Common Anorectal Disease Anorectal pain Rectal bleeding Anal mass Pruritus ani ! "# $% &$ ' ! ($)* ! (*+&$ ' ! ), ! -"+. !/ ) $ $$0 &.( 1 ),1 1 $*+ !* & $0$*+$)2 ,+( "1 ),!) #(+ ) (#3 $& 4 $ $% -*# , , $ % (#"#$!2 ! !* ! $ *+4 &.( 5( !* .1 -"+. )!$& $.&$%*#),$ $*#$*+&$ ' ! $& 3 ) ) $*#! ! ),$& !($ ) (#3 (+ $ $0 &.( # ($ (), 35 (+ $!) (#(. $! &.( 1 !"#$%&'(" )*+,"-./ 2 !* rectum *)3 1.. (+ $*+ sigmoid colon $&+ sacral promontory .&#.(+&$ '(+ levator ani muscle -"+, )1 !)$0 anal canal 1 rectum , ' 12-15 $-&$ %#. rectum $0 longitudinal muscle 1 ( taenia ), rectum 1 ( mesentery, sacculations # appendicae epiploicae rectum ( 3 lateral curves * . ),) convex 1 . ) convex 1 - rectal mucosa &$ '! "# $( valves of Houston . !/ (, ' 3 rectum $0 3 . * upper, middle ), lower part ( (+ 1) 1 1 3 rectum ! , sacrum, coccyx, levator ani m., coccygeal m., medial sacral vessels ), sacral n. plexus ! rectum % & urinary bladder, ureter, vas deferens, seminal vesicles ), prostate !/&& uterus, fallopian tubes, ovaries ),. posterior vaginal wall anal canal *)3 1.. (+$&+ anal verge :" anorectal ring ( , ' 4 $-&$ -"+ anorectal ring $0) puborectalis muscle ),. : )3 1 ! anorectal ring . dentate line 1-1.5 $-&$ anal verge $0 ,! anoderm perianal skin anoderm $0 squamous epithelium (+($.,. 3 secondary skin appendage -"+1 hair follicle, sebaceous gland ), sweat gland dentate line !* pectinate line $0 true mucocutaneous junction &$ ' 1-1.5 $-&$ $!* anal verge ,, 6-12 &))&$$!* 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 / $& anorectal abscess ), fistula in ano 2 2 "#" "$ Anorectal pain (+ !$0 (+ !$& 3 /), 3 $&%( &,3 12 . :! &&5 (+ ! -, & ), 1 $*+ ), ()4',$5 ,(+ 1 4 ((+ 3) !&$ '(+ +3 dentate line ($.,. ."$2 #! . $! &$ '(# . :3 ! ."$2 1%$ 6 '((+. $! (+ !$!* &$ ' dentate line !*&$ '1. -"+$*+)3 1.. (#1 ($.,. ."$2 $0 ." "!* #"$0 3 ! (+ ."$2 3 3 %& anorectal pain "$ 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 , !*: , - $)*(+.