ANAL PAIN
JAMES FRANCOMBE
CONSULTANT COLORECTAL
SURGEON
WARWICK HOSPITAL
ANAL PAIN
•RELATIVELY COMMON
•SEE OFTEN IN CLINICS
•SEE OFTEN AS EMERGENCY
•TREATMENT PERCEIVED EASY
•TREATMENT CAN BE DIFFICULT
•OUTCOME VARIABLE
ANAL PAIN
AETIOLOGY
• FISSURE IN ANO
•ABSCESS/SEPSIS/FISTULA
•TRAUMATIC
•NEOPLASTIC
•THROMBOSED HAEMORRHOIDS
•THROMBOSED PERIANAL
HAEMATOMA
•RECTO-ANAL INTUSSUSCEPTION
HAEMORRHOIDS
DO NOT CAUSE PAIN ....... UNLESS
THROMBOSED
THEY ITCH, FEEL SWOLLEN,
UNCOMFORTABLE, ANGRY, FLARE
UP BUT THEY DO NOT CAUSE PAIN
UNLESS THROMBOSED
THROMBOSED HAEMORRHOIDS
PAIN RELIEF
LAXATIVES
SPHINCTER RELAXATION (
ANOHEAL/GTN)
‘THE FROZEN FINGER’
IF ALL ELSE FAILS
SURGICAL EXCISION
THROMBOSED
PERIANAL
HAEMATOMA
THROMBOSED PERIANAL HAEMATOMA
 PAINFUL
 ACUTE ONSET
 MAY HAVE BEEN
STRAINING/COUGHING PROLONGED
SITTING
 SPONTANEOUS
THROMBOSED PERIANAL HAEMATOMA
TREATMENT
 ANALGESIA
 ANOHEAL
 LAXATIVES
 ICE-PACK
USUALLY RESOLVE SPONTANEOUSLY
THROMBOSED PERIANAL HAEMATOMA
TREATMENT
SURGICAL IF MEDICAL FAILS
 INCISE AND DRAIN
LA (SKIN TAGS)
 EXCISE
?GA (NO TAGS)
FISSURE IN ANO
•COMMON
•PAINFUL DEFECATION ‘PASSING
GLASS’
•BLOOD SPOTS AND DRIPS
•INTERMITTENT
•PAIN  AFTER 1-2 HOURS
•OFTEN CONSTIPATED ‘HARD MOTION’
FISSURE IN ANO
ISCHAEMIC ULCER -USUALLY POSTERIOR
SPHINCTER SPASM - POOR BLOOD SUPPLY
NATURALLY SLOW TO HEAL DUE TO ABOVE
FISSURE IN ANO
TREATMENT
DECREASE PAIN
-LIGNOCAINE GEL
REGULATE BOWELS
-LAXATIVE
SPHINCTEROTOMY
-CHEMICAL
-SURGICAL
FISSURE IN ANO
SPHINCTEROTOMY
-CHEMICAL
•DILTIAZEM 2% TOPICAL BD 6 WEEKS
•RCT BETTER THAN GTN (LESS SIDE EFFECTS)
•BOTOX INJECTIONS
•HEALS 75% AT 6 WEEKS
•RELAPSE MAY BE HIGH
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.
FISSURE IN ANO
POOR MEDICAL RESPONSE TO
TREATMENT
SENTINEL TAG
LONG HISTORY >6 MONTHS
FIBRES OF IAS EXPOSED
ABSCESS
•COMMON
•EMERGENCY
•CRYPTOGLANDULAR THEORY OF ORIGIN
•PERCEIVED ‘JUST AN ABSCESS’
•USUALLY LEFT TO JUNIOR SURGEON
•POOR OPERATION
ABSCESS
•ACUTE SITUATION
•INCISE AND DRAIN
•BIOPSY SKIN (?CROHNS)
•RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA)
•PACK GENTLY (IF AT ALL –NEW EVIDENCE)
FISTULA
•ABNORMAL CONNECTION BETWEEN 2
EPITHELIASED SURFACES. A TUNNEL
•DEVELOP FROM ABSCESS (25% FORM
FISTULA)
•DISCHARGE INTERMITTENTLY PRECEDED BY
PAIN
FISTULA CLASSIFICATION
INTERSPHINTERIC
TRANS-SPHINCTERIC
SUPRALEVATOR
EXTRASPHINCTERIC
+/- SECONDARY TRACTS/HORSESHOE
FISTULA TREATMENT
INTER-SPHINTERIC
LAY OPEN
TRANS-SPHINCTERIC
LOW
-LAY OPEN
HIGH
-SETON/FLAP/PLUG
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%
ANAL ANATOMY
NEOPLASTIC
USUALLY SQUAMOUS CELL CA
HOWEVER VARIETY
MELANOMA, LOW RECTAL CA
CLEAR CELL CA
RARIETIES
TRAUMATIC
 SELF INDUCED-SEXUAL GAMES
 INFLICTED- TRUE TRAUMA EITHER RTA,
CHILDBIRTH, IMPALEMENT
STUPIDITY-USUALLY WHILST UNDER THE
INFLUENCE!!!!!!!
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
RECTOANAL INTUSSUSCEPTION
TREATMENT
 BIOFEEDBACK
 DEFECATORY DYNAMIC RETRAINING
 LAPAROSCOPIC ANTERIOR RECTOPEXY