Common Office Anorectal
Problems
Sandra J. Beck, M.D., FACS, FASCRS
Associate Professor of Colon and Rectal Surgery
University of Kentucky Medical Center
Disclosures

None
Benign Anal Rectal Disease
Anatomy of the anal canal and
perianal spaces
 Benign Anal Rectal Disease

– Abscess and Fistula
– Fissure
– Hemorrhoids
Overview of Anatomy

Anatomy
– Pelvic and Perirectal Spaces
– Anatomy of Anal Canal
Retrorectal Space
Waldeyer’s Fascia
Supralevator Space
Levator Ani Muscle
Deep Postanal Space
Superficial Postanal
Space
ANAL CANAL
Peritoneum
Levator Ani m.
Puborectalis m.
Deep External
Sphincter m.
Internal
Sphincter m.
Transverse Septum
Supralevator
Space
Ischioanal Space
Intersphincteric
Space
Perianal Space
ANAL CANAL
Anal
Transitional
Zone
Column of
Morgagni
Dentate Line
Anal Crypt
Anal Gland
Anoderm
Patient complaints
Anal Pain
Bleeding
Drainage
Time course
Fissure
Knifelike pain with BM
Passing Glass Brick, Throbing
Pain with BM:minutes to hours
Blood on toilet paper
No drainage
Small tag or “hemorrhoid”
Hemorrhoid
Abscess
Acute or Chronic
Bleeding itching burning
Sudden swelling, +/- pain
Prolapse
Difficulty with hygiene
Pain rarely knifelike
Generally Acute
Minimal bleeding
Pain Swelling over large
area not associated with BM
+/-Purulent Drainage
Rapid increase in size
Diagnosis and Treatment of
Anorectal Abscess and Fistula-inAno
Anorectal Abscess
Etiology

Cryptoglandular abscess
– Most common
– Infection in the glands at the dentate line

Other causes
– Crohn’s and Ulcerative Colitis
– Tuberculosis and Actinomycoses
– Malignancy
– Foreign Bodies, Prostate Surgery or
Radiation
Fistula Description

Clock description
– Does the anus tell time?
– Relies on description of patient’s position:
supine, lateral, prone and relative landmarks

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
Left
Right
Right posterior
Left posterior
Tailbone

There is an area of induration and
erythema in the right posterior
quadrant that is likely an abscess
that has spontaneously drained
Abscess Classification

Four Types Based on Space Involved
– Perianal - 19-54%
Most
– Intersphincteric - 20-40%
Common
– Ischioanal - 40-60%
Rare
– Supralevator 2% or less
Supralevator
Abscess
Intersphincteric
Abscess
Ischioanal Abscess
Perianal Abscess
HORSESHOE ABSCESS
Supralevator
Space
Intersphincteric
Space
Ischioanal Space
Anorectal Abscess
Treatment of Perianal and
Ischiorectal Abscesses

Diagnosis - usually straightforward
– Erythema and Pain over affected area
– Fluctuance

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

Pezzer catheter
 Solid mushroom
top so stays in
 Less tissue
ingrowth

Malecot
 Allows tissue
ingrowth
 More painful to
remove
Peri anal abscess - ? Antibiotics
Not usually indicated if there is
adequate drainage
 Indicated for patients with:

– Obesity
– Diabetes
– Imunocompromised
– Extensive large abscess or recurrent
abscess
Fistula-in-Ano

Definition
– abnormal connection between two
epithelial surfaces.

Classification:
– Parks: Defines fistula by course of tract
– Goodsall’s rule
Diagnosis
 Treatment

– Goals
– Options
How does patient present?





May have had a history of abscess
History of Crohn’s disease
May present at the same time as abscess
Complain of intermittent increase in
pain/swelling followed by spontaneous
drainage
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

Refer to Colon and Rectal Surgeon or
General Surgeon
 Reassure patient – rarely cancer, most do
not need a colostomy
 If suspect Crohns
– Gain control of perianal sepsis
– Then complete full workup and staging

Goals of therapy
– Get rid of the fistula/connection
– Preserve continence
Surgical Options

Primary fistulotomy
– Mainly for low, superficial fistula
– Risk of fecal incontinence

Fibrin Glue/Fistula Plug
– Utilizes substrate as scaffold to fill tract
– Does not involve cutting muscle

Cutting or draining setons
– For deeper tracts that involve significant muscle
– Risk of fecal incontinence


Rectal advancement flap
Lateral internal fistula transection
– Newer procedure. No foreign substrate
– Cuts fistula tract, not muscle
Fistula in ano
Fistula in ano
Fissure in Ano

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

Acute fissure results from trauma to the
anal canal most commonly from a large
fecal bolus
 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

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

Pain is the main symptom
– Sharp, cutting or tearing during
defecation
– Duration is few minutes to hours
Bleeding – bright red and scant
 Skin Tag
 Mucous discharge resulting in
itching

Fissure in Ano
Diagnosis

Diagnosis often made on history alone
 Inspection – gently spread the buttocks
and the fissure becomes apparent
 Triad of chronic anal fissure
– Sentinel pile
– Hypertrophied anal papilla
– Anal ulcer
Fissure in Ano
Differential Diagnosis
Intersphincteric abscess
 Pruritus Ani
 Fissure from inflammatory bowel
disease
 Carcinoma of the anus
 Infectious Perianal conditions
 Leukemic infiltration

Fissure in Ano
Crohn’s Anal Fissures
Acute Fissure in Ano
Treatment
Increase dietary fiber
 Local anesthetic to prevent spasm
 Nitroglycerin or Nifedepine Ointment

– Not commercially available
– Must be mixed by pharmacist
Warm tub soaks
 4-6 weeks of treatment

Chronic Fissure in Ano
Surgical Treatment

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
What are they?
 Where are they?
 Why do they become symptomatic?
 Classification?
 How do you treat them?
 Can they be avoided?

Hemorrhoids
What are they?
Specialized highly vascular cushions
consisting of discrete masses of
thick sub mucosa that contain blood
vessels, smooth muscle and
connective tissue
 Aid in anal continence

Hemorrhoids
Where are they?

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

External Hemorrhoids
– Below the dentate line
– Blood drains through the inferior rectal veins
to the pudendal veins on into the iliac veins
Hemorrhoids
Symptoms?

Chronic constipation
 Diarrhea
 Trauma to the hemorrhoids during
defecation cause the most common
symptoms
–
–
–
–
Pain – generally not “knife-like”
Itching
Burning
Bleeding
Hemorrhoids
Classification- Internal Hemorrhoids
1st degree – bulge into the lumen
 2nd degree – prolapse with bowel
movement but reduce spontaneously
 3rd degree – prolapse spontaneously
and require manual reduction
 4th degree – permanently prolapsed
hemorrhoids that cannot be reduced

th
4
Degree Hemorrhoids
Hemorrhoids
Treatment Principles

Thorough physical exam to
determine severity and rule out other
pathology
– Refer for surgical evaluation if white or
discolored, firm or fixed
Determine if the problem is internal,
external or both
 Assess the symptom complex

Treatment

Topical agents: Proctofoam, Anusol HC
Analpram, Proctosol cream…
 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

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

Infrared Photocoagulation
– Indicated in 1st degree hemorrhoids
– Causes photocoagulation of small
vessels
– Performed in office or “Hemorrhoid
Relief Center”
– Minimal pain
Closed Hemorrhoidectomy
Indication

Hemorrhoids are severely prolapsed and
require manual replacement
 Patients fail to improve after multiple
applications of non-operative treatment
 Hemorrhoids are complicated by
associated pathology such as ulceration,
fissure, fistula, large hypertrophied anal
papilla or extensive skin tags
Closed Hemorrhoidectomy
General Principle
Most can be performed with local
and IV Sedation
 Prone/Kraske position is the best
 Infuse the area with local anesthetic
with epinephrine for hemostasis
 Fleets enema 1-2 hours prior
 No antibiotic prophylaxis is
necessary

Closed Hemorrhoidectomy
Closed Hemorrhoidectomy
Closed Hemorrhoidectomy
Post op Result
PPH Stapling Procedure for
Hemorrhoids
Not for every hemorrhoid
 Ideal for Grade 2 and 3 with minimal
external component
 Prevents prolapse and thus less
trauma to hemorrhoid with bowel
movement

PPH Stapling Procedure for
Hemorrhoids
PPH Stapling Procedure for
Hemorrhoids

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

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






Can sometimes be difficult to distinguish
from hemorrhoids
Cauliflower type appearance
History of HIV, History of abnormal pap
smear
Homosexual males usually but can be
seen in the heterosexual population
Caused by HPV virus
Increased risk of anal cancer in the
immunocompromised patient
Treatment - Topicals
Aldara (Imiquinod) >50% initial response
 Topical 5-FU – 90% initial response
 Condylox (podofilox)


Each have high local toxicity

Practice Parameters for Anal SquamousNeoplasms
www.fascrs.org
Treatment
Photodynamic therapy
 Wide Local Excision
 Targeted destruction with cautery
and/or Infrared coagulation
 Observation of AIN I/II with removal
of visualized lesions
 Excision of AIN III

Anal Squamous AIN
High recurrence rate with all
techniques
 Close follow up to detect
progression to invasive carcinoma
 Anal pap smear vs high resolution
anoscopy
 Optomize underlying conditions

?