Perianal Problems
Haemorrhoids
Definition: prolapse of mucosa of anal canal, associated with congestion of superior haemorrhoidal
venous plexus; due to straining and high sphincter tone
Positions: R anterior, R posterior, L lateral
perianal > ischiorectal > intersphincteric, submucosal, high intermuscular > supralevator
Degrees: 1st degree (bleed, but no prolapse); 2nd degree (prolapse on straining); 3rd degree (persistently
prolapsed); 4th degree (irreducible); internal occur proximal to dentate line
Complications: haemorrhage, thrombosis, perianal irritation
Investigations: indications for colonoscopy: Fe deficiency anaemia, +ive FOB, >40yrs with FH bowel
cancer, >50yrs with no recent colonscopy
Management: reduce prolapse, warm baths, topical analgesia / steroid, stool softeners; injection for 1 st
and 2nd degree haemorrhage control (complications – pain, ulceration, intra-mucosal injection,
haemorrhage from sup haemorrhoidal artery, abscess); thrombosed external haemorrhoids can be
excised under LA
Indications for OT: 3rd degree; 2nd degree when prolapse is major problem or failed sclerotherapy;
strangulation
Anal Fissure
Definition: triangular tear at anal verge after passage of constipated stools; often point away from anal
verge; originate in skin and rarely extend to valves
Position: posterior (90% males, 60% females)
Acute: painful, superficial
Chronic: deep
Symptoms: pain on defecation, small amounts of bright red bleeding, constipation
Management: LA ointment; GTN ointment has been used with some success; sphincterotomy or anal
stretch for chronic
Perianal
Haematoma
(external
haemorrhoid)
Definition: acute rupture of tributary of inferior haemorrhoidal plexus under perianal skin
Symptoms: pain after straining, lump; may rupture / ulcerate
Management: analgesia, ice, LA; usually resolve within 1//52; may need cruciate incision and drainage
Perianal
Abscess
Anal Fistula
Pilonidal
Abscess
Cause: Staph, E coli, Proteus; from anal fissure, perianal haematoma, haemorrhoid injection site, hair
follice, anal gland
Risk Factors: ulcerative colitis, Crohn’s disease, diabetes, cancer
Types: perianal (most common; superficial to anal margin); ischiorectal (between anus and sphincters
medially, and obturator internus laterally); submucous / intersphincteric; pelvirectal / supralevator
(above levator ani, below pelvic peritoneum)
Symptoms: pain, fever, discharge
Management: incision and drainage under GA; may need antibiotics if rheumatic heart disease, diabetes,
immunocompromised, prosthetic device
Definition: abnormal connection between anus and skin; occurs in 50% abscesses
Symptoms: discharge, itch, recurrent abscesses
Management: incision and drainage
Definition: localised infection in natal cleft; usually due to ingrowing hairs
Symptoms: pain, fever, local infection
Management: analgesia, antibiotics, excision