Benign anorectal conditions

Presenter : Muhorakeye Bona Gloria

SUPERVISOR :Dr NSHIMYIYERA Jackson

11/06/2024 Anorectal Benign Conditions 1

 OUTLINE
INTRODUCTION
ANATOMY
HEMORRHOIDS
ANORECTAL ABSCESSES
FISTULA IN ANO
ANAL FISSURES
RECTAL PROLAPSE
TAKE HOME MESSAGE
REFERENCES
 INTRODUCTION
• Benign anorectal conditions are non-cancerous conditions
which involve anus and the rectum
• They are common in primary care settings, but
• Some patients are embarrassed to seek medical attention
• These conditions include: hemorrhoids, perianal pruritus,
anal fissures, fistula in ano, perianal abscess, condyloma,
rectal prolapse, and fecal incontinence
• The most common ones are:Hemorrhoids, anal fissures,
and fistulas
• symptoms can be similar to those of cancer, so malignancy
should be considered in the differential diagnosis
• History, physical exam and some investigations are useful in
diagnosis
ANATOMY
ANATOMY : Rectum

• The Rectum is a continuation of the sigmoid

colon and extends to the anal canal.
• It is about 12 -16cm long
• Subdivided into three parts:
The upper third lies intra peritoneal
The middle third retro peritoneal
The lower third under the pelvic diaphragm
and therefore extraperitoneal
 Anatomy ctd
THE RECTUM:
• 3 constant transverse
folds(Houston’s valves)
• (Upper.ant) Peritoneal coverage
• (lower part) Mesorectum
• Anal rectal angle (made by
puborectalis muscle)
• Fascia propria. an extension of
the pelvic fascia
• Ends at Dentate line (pectinate
line)

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Arterial Supply of the rectum

• Superior rectal artery (chief) -inf.

Mesenteric A Nerves supply
The sympathetic is from the lumbar
• Middle rectal artery –Internal iliac A splanchnic nerves originating from L1
to L2.
• Inferior rectal artery- Internal
Pudendal A Parasympathetic supply originates
from pelvic splanchnic nerves.
• Median sacral artery – Abdominal
Aorta (back) The sensation is carried by the
parasympathetic system to S2, S3, and
Venous drainage S4
The superior hemorroidal veins drains
into
rectal veins, superior rectal vein and then
inferior mesenteric vein.
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 ANATOMY: Anal canal
• The anal canal begins at the anorectal junction, ends at the anal verge.
• Length 4.4 cm in males and 4 cm in females
• Anorectal ring at the narrowing junction. consist of (external anal
sphincter and the puborectalis muscles. Which can be clearly felt
digitally.
• Anal Sphincters, role in
maintenance of fecal continence.
• Internal sphincters
• is composed of circular, non-
striated involuntary muscle supplied
by autonomic nerves
• External sphincter, is composed of
striated voluntary muscle supplied
by the pudendal nerve
• The 2 sphincters overlaps leaving
the Inter sphincteric groove.

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 Anatomy –anal canal

Arterial Supply Innervation

Superior to pectinate line: inferior
superior, middle and inferior rectal
hypogastric plexus (Sympathetic maintain
vessels. tonus of IAS)
Venous drainage (Parasympathetic peristaltic contraction of
• The upper canal is drained by the defecation)
superior rectal veins into the
inferior mesenteric to portal Inferior to pectinate line:
venous. Sensitive to pain, touch, and temperature.
• Lower anal canal, by the middle somatic from inferior rectal nerves plexus
and inferior rectal veins drain into
the internal iliac veins to systemic
venous. Lymphatic drainage of the lower half of
the anal canal goes to inguinal lymph
The submucosal Hemorroidal plexus nodes
drains into all the 3 veins.

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Common benign anorectal Conditions

•Hemorrhoids
•Ano -rectal abscesses
•Fistula in ano
•Anal fissure
•Rectal prolapse

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 HAEMORRHOIDS

• Defined as masses or clumps ("cushions") of tissue within the

anal canal that contain blood vessels and the surrounding,
supporting tissue
• common anal pathology(10%),
• but many patients are embarrassed to consult health facilities
for care
• The prevalence increases with age
• people with 45-65 years of age.

• Classified into:
Internal hemorrhoids and
External hemorrhoids
• Internal hemorrhoids:
They are proximal to the
dentate line,
covered in columnar
epithelium, and have visceral
innervation
• External hemorrhoids
 distal to the dentate line,
 covered by squamous
epithelium
 They are perianal
Subcutaneous,
 somatically innervated,
Pathologic when venous
plexuses spontaneously
rupture.
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• Internal hemorrhoids External hemorrhoids
 Grades of internal hemorrhoids
• They are graded according to the degree to which they
prolapse from the anal canal :
• Grade I hemorrhoids are visualized on anoscopy and may
bulge into the lumen but do not prolapse below the dentate
line
• Grade II hemorrhoids prolapse out of the anal canal with
defecation or with straining but reduce spontaneously
• Grade III hemorrhoids prolapse out of the anal canal with
defecation or straining, and require manual reduction
• Grade IV hemorrhoids are irreducible and may strangulate

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PATHOPHYSIOLOGY CAUSES/ETIOLOGY:
Low fiber diet
Straining and constipation
Inadequate intake of fiber
• Less bulky stools
Pregnancy
Obesity
• Straining at defecation Prolonged sitting
Portal hypertension
• Increased intraanal pressure Chronic diarrhea
Familial( family history)
• Decreased venous return Colon malignancy(Tumors in
the pelvis)
Anal intercourse
• Enlarged hemorrhoidal Inflammatory bowel diseases
venous cushions
 diagnosis and Clinical external hemorrhoids
Features • Dilated venules, usually mildly
symptomatic
Depend on type(external or • Pain after bowel movement,
internal) and degree associated with poor hygiene
 Internal hemorrhoids: • Sensation of pain full masses
(2-3) in the anal canal
• Engorged vascular cushions ,
branches of superior Thrombosed hemorrhoids:
hemorrhoidal vein, usually at • very painful
3, 7, 11 o’clock positions • resolve within 2 weeks,
(lithotomy position) • may leave excess
• Painless rectal bleeding skin(perianal skin tag )
• Anemia
• Prolapse
• Mucus discharge investigations:
• Pruritus Flexible sigmoidoscopy
• Burning pain Anoscopy
• Rectal fullness sensation Colonoscopy
 MANAGEMENT
Complications of haemorroidectomy:
 Recurrence, infection
 Conservative  Acute retention of urine,
 Medical Treatment  Haemorrrhage
 Surgery  Stricture, fecal incontinence

CONSERVATIVE MANAGEMENT
• The initial treatment in new-onset symptomatic hemorrhoids is conservative.
• Dietary and lifestyle modification:
insoluble fibers , plenty of water
regular Physical Exercises
• Warm water Sitz baths can relieve irritation pruritus and spasm of the anal
sphincters.
MEDICATIONS FOR SYMPTOMATIC RELIEF
• Topical anesthetics (Benzocaine 5 - 20% rectal ointment)
• Steroids, emollients, and antiseptics. (Hydrocortisone 1-2.5%) no more than 7
days.
• Venoactive agents: Nitroglycerin 0.2 - 0.5% (relieves pain from sphincter spasm)
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 SURGICAL PROCEDURES
For symptomatic internal hemorrhoids that are refractory to conservative
medical treatments.

B. Sclerotherapy is indicated For Patient on

A. Grade I, II, or III internal anticoagulant drugs, immunocompromised,
hemorrhoids, Rubber band portal hypertension,
ligation

• Acutely Thrombosed external hemorrhoids : benefit office-based excision.

C. Significant ext.hemorrhoids, Prolapsed, incarcerated intern.hemorrhoids: Surgery
Hemorrhoidectomy
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 ANORECTAL ABSCESSES
• Are infection typically originating within an obstructed
anal crypt gland, leading to pus collection which forms an
abscess
• common bacterial causes: E. coli, Proteus, Streptococci,
Staphylococci, Bacteroides, and anaerobes

Classifications:

• Perianal(60%)

• Ischio rectal(30%)

• Inter sphincteric

• Supra levator
 Causes/risk factors
• Blocked gland in the area
• Infected anal fissure
• Sexually transmitted infection
• Inflammatory bowel disease (Crohn's disease and ulcerative colitis)
• Anal sex
• Chemotherapy drugs used to treat cancer
• Diabetes
• Use of medications such as prednisone
• Weakened immune system (such as from HIV/AIDS)
 Diagnosis and clinical Presentation
Is clinical except when the abscess is deep
SIGN AND SYMPTOMS:
• Swelling around the anus with Constant,
throbbing pain that worsens on sitting.
• Fever, malaise
• Constipation
• Discharge of pus from the rectum.
PHYSICAL EXAMINATION:
• Fluctuant lump or nodule which is red, tender at
edge of anus.
• Painful, hardened tissue on rectal examination.
investigations:
Proctosigmoidoscopy
Ultrasound

Management Complications

• Incision and drainage of

• Anal fistula
abscess, • Body wide infection
• drained abscesses are usually (sepsis)
left open, and there are no • Continuing pain
stitches put on.
• Antibiotics:
• Recurrence
Augmentin or • Scars
combination of
metronidazole and
ciprofloxacin.for 10 days
Some surgeons recommend sits
baths post op
FISTULA IN ANO

• A fistula is abnormal communication between two epithelial

surfaces.
• A fistula in ano develops from the inner lining of the anus through
the tissues that surround the anal canal opening on anal cutaneous.
• Has internal opening in the anal canal and one or more external
openings on the perianal skin.
• The majority arise from delay in treatment or inadequate treatment
of anorectal abscesses
ETIOLOGY
• Anal canal glands situated at the dentate li ne
• Previous anorectal abscess.
• Obstetric injury
• Other causes include: trauma, Crohn disease, carcinoma, radiation
therapy, tuberculosis, fungal(actinomycoses), and chlamydial
infections
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 PATHOGENESIS

• Infection and inflammation of the anal crypt gland.

• Abscess formation
• Spread of the infection through all layers of anal canal
• Perianal abscess formed
• Abscess burst to exterior perianal region
• Connection established from anus or rectum with the
perirectal skin

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 Diagnosis and clinical features
• Starts with history and physical exam
• Patient presentation:
Non-healing anorectal abscess following drainage
chronic purulent Malodorous drainage
a pustule-like lesion in the perianal or buttock area.
intermittent rectal pain mostly during defecation

• Physical examination:
Excoriated and inflamed perianal skin.
The external opening,
or palpated if incomplete or blind-ended.
inflamed, tender, and/or draining purulent fluid.
A palpable cord leading into anal canal may be present
• Exam Under Anesthesia: Anoscopy, Fistulogram.
• Endo anal US/ MRI is gold standard 26
FISTULA IN ANO – Goodsall’s
rule
Useful in exploring fistula tract’s opening in
anal canal.

Goodsall rule is an excellent guideline.

states that:

An external opening anterior to a

transverse line drawn across the anal verge
is associated with a straight radial tract into
the canal,

An external opening posterior to the

transverse line follows a curved fistulous
tract to the posterior midline rectal lumen.

Exception: Arterial fistulas lying more than

3cm from anus may have curved tract.
 PARKS CLASSIFICATION

Type 1. Intersphincteric 45%

Begins at the dentate line and ends at
the anal
verge, along the Intersphincteric plane.

Type 2. Transsphincteric
through ischiorectal fossa, internal and
external sphincter, and terminates in
the skin.

Type 3. Suprasphincteric anal crypt

and encircles the entire sphincter
apparatus

Type 4. Extrasphincteric : proximal to

the dentate line, encircles the entire
sphincter, levator ani.
Is typically not cryptoglandular in
origin.

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 Treatment and Management

• Surgical treatment is the mainstay of therapy and is

required.
 Simple Fistulas: Fistulotomy: Laying open of the fistula
tract (involving less that 30% of ext sphincter)
 Fistulectomy: Fistulous tract is excised completely.
Seton technique (with Cable-Tie Seton) kept for 3 months.
Advanced flap and glues (complex fistulas covering)
 LIFT procedure (ligation of intersphincteric tract)
• Post operative: Sitz baths, antibiotics, analgesics and
laxatives.
Complications:
• Incontinence
• Recurrent pain after surgery
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 Anal fissure

• An anal fissure is a tear or ulceration in the

lining of the anal canal below the
mucocutaneous junction (dentate line).
• It is one of the most common benign anorectal
diseases and
• one of the most common causes of anal pain
and anal bleeding.

• ETIOLOGY:
• Primary causes: local trauma, such as
constipation, diarrhea, vaginal delivery, or anal
sex (Majority)
• Secondary causes: Crohn disease, other
granulomatous diseases, malignancy , leukemia),
or communicable diseases (eg, HIV infection,
syphilis, chlamydia)
 Diagnosis and clinical features
• Diagnosis: history and physical exam
• CLINICAL MANIFESTATIONS:
Acute anal pain, severe on defecation.
Anal bleeding, usually as
hematochezia( can see Blood on toilet
paper).
Acute sphincter spasm, prevents DRE
• P/E: Longitudinal tear in the anoderm
chronic anal fissures are accompanied by
external skin tags (sentinel pile).
DRE exclude other pathologies. (tubercular
ulcers, tumor,)

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 Treatment and management:

• LIFESTYLE MODIFICATION:
 High-fiber diet,
adequate fluids,
avoids straining during defecation.
Good anal hygiene.
Sitz bath: Warm sitz baths, relax the anal sphincter and improve blood flow to the
anal mucosa.
• TOPICAL ANALGESICS
• TOPICAL VASODILATORS (nitroglycerin 0.2%–0.4% ointment,)

• SURGICAL INTERVENTION:
 Sphincterotomy: low risk of incontinence
Botulinum toxin A injection, paralyze your sphincter.
V-Y advancement flap,
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Subcutaneous fissurectomy.
 Rectal prolapse
• Defined as
the protrusion of mucosal or full-
thickness layer of rectal tissue out
of the anus.

• It is a relatively
uncommon condition

• There are two main types of rectal

prolapse:
• Partial thickness – the rectal mucosa
protrudes out of the anus
• Full thickness – the rectal wall
protrudes out the anus

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• Mainly affecting older females

 PATHOPHYSIOLOGY RISK FACTORS
• The current theories surrounding full • The main risk
prolapse suggest that is a form of factors for rectal
sliding hernia, through a defect of the
fascia of the pelvic region. This may be
prolapse are:
caused by chronic straining secondary • Increasing age
to constipation, a chronic cough, or • Female gender
from multiple vaginal deliveries • Multiple
deliveries
• Partial thickness prolapses are • Straining
associated with the loosening and
stretching of the connective tissue that • Previous traumatic
attaches the rectal mucosa to the vaginal delivery
remainder of the rectal wall
 Diagnosis and clinical features
• Digito-rectal exam(DRE)
• Defecating proctography and examination under anaesthesia may be the
only means to diagnose clinically.

• CLINICAL FEATURES:

Typically present with rectal mucus discharge, faecal incontinence, per

rectum bleeding, or with visible ulceration

Full thickness prolapses initially present with a sensation of rectal

fullness, tenesmus, or repeated defecation.

On examination, the prolapse may not always be evident, but can be
identified by asking the patient to strain.

A DRE should be performed, often on which a weakened anal sphincter is

identified
Management and treatment
• Conservative management:
More common in those unfit for surgery, with
minimal symptoms, or in children (as most
prolapses in children will resolve
spontaneously).
Initial management often involves
increasing dietary fiber and fluid intake.
Minor mucosal prolapses may be banded
• Surgery:
It is the only definitive management
 Take Home Messages

• Benign anorectal conditions are among common causes

of consultation in primary care settings
• Diagnosis of such conditions is mostly clinical
• Constipation is among risk factors for some of the
conditions
• So enough water, fruits and vegetables intake is
important in prevention
• If not treated properly, these conditions can lead to
severe complications
• Prevention is better than treatment, so
• Remember to do patient education, 37
References

• Rwanda surgical treatment guidelines

• Bailey and love’s short practice of surgery 25th edition
• uptodate
• https://www.aafp.org/pubs/afp/issues/2020/0101/p24.html
• https://www.aafp.org/pubs/afp/issues/2012/0315/p624.html

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