrhoids Classification- Internal Hemorrhoids

l 1st degree – bulge into the lumen l 2nd degree – prolapse with bowel movement but reduce spontaneously l 3rd degree – prolapse spontaneously and require manual reduction l 4th degree – permanently prolapsed hemorrhoids that cannot be reduced 4th Degree Hemorrhoids Hemorrhoids Treatment Principles l Thorough physical exam to determine severity and rule out other pathology – Refer for surgical evaluation if white or discolored, firm or fixed l Determine if the problem is internal, external or both l Assess the symptom complex Treatment l Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream… l 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 Treatment Office and Minor Procedures l 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 Treatment Office and Minor Procedures l Infrared Photocoagulation – Indicated in 1st degree hemorrhoids – Causes photocoagulation of small vessels – Performed in office or “Hemorrhoid Relief Center” – Minimal pain Closed Hemorrhoidectomy Indication l Hemorrhoids are severely prolapsed and require manual replacement l Patients fail to improve after multiple applications of non-operative treatment l Hemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags Closed Hemorrhoidectomy General Principle l Most can be performed with local and IV Sedation l Prone/Kraske position is the best l Infuse the area with local anesthetic with epinephrine for hemostasis l Fleets enema 1-2 hours prior l No antibiotic prophylaxis is necessary Closed Hemorrhoidectomy Closed Hemorrhoidectomy Closed Hemorrhoidectomy Post op Result PPH Stapling Procedure for Hemorrhoids l Not for every hemorrhoid l Ideal for Grade 2 and 3 with minimal external component l Prevents prolapse and thus less trauma to hemorrhoid with bowel movement

PPH Stapling Procedure for Hemorrhoids PPH Stapling Procedure for Hemorrhoids l Benefits – Less pain as compared to traditional closed hemorrhoidectomy – Less blood loss during the procedure – Less chance of anal stenosis PPH Stapling Procedure for Hemorrhoids l 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 Perianal Condyloma l Can sometimes be difficult to distinguish from hemorrhoids l Cauliflower type appearance l History of HIV, History of abnormal pap smear l Homosexual males usually but can be seen in the heterosexual population l Caused by HPV virus l Increased risk of anal cancer in the immunocompromised patient

Treatment - Topicals l Aldara (Imiquinod) >50% initial response l Topical 5-FU – 90% initial response l Condylox (podofilox) l Each have high local toxicity l Practice Parameters for Anal SquamousNeoplasms www.fascrs.org Treatment l Photodynamic therapy l Wide Local Excision l Targeted destruction with cautery and/or Infrared coagulation l Observation of AIN I/II with removal of visualized lesions l Excision of AIN III Anal Squamous AIN l High recurrence rate with all techniques l Close follow up to detect progression to invasive carcinoma l Anal pap smear vs high resolution anoscopy l Optomize underlying conditions

?