Common Anorectal Disease

Anorectal pain Rectal bleeding Anal mass Pruritus ani

! "# $% &$ ' ! ($)* ! (*+&$ ' ! ), ! -"+ . !/ ) $ $$0 &.( 1 ),1 1 $*+ !* & $0$*+$)2 ,+( "1 ),!) #(+ ) (#3 $& 4 $ $% -*# , , $ % (#"#$!2 ! !* ! $ *+4 &.( 5( !* .1 -"+. )!$& $.&$%*#),$ $*#$*+&$ ' ! $& 3 ) ) $*#! ! ),$& !($ ) (#3 (+ $ $0 &.( # ($ (), 35 (+ $!) (#(. $! &.( 1

!"#$%&'(" )*+,"-./ 2 !* rectum *)3 1.. (+ $*+ sigmoid colon $&+ sacral promontory .&#.(+&$ '(+ levator ani muscle -"+, )1 !)$0 anal canal 1 rectum , ' 12-15 $-&$ %#. rectum $0 longitudinal muscle 1 ( taenia ), rectum 1 ( mesentery, sacculations # appendicae epiploicae rectum ( 3 lateral curves * . ),) convex 1 . ) convex 1 - rectal mucosa &$ '! "# $( valves of Houston . !/ (, ' 3 rectum $0 3 . * upper, middle ), lower part ( (+ 1)

1 3

rectum ! , sacrum, coccyx, levator ani m., coccygeal m., medial sacral vessels ), sacral n. plexus ! rectum % & urinary bladder, ureter, vas deferens, seminal vesicles ), prostate !/&& uterus, fallopian tubes, ovaries ),. posterior vaginal wall

anal canal *)3 1.. (+$&+ anal verge :" anorectal ring ( , ' 4 $-&$ -"+ anorectal ring $0) puborectalis muscle ),. : )3 1 ! anorectal ring . dentate line 1-1.5 $-&$ anal verge $0 ,! anoderm perianal skin anoderm $0 squamous epithelium (+($.,. 3 secondary skin appendage -"+1 hair follicle, sebaceous gland ), sweat gland dentate line !* pectinate line $0 true mucocutaneous junction &$ ' 1-1.5 $-&$ $!* anal verge ,, 6-12 &))&$$!* dentate line $0 transitional zone -"+ squamous epithelium anoderm $)(+$0 cuboidal ), columnar epithelium (+. anal canal :) internal ), external sphincter internal sphincter $0) $*# -"+ circular smooth muscle rectum $0 involuntary muscle external sphincter , voluntary striated muscle 3 . * subcutaneous, superficial ), deep group &$ ',! internal ), external sphincter $( intersphincteric plane $0 fibrous tissue -"+ longitudinal smooth muscle rectum $((%*+!"+ conjoined longitudinal muscle

2 columns of Morgagni , mucosa (+! "# , ' 8-14 $!* dentate line &$ ' ) ,! column of Morgagni ), * anal crypt ; anal crypt , anal gland -"+ %# submucosa ),( & $ 1 intersphincteric plane ( (+ 2) anal gland $0. $!(+.3 / $& anorectal abscess ), fistula in ano

2 2

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3 %& anorectal pain "$ 5

' -, &.&+ 1(# * )4', ,,$ ) :(+ 3 ! (+ .&+(+,!( "# $% $ : , 1!* <& $ = (+$(+ *+ $% $)* ! !* ! ,3 4 - )4', $% !)"# ,! $0 !* $*# *#!*> ! $!* : ,1 . (tenesmus) (+. ? $)(+) !* $ )*+1! 7 - ,,$ ) $2 $% ',: , !* !) : , (+$01 !* ( !) : ,$0%+ !*$0 (+1 . ? : , (+$&"#$ ) ) *6 - 3 ! (+ $% &$ ' ! &$ ' ! )" ! !* (+ , - , & ($ =. ? ! 6 !* .3 $2 $ ! , & . : ,!* %&# *) ,'( 1&$!,,&$ '!* ! - (+$(+ *+ $% !*$)* ! )4', , :(+ : , $0 - ,3 (+(;& +3 $% &$%*# HIV ,$2$2$)* !* ,$2 #3 $!)* , & 1 5 .( , & 1&$!,,&$ '), !

4 ($ (+&$ '), ! &(!*1 $*+ . $! acute anorectal pain &&51 #. $ *+! )5( (+ ! $. $*#$*+!*$0AB ! !$)* !* & ),$ $*#$*+(+ ! $*#&$ '!*(+ ! 4 ! ) $*#! !1 ,% (patulous anal orifice) -, &$*+ $ = ! !* .3 $2 $ ! (# 2) $*# ),$.,. *+ $*+ $& degenerative neuromuscular process ! 1 && ! &# * (digital rectal examination) )$ *+! 1.), ! -"+ ) $*#! ! $2 $.$*#$*+!*AB&$ ' ! '((# ! .3 / )3 ; ! !)), &$ '(+ & $0AB $*+ . $!AB !) !*( )) 1. &?( bimanual palpation *%&# * 2 &# * &# %(# ! . &# C(+& ! : ( $2 (AB) 1:"(+3 ! # 7 $*#!*)1.!* ! 1.!* ! -"+$& $( ; !* $&AB&$ ' ! !$)*(+&$ ' ! !* )4',&& ,$% ,2 ! ,$!) (!*$)* ( )&+$!2$!*$*# $0 % ! .3 / )! ( $2 $. )! !* )3 1 )! ),2 3 !.. $0,$2 )! !/& )3 ( (+ )!*!*B)#. !*1 $*+ (+ ! (. $! ($ % "+ ",)"$. '((+ ( ',(+ !*'((+.. ! %&1 3 ! &# * $*+ $0 3 ! "#),1 * 4 -"+. )! &&5 13 1 )3 ),1 1) (+ ) 1 acute anal fissure, anorectal abscess (+$!21% ; ! thrombosed external hemorrhoid ), prolapsed strangulated internal hemorrhoid ! &$ '),; !& ( (+ ! . $! (+ !. 1. !* $*#$*+; !!*1. !*$& functional !*1 (. $!(+ % -"+$& (+(; ,-"$= !*'((+$0 proctalgia fugax ), levator syndrome -"+1 &&5$ &+$& 1 3 anoscopy !* proctoscopy . :! &&5 1 3 ,, ),3 !) (+3 ! &# *) 1 $2 1 . :! &&5 1 $*+ 3 anoscopy 3 ! $2 "# '((+( $.1.), !!* $.!*$0AB% ! .$$*+; 1.), ! (

5 $. !*()!*1 .$ (&.( !*$*#; !(+. :?& . $! 1!*1 4 ! ( $2(+) $*# levator ani (!*1 ( spasticity !.. $0 levator syndrome4 2) $*#! ! ! & !&# * '((+ ) $*#! ! 1 ?&.; *+&$ '!*; ! !.. (/! ,,. !*$& $ = ! !* .3 $2 $ ! "+ . . : ! ) $*#! !14 #3 $0( $ ,$%*# !*!&%&#$*#. ?&$ *+!1 &&5 (+: anoscopy 1 && $*+ . $! . &$ '(+. : 1 !*$& extrinsic disease processes 3 $01 &&5$ &+$& 1 (()" ** 4 ! 3 anoscopy 1 . :?& . $! !* ?&.; (+1.), !-"+ )3 1.!/ . (+ ."#1$ &+$& ,3 !. flexible sigmoidoscopy -"+. : )3 1.!/ 1:"&$ ' descending colon !* splenic flexor colon '( 3 $0 )3 1.!/ #! (colonoscopy) $% $*#(+1.), ! '((+ )&$ ' ! 1. (+, 6-10 $-&$ ! -"+.. ,$0 solitary rectal ulcer ,3 !3 flexible sigmoidoscopy $ *+)4',) !&%&#$*#. ?& & #! $ : ,',(+:)% )3 1.*+ ) ! ),. : &&5; , incomplete rectal prolapsed 1 '((+1 . :! . $! $2 1 3 )*+$.( :(+.!*$-$ & $&$ '$%& $5 ,!/& $*+ ?&.; 1 . :3 !$& !1 (# :#3 !*$*#&$ '! , sacrum 1 !*,+ chronic intramuscular abscess ! ! &# *),3 . ) !),)3 1.!/ & &$ ' !$*## $& ; ,-"$= !*(+ 1 * $.*+ $.,. cauda equina !* peripheral pelvic pain pathways () + 4 (+3 !$& !1 Organic causes Inflammatory conditions Anorectal abscesses Anal fistula Proctitis

6 Crohn's Ulcerative Idiopathic Radiation Infectious Pararectal inflammation Prostatitis Tubular ovarian abscess Endometritis Diverticular abscess Pelvic appendicitis Mechanical causes Anal fissure External hemorrhoidal thrombosis Acute hemorrhoidal prolapse Incomplete rectal prolapse (retroanal intussusception) Descending perineum syndrome Pelvic surgery Pudendal neuropathy Neoplastic causes Benign tumors Peripheral nerve Muscle: anal sphincter or pelvis Peripheral nerve muscle: anal sphincter or pelvis Bone endometriosis: sacrum or pelvis Malignant tumor: primary and metastatic Rectum Anus Prostate Cervix Uterus Ovary Nerve: peripheral cauda equina Bone Pelvic muscle

7 Krukenberg tumor Neurogenic causes Multiple sclerosis Peripheral neuropathy Degenerative lumbosacral disk disease Orthopedic causes Coccygeal trauma Sacropelvic fractures Osteogenic tumors Functional/idiopathic causes Levator syndrome Proctalgia fugax Depression Chronic idiopathic rectal pain ()+ , (-"& + "$ ./ 0 *#)$ ) $& anorectal abscess (1 '((+$0 perianal abscess $*#$*+ !* $2&$ ' ! ',(+ intersphincteric !* ischiorectal abscess 1 $. '((+$0 3 !: ,),.. ,)3 18 !) ! *&$ ' , 1 (!* $. $*#$*+!$!2 $0)4',$5 , postanal space abscess (+$0 "#$*+( 1!* . ? intersphincteric abscess 9 (+$&"#(,! !* !) : ,!/ !*2 ),$0 !)$!* (((+&$ ' ! ), ("#!) : , $& anal fissure !* anal abrasion 1 *#(+$&"#( ), #. ? $ !*! 1 thrombosed external hemorrhoid ( % 1-2 # ("# 1 : , ."$!*: 11 . #(+1 ( , 1: ,-#3 1 ( ,$ &+ . ? inflammatory !* neoplastic condition anorectum !)(+ ) !$2 $& levator muscle spasm !* proctalgia fugax -"+1 &&5& $0 (+$& &.( ),1 4 &.( 1 3 $0 (+ (+ rectum $& $.$)*$%& !* $*# &$ '!) 1. ( "&$ '(# (+, (coccygeal pain) (+(. $! ! ), (+(, & 1&$! ligament !* periosteum coccyx ), # $& (+( $. presacral cyst 3 ! (+ coccyx 1$% 9

8 ""/5 4 . $! $% '($0 anorectal abscess ! , ! 1 ! D&%( , $ ) (+(;& +3 $% &$%*# HIV $ ! 1 $ (3 ) steroid !* ;& ), (+(, &1 5 .&$ ' ! ,." )) ( !) 1 , ! 7 " acute anal fissure 4 C1 !( ! $ &+ ! !, )1 *+#3 % ! #3 '!;& 40 = $-)$-(. ! $ % )! $ ) 4 . ! ! 1 ! !*'($0 chronic anal fissure !4 3 lateral internal sphincterotomy * ) $*#! ! . )! $ ) 3 . ! ( .)$0-#3 $ (), 1.3 1 ! , ) $ &+ ( )3 1.10 ( &?(4 chronic anal fissure , ), !) %&$% ) nitric oxide, botulinum toxin, calcium agonist, cholinergic agonist, alpha-adrenoceptor antagonist ), beta-adrenoceptor agonist $0 12 )(+( ) 4 1 $0(+ * .! +3 ), .)$0-#3 . 3 lateral internal sphincterotomy 11, 12 '((+$0 thrombosed external hemorrhoid ! hemorrhoidectomy ( ! ( !*$0 1 $& 42-72 %+ $*+ 1 1 3 elective case ),% $ 1( '((+$01 !5( % $5 ,(+), evacuate clot 1(+! 13 (+$& $*#!*)3 1.$. 3 $& 4 (+$5 , # 4 chronic idiopathic perineal pain -"+1 proctalgia fugax (levator syndrome), coccydynia, descending perineum syndrome ), chronic idiopathic anal pain # (+.3 / * !3 ) ), &&5$ *+* 1 1(. $! ,$2 14 ( &?( 4 !) &?( $% % #3 ! ) ) $ ! 1 ("# 5( steroid $ 1&$ '(#6 !*3 direct nerve ), muscle blocks 4, biofeedback % 1 ((+ 4 $!) (#1 1) $*+ 1 . $! $& (+%$+$ ! (, &$*# ,3 ! $ &+ ! !* $!2, : , $*+ : ,(+& 3 !) 114

Rectal bleeding (+($)* !$!*$0 $* ( && :" . !/ 1 % ,$2 12 ,$0 (+3 !$0 :" %( &1 &&5$ &+$& (+($)* ! ( :,. (+.3 / 2 , * $ *+! 1 % ,$2 ),$ *+ ! . $! ($)* (+($)* ! $5( )& ' $0 $* ! 1 4 )

9 (+(#,) :"$)*(+ !$*# & '1 $ # hematochezia * ($)* , '((+& '$)*(+1 ), (.// '%( (+& !.. $0$)*(+ $& ! . ) $0 15 outlet bleeding * - $)*.(., 4%3 , !* : , - $)*(+. ? : , - : ,1 $)(+) - 1 ($.(+ $& colorectal cancer !.. $)*(+ !!*1. suspicious bleeding - (+($)*.($ !*$)*. , !*$0$. , - (+( $)(+) : , !* (+( ! - ($.(+ $& colorectal cancer !.. $)* 1.!*)3 1.!/ . (+ $!*"#1 "+ $&+ ,$& $)*(+ .// '%( ! &( -(1 1 resuscitate $ . :-, &), ),$( )3 #1 "6/7"+/( . :,$& (+ chronic rectal bleeding 20 3 : 15 1. $)* $ 1 2. $)* 1! 3. )4',$)*(+$0 1 ,!* 4. .($)*$0 1 5. $!2$)*(+1! , 4%3 , : , !* , 6. $)*(+(& '$ 1 7. $0 "#!*1 8. ( ',: , !*1 9. : ( ',: ,$0$5 ,$ ) (+($)*!*1 10. (*+(+ !!*1 11. : (*+(+ ! ) !* ) )$ 11 12. : (*+(+ ! ( (+ !*1 13. )4', : ,$0 1 14. (,1(+$ &+$)(+)1!*1 15. $ : ,!*1 1! 16. $)*$5 ,$ ) (+$ : ,!*1 17. $ (/! ! !*1

10 18. $ (, &$0 polyp !*,$2(+)3 1.), ! !*1 19. (, & $0 polyp !*,$2(+)3 1.), !!*1 20. .; + 1$0 1 !) (+ 1 3 : # 20 . :1 $)*(+ ,(. $! ,1 $0 outlet !* suspicious ),3 &&5 1 1 ((+ 4)

4 %& rectal bleeding "$ 5

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11 , $)*(+ prolapsed internal hemorrhoid !* external hemorrhoid !4 3 hemorrhoidectomy ! internal hemorrhoid ),(& '1 4 ! $ &+ ! ,3 !, #3 ),)1& ' !* 4 5( sclerosing agent !*3 rubber band ligation &$ '! &.( (+($)* $)*(+ hypertrophied anal papilla ! 1 ("#!) 1 $ &+ ! ,3 !3 excision -"+. :3 1 5( % $5 ,(+(+ ! ! $& acute anal fissure !4 &?(, , 1 !!* ,2 ), 3 lateral internal sphincterotomy '((+$0 chronic anal fissure ! $0$)* $*#&$ '1.), !!4 %&$*## '($0)3 1.$.(+$& &$%*# 4 ! D&%( , ! $& 5 . (),+ 1 (,$2)$0-#3 ! , ) (+$ )*! ,)*+ 1 3 $*+1. ), ! 1 ELP .co

Anal mass (+ (+ ! $ $0 &.( ),( ) , ) $0 ,$2!*1 (! (+! &&5),3 $& 4 (+$! ,. 1 ' 16 - : $*+(+3 $ , $% ,,$ ) . $!(+ $ &+ $ )*+(+$ ! ; ,$)* (#3 !*!1!) !*( &$ '), ! - :(+ : , $)(+))4', : , )4', , - , &$(+ $ = $5 , &+) $ = $ = ! !* .3 $2 $ ! 3 <& $ =(+$.(+ $0 & $ =. ? #, & $0 & $ =. ?), 4 ( - ,3 $% &$%*# HIV $0 ($ &$ ' ! ! (+ . : 1 : ! ) (+(+&%& +3 !*, - #. !! $ %& ! %1K. $ *+ $!2(+%$ ! ) 16 - .$)4',& ! ! 3 ! ), . ? anal verge erythema &&.(& (#3 !*!1!) ) ),! &$ ')$ ($% &$ ' perineal body ), gluteal cleft

12 - )4', $% 2 $2 () "& $*#$*+&$ ' $ ( -"+ $& )) $*# - '((+..$*#%& ,*+(+ ( , 1$*# $% #3 $!)*&$ ' !( % ), $0 ! &# * . : . ?,! !),1. '((+( $5 ,(+ ! . )! $011 )3 ),3 !1)(+1 $ ( !*1 : ,3 !3 ; % % !* .) $ *+!1 &&5(+: . anoscopy ) $ *+ ; ! ! ), ),$( $(+ &.( (+ "# ), anal crypts !1!) $ $*#(+*+ !* &&$*+1.), ! ! ', & (), -#3 !) ! % !* .) (()" ** '((+..$*#%& $% squamous cell carcinoma, lymphoma, melanoma, adenocarcinoma !* basal cell carcinoma !)1)%&#$*#(+ ) $ &+$&$ *+,, 1 $% 3 colonoscopy adenocarcinoma ), $-$ )*+$.( :(+.!* 3 $-$ & $$ *+! , (+$0 16 ()+ , (-"& + "$ ./ 0 ! (+ ( !*(#3 !*!1!) !.. (. $! $. ! &:"$*# ! % ),1 ( $2(+ $0 1 (1 !* #$!2! 1!) anal crypt ',3 anoscopy ! & $0AB 1$ . !/ $0 (+ perianal !* ischiorectal space 16 &$ ' ! 1 ( ),(, &$0 &.( ! & $0 skin tag ! 1 .; ,& *+(+ !$*+$ : , : ,.(& ($)*.(.! !) ,!*$ )* , )$ 1 !$!).&#. $ : , !*%*) ! &:" &.( ; ! &# *1 1 &.( 1 anoscopy !!*(, &$0 &.( ; #( (+), ,! ), . ? ( (+. (+ 3 ), 4 (+ (.( )#3 ! &:" thrombosed external hemorrhoid -"+$0 perianal hematoma 17 (+ anoderm ."#11:", dentate line #& !&$ '$!* $)*$& $ . )!$& ),, $)* ),($)*1!) 16

13 (+ ! (+ !',: , ),($)*.& ' $)2$HI&, 4%3 ,(+%3 ., ! !*(, &$0 )5( (+ ! $& ! & (+ (+ !#$0 sentinel pie ! $0(+. :$ )*+(+$ 1 $0 hypertrophied anal papilla (+( !/ -"+$& anal papillae (+, dentate line 16 )4',$0 , ! !*$0!/ ) ,!)+3 $0 ! 1 ( ! &$ '1 ., (#3 $!)* ), ?&.; 3 !($)*1', )4',$( 1(+. *+ ,$ = $% % ) % & !*% (, &$0 & $ =. ? !*() $%*# HIV $0 ! &:" condylomata acuminata ! & $ =. ?%&*+ ), $ *+! 4 1)(&+"# 16, 18 ! $0(+ % !*'((+$0)$*#1 ! ()&+$!2 ,3 !!&%&#$*#. ?& & $*+ $0 squamous cell carcinoma, lymphoma, melanoma, adenocarcinoma !* basal cell carcinoma $5 ,! $0.($!.. melanoma 12 1 (.(1 ! $ (, &$0AB 'L. $0,,$ ) ),4 1 ! ! &:" adenocarcinoma (+$& anal gland (+ "#% )4',! ) ($!) ; $*+!/ "#$$0)(! 1!) #( $2 (, & $0AB ! 2&$ '21 ! )3 1$0 2 (tract) %#1& ! 21(+$M ! ! &:" #$0 external opening AB 'L. 1 . probe (+! $*+ 3 ! ),$& false tract 116 (+ $0$ =!/& ; ,)! *+ ! ',$ : , ,,)$ 1$!*)1 '((+$0 *+ ! ',*!*$& ),)1 1 $0.(% & )*+ ) $*+% $0 ! (+$& $*+)3 1.$0 ) (concentric fold) ! & $0 rectal procidentia -"+ prolapsed internal hemorrhoid (+$0 =( (radiated fold) 19 ((+ 5.1 ), 5.2)

5.1

5.2 5.1 5.2 %& anal mass "$ 5

, 16 4 anal abscess , ! '((+$0 perianal !* superficial ischiorectal space . :, 1(+! ! $0AB(+--,3 ! , !(+! !/ ! $0 &.( !,,(+ 2 !* 3 ),1 (; ,- . :! 4 & ! &.( !* hemorrhoidectomy '((+$0 acutely thrombosed external hemorrhoid (+$0 48-72 %+ ! hemorrhoidectomy ! 48-72 %+ ! $ $ &+ ! ?% & thrombosed external hemorrhoid $)*),) ! 1 1 . ! '((+ $*+ )) ! 4 , , ! 3 ,3 + $ ), $ &+ ! $ *+C 13

15 %(# excision hypertrophic anal papilla *$ *+ 3 ., ) ." (+1 . ), $*#1 1 . !/ hypertrophic anal papilla . :4 1 1 4 ., &$ '!( ! $ &+ ! $ *+$ 4 condylomata acuminata * 3 excision ), fulguration 4 podophyllin !* bichloroacetic acid 1 1)'($0!/ ), 11 + :"$*+ ( !),% ) ( %*+ imiquimod $0 &$ '(+$0 $ *+$ &+ . ;& $5 ,(+20 3 %4 $.& 3 excision $ *+!1) 4 (+("# '($02$0) 3 !&%&#$*#. ?& & . !/ . : !&%&#$*#. ?& & 5( % $5 ,(+ #! 3 1 ! % $ 1. !)!* .) !* 3 ultrasonography ),$($(+ 2 3 ! ),&= ,3 !3 Lay-open fistulotomy 4 AB 'L.$ *+C ) $*#! !; '((+$0%&(+--!*$0-#3 1 . :3 fistulotomy 1 ,3 !3 seton procedure $0 cutting !* drain 21 12 ",)"1 $. 3 seton procedure 3 !$& )# ,(+&& ( ,$)21 3 endorectal advancement flap $0( &?( 4 fistula (+--!*'((+$0-#3 3 M internal opening flap 1.&$ ')$ ( 12 $0 &?((+( (+(,. '. 4 rectal procidentia -"+3 1# ! $ *+)3 1.!/ . (+ * $2"1.$ , sacrum !* ! -"+$0 (+ ),); % $*+ . :3 1 ! % $ 1.!) !* 5( % $5 ,(+ $0(+& $5 ,'((+( ! ) -"+. : ) % )1$% 19

Pruritus ani $0 ."1 . & !(+ $*1 1 3 ! $ 8 3 pruritus ani 1 % 3 &&5 $0 -"+(. $! =) . !/ ), 50-90 1 . $!13, 21 .&+.3 / * ! 3 &&5(+:), 4 (+$! ,. # & 4 (+ $*+ (+4 ) 1 1) ( ,$&-#3 ),! 4 (+$! ,. 1 1), 1-5 ,% % 1 !/& 4 $ 21 % 50-60 B8 $0 1 &$ '(+$0 "#$*+ "# $ 3 !& ! $0) ),&$%*# 1 (+$0)(# 3 !$& $) (vicious cycle) ),$ -"+&+3 ! $0 "# 22 $0. $! Q 18

ANAL IRRITATION

CAUSE OBVIOUS NO CAUSE FOUND

Fistula in ano PRURITUS ANI Hemorrhoid Treadworm

)H.IJ)&K &#-(L,MN&O/P "/." !,"-./

' , &$0.&+.3 / % . $! $& 21, 22 - )4', $ ) (+ . ?'!;&!* %*# . $0 1 (+ &$ '*+ - : , )3 ., . !)+ % ) $.!*$0)(+% ) ($ =. ? ! - % $% ) D&%( , 1 tetracycline, quinidine colchicine, mineral oil 8 ! - , ! *+ K#(+( 1 ( $K( K. !* . K$% 1= ( % $) #3 % $ *+*+ ) 8 *+. .. ,.($ - ,$;$.*# $.(.($.*# . - )4', 3 ) ; , $ ( )!*-"$= 23 ),R , $=4R& - systemic disease $% $ ! 1 $*# $ ( $.$)*. !*( !* multiple sclerosis -"+3 !3 ., &$ ' !1 - , & &$%*# $% ?&$. !!1 $& !& 24 ' $%*# - , & $0 ! $% &.( ) ! AB 'L. )3 1.! !* ($*#&$ ' !),1. &$ ' !),1. - , &!,3 $* 5 .(4 &$ '$%& ($ 1 $()3 1. ! ( !*(#"# ! (.. $ ( ( ($ *+* (+3 $0.3 ! $ ,$%*# $ *+. ! $%*# !* !&%&#$*#. ?& & ! , - $ %&)3 !* prone jackknife 22

17 & ! ! ()4', !*% %*#(+ &!*1 $5 , 8 )"!*1 ( &&& !&$ ' ! (+ ) )"& !&$ ' *+ !*1 24 !* ,(+& #3 ! &# * $ *+)4', , ),. ! occult blood 2) $*#! ! (# + 1. :,$&$*+ 4 ., 122 $)2* $ *+! &$%*# !* & !*+ 24 (# .$ ,$ =; $*+ ( & $ =. ? )4',& !(+&&(+$& $ Washington Hospital Center $0 4 ,, * 21 ,,(+ 0 & !& ,,(+ 1 & ! $. ,,(+ 2 white lichenified skin ,,(+ 3 lichenified skin !* coarse ridger skin !* ulcer $ # 3 anoscopy $ *+,$& ! (()" ** ! 1 && $ &+$& 1(# - $)*! ,#3 )),$)* - 3 $-$. C)3 1.!/ !*3 sigmoidoscopy $ *+! ( proctitis, infection !* inflammatory bowel disease !*1 ! .. 3 $ ,$%*# !* %&#$*# ?& & - 3 manometry $ *+ compliance .". rectal balloon ) (+&& %+ ) $*#! ! 3 !$& ,$)21$)2 ),$& 121 Caplan 3 patch test , 27 3 !$& 1 ), 44 8 - (+*+ K ),.. (. $! K !3 manometry ),!) *+ K !) *+ K resting pressure )) 21 - ! ,$HI $!*.. ( ,$)2 !3 saline infusion test . #3 $)* . /$ 1 !) ! )# : ,1 "& '#3 $)*. /(+ . : $21 1. ! & '#3 $)*. /(+$21 1$ ( 600 ml . * $0 early leakage !*( soiling $*+ &1 1300 ml. 21 - '((+& !&&!& ! % WoodB lamp !*. %&#$*# ?& & $ *+ &&5 - $)* serology . : &&5 syphilis ), & $ =. ?*+122 - ! 1 ?&$. 3 scotch tape test 22

18 ".8Q/)R" 22 CDEFGHCIDJKLMNO pruritus ani PQRSTU

Personal hygiene Poor cleansing habits resulting in chronic exposure to residual irritating feces; conversely, overmeticulous cleansing with excessive rubbing and soap use

Diet Consumption of large volumes of liquids: coffee (caffeinated and decaffeinated, coffee-containing products), chocolate, citrus, spicy foods, tea, beer, and foods high in milk content; vitamin A and D deficiencies

Anatomic compromise Obesity, deep anal clefts, excessive hair, tight-fitting clothing (tight clothing or clothing that impairs adequate ventilation), fistula, fissure, skin tags, prolapsing papilla, or mucosal prolapse

Systemic disease Jaundice, diabetes mellitus, chronic renal failure, iron deficiency, thyrotoxicosis, myxedema, Hodgkin's lymphoma, polycythemia vera

Gynecologic conditions Pruritus vulvae, vaginal discharge (endocervicitis, vaginitis)

Neoplasms Bowen's disease, extramammary Paget's disease, squamous cell carcinoma, cloacogenic carcinoma, rectal or polypoid lesions

Diarrheal states Irritable bowel syndrome, Crohn's disease, chronic ulcerative colitis

Radiation Postirradiation changes Psychogenic drugs Anxiety, neuroses, psychoses Quinidine; colchicine; antibiotics (tetracycline); IV hydrocortisone phosphate; ointments or creams that contain "caine" drugs; and nonprescription medications for personal hygiene such as per- fumed soaps and ointments that may contain

19 alcohol, witch hazel, or other astringents

Dermatologic conditions Psoriasis, seborrheic dermatitis, atropic dermatitis. lichen simplex, and lichen sclerosis;

Infections viruses[herpes simplex, cytomegalovirus, papilfomavirus; bacteria[Staphyto coccus aureus, erythrasma, mixed infections; fungi[derma tophytosis, candidiasis; parasites[pinworms, scabies, pediculosis; spirochetes[syphilis

Idiopathic

8Ds ,MNTU'T.".8Q/ pruritus ani 8 Diseases of the anorectum Diabetes and dyscrasias Diseases of gynecologic origin Diarrheal states Drugs Diet and deficiency of vitamins Dermatoses Disposition of patient , ! $& ! -"+ 1), 25 8 $% &.( ) ! AB 'L. !*$*#(+ !!*1.!3 $& 4 # '((+ skin tag !/ 3 ., ! ! & ' excision 12 ="4 Jensen $($( ; !) excision skin tag ! ), 67 . ) 1 1 ! ), 55 -"+1 ( (.3 / .:&&25 4 ?&$. !, mebendazole 100 &))& #$( ),#3 ! ! ),3 ., 21 12 . !/ 1 . :! . $!(+&1 (idiopathic pruritus ani) -"+ ) (#( 4 (+$0(+%$ . + 1 % ,$2 ), = * 4 $0 ( :,. 4 * 3 !& !&$ ' !! ., ( $0 -"+3 1 ! 4 ., : 22

20 , ! (+: K #(+1 ( $K( % ) % $) $( )S) ,$*$= 2 . ! : ! !) , ! 1 : ( )$0-#3 $5 , K$*+ . ?& ' K(+, (+.3 / *,, 1 !( ,,(+&$ ' ! (+$0 !, ) )!* antihistamine $% diphenhydramine hydrochloride (Benedryl ) 25 mg . 4-6 #/ !* chlorpheniramine maleated 4 mg . 24 %. ),) silver nitrate ! -"+);),% ) 1 ($.( *.(& $.*# ),&# * 24 ( (+) :" 5( % $5 ,(+$ *+) % $2 !* 5( methylene blue $ %#& !3 ) $.,. ."&$ ' ! 12 $& $ & ! ),1 ) 4 ,, 26 ! ! * 4 ( 4 1 ! "4 1 & 0-1 2., pruritus ani 22 1. :,. 4 * 3 !&$ ' !., ! ),(; ,$0 2. ,! #3 !) 3 ., &$ ' ! #3 %. (+&$ ' ! $*+ . (<?&W$0 3 !$& , $ * #-!! ! !*$ (+$ !! 27 !$&:) 3. !) : , # 13 ., &$ ' !1., 1 ( ,!)$!)* !*%*#5, &. % (+1 (. .)S)- ),1 &#$=4 !& ! $0$ ) !)($)(+ %, 4%3 ,$*+ 3 !$& , $ *(+& ! : 13 ., () ( ,$)2 !. ! #3 120 &))&)& ) 4. $% ), $ !%.3 )($)2M(+ anal crease .3 )( ( $)2 (+1 3 !."3 / C$2!*C .3 )( ! ,! )3 .(%*#5, ,3 !$)(+ ! 5. % #3 $0$ ) 20 ( % ) 1 . . !*#3 *+)1#3 ), + !)% 1$%2 !! 6. ! ,$0!/ ),&+ $. $ *+(+,1: , !1., 1 ( mechanical !* chemical trauma -"+3 1 - !& $ &+ ! - & (+( ),*+#3 !*#3 )1 ), 8-10 - !)($)(+ ! (+3 !: ,$!) !*$& $% ) ! .$2 K#(+( ),1 ( $K( $( :+ + ), ! (+3 !$&> - 7. : $ ',!) ,3 !. :* AC 8. ( .)$0-#3 1 9. $*+( &&1 $& $ *+ 4 (+:$! ,. 1

21 10. ! 13 ., ! : &?( ),3 ! !! () ( hydrocortisone cream ; ) *, % (+( & 2 # /. ! : ( ("#!& 3-4 . ! (+.3 / * ! $5 , (+ steroid cream $*+ ,, 3 !$& skin atrophy ),&$%*#$0 secondary pruritis !* burn 121

22 Evaluation of the Normal IBD, anal canal/ pelvic tumors, deep perianal abscess,functional/ idiopathic causes, levator syndrome complaint of Inspection anorectal pain Abnormal Anal margin tumors, descending perineum syndrome, thrombosed external hemorrhoid, acute hemorrhagic prolapse, perianal abscess, anal fissure, anal fistula Anal ultrasound Normal Perianal absce ss, degenerative neurologic disease, functional/ idiopathic causes, levator syndrome Treatment Anoscopy Abnormal Fissures, tumors anal canal, inflammatory processes of the anorectum, prolapsing internal hemorrhoids Directed Anorectol Endoscopy history examination Normal Hemorrhoids, fissure, fistula, extraintestinal pelvic tumors or abscesses, functional idiopathic cause, degenerative Proctoscopy neurologic diseases Abnormal Inflammatory conditions of the rectum, incomplete rectal prolapse, tumor distal rectum

Normal Anal canal tumors, IBD, functional/ idiopathic causes, degenerative neurologic disease External Abnormal Ischiorectal abscess, fissure, anal margin tumors, thrombosed external hemorrhoid Palpation Depression Normal Internal Abnormal Pelvic abscess, prostatitis, pelvic inflammatory disease, intersphincter abscess, deep posterior anal abscess, tumors anal canal/ distal rectum, tumors (extracolonic) pelvis, IBD, degenerative neurologic disease, levator syndrome, incomplete rectal prolapse

IBD= inflammatory bowel disease

1* # .()1 2 anorectal pain 4

Chronic rectal bleeding

Lateral internal Outlet bleeding Suspicious bleeding sphincterotomy

Anal fissure Anoscopy flexible sigmoidoscopy Anoscopy

Ulcerated external Cause found Cause not found Rigid proctoscopy hemorrhoid Colonoscopy

Internal Treat hemorrhoid

Prolapse Bleeding stops Bleeding continues

Proctitis Follow up

Neoplasm Inflammatory Diverticular Neoplasia Rectal Benign bowel disease disease prolapse anorectal disease

CrohnBs colitis Ulcerative colitis Benign Malignant

Treat appropriately 1* # .()1 2 chronic rectal bleeding 15

24 Anal mass

Diagnosis Evaluation Treatmant

Abscess Incision and drainage Pain Exam under Thrombosed Excision anesthesia external hemorrhoid Conservative History Inspection Palpation Condyloma Excision Fulgeration No pain Neoplasm Biopsy Anoscopy Hypertrophied Excision anal papilla Conservative

Fistula Fistulotomy Seton Advancement flap

1* # .() ,1 2 anal mass 16

25 Diabetes Renal failure Jaundice Pruritus ani History, physical exam Diagnostic evaluations Systemic diseases Lymphoma Myeloproliferative disorders

Culture/ O&P exam Anoscopy Sigmoidoscopy Diagnosis - Biopsy specific test Serology Scrapings/ exam by magnification Scotch-tape test WoodBs lamp exam

Ano rectal/ vaginal Diarrheal Diet and Anatomic Dermatoses Anorectal Anorectal Other: radiation or Idiopathic infecction states drugs predisposition neoplasm diseases psychogenic

IBD Coffee Deep gluteal cleft Bowens Treatment Obesity PagetBs Hirsutism Topical and Chemical exposure Cloacogenic oral medications Irritant soaps Squamous Fistula Mechanical cleansing Fissure Viral Bacterial Parasitic Fungal Psoriasis Hemorrhoids Seborrheic dermatitis Sphincter incompetence IBD= inflammatory bowel disease O&P= Ova & parasites

1* # .()1 2 pruritus ani 22

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27 18. Gordon PH. Condyloma acuminatum. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc., 1999; 323-339. 19. Gordon PH. Rectal procidentia. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc., 1999; 503-540. 20. Vukasin P. Anal condyloma and HIV-associated anal disease. In: Beart RW, editor. Surg Clin North Am 2002; 82(6): 1199-1211. 21. Smith LE. Perianal dermatologic disease. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc., 1999; 303-321. 22. Hicks TC, Opelka FG. Pruritus ani. In: Wexner SD, Vernava AM, editors. Clinical Decision Making in Colorectal Surgery. New York: IGAKU-SHOIN Ltd., 1995; 49-54. 23. Dasan S, Neil SM, Donaldson DR, Scott HJ. Treatment of persistent pruritus ani in a combined colorectal and dermatological clinic. Br J Surg 1999; 86: 1337-1340. 24. Keighley MRB, Williams NS, editors. Pruritus ani. In: Surgery of the Anus, Rectum and Colon. 2 nd ed. China: W B Saunders Company Ltd., 1997; 580-591. 25. Jensen SL. A randomised trial of simple excision of non-specific hypertrophied anal papillae versus expectant management in patients with chronic pruritus ani. Ann R Coll Surg Engl 1988; 70: 348-349. 26. Farouk R, Lee PWR. Intradermal methylene blue injection for the treatment of intractable idiopathic pruritus ani. Br J Surg 1997; 84: 670. 27. Shocket E. Anal cleansing vs. irritation. Dis Colon Rectum 2000; 43(8): 1176-1177.