BENIGN ANAL

CONDITIONS
Surgery Lectures, S1
WINA, F M.
OUTLINE
I. ANORECTAL ABSCESSES
II. FISTULA – IN – ANO
III. HAEMORRHOIDS
IV. FISSURE IN ANO
V. RECTAL PROLAPSE
ANATOMY OF THE RECTUM & ANAL
CANAL
• Rectum is distal 15cm terminal portion of large intestine and anal
canal is approx. 4cm of GI tract.
• Rectum: 4 layers; mucosal, submucosal, 2 smooth muscle layers.
• Anal canal: internal sphincter, external sphincter, intersphincteric
plane
• Dentate line – dividing neurovascular supply
• Aorta

•
 Endodermal
Columnar
Autonomic
Superior rectal artery;
portal drainage
PECTINATE/DENTATE LINE
Ectodermal
Squamous
Lymph to
Somatic
inguinal nodes Inferior Rectal artery;
systemic drainage
ANORECTAL ABSCESSES
• DEFINATION:
suppuration of anorectal region, usually arise from inflammation of
inter-sphincteric anal glands leading to abscess formation
CLASSIFICATION
• Intersphincteric
• Ischiorectal -30%
• Perianal- 50%
• Supralevator-< 5%
• Intramuscular
• Submucosal
• Subcutaneous
AETIOPATHOGENESIS
• Aetiology
-60 %- E.coli
-23% -Staph. Aureus
-others Bacteriodes, Steptococcus, Proteus
- mixed infection
• Others-Penetration of rectal wall by fish bone
-Blood borne infection
-Extension of cutaneous boil
Underlying rectal Dx
- neoplasm
- Crohn’s dx
- actinomycoses, Tuberculosis, Chlamydial inf.
Immunoincompetence
- DM, AIDS, Pt on cytotoxic drugs
- Trauma/surgery
Anal fissure
Radiotherapy for anorectal ca, ca prostate
 CLINICAL FEATURES
• History
-pain –throbbing ,worse with movement, sneezing,^ intraabdominal
pressure
-swelling(+ pain)- about 95%
-fever 12%
-Perianal discharge 12%
-diarrhoea
-skin excoriation
-external opening
• Past medical hx
Trx for inflammatory bowel dx, diverticulitis
radiotherapy for anorectal Ca, Ca prostate
Trx for rectal, anal, Perianal dx, Trx for AIDS, Trx for Tb
Drug hx : steroid, cytotoxic drugs, immunosuppressant drugs

• Review of systems
weight loss
abdominal pain
change in bowel habit
• Diff. Diagnosis
Hidadenitis suppurativa
Infected inclusion cyst
Pilonidal abscess
Bartholin gland abscess
Periprostatic abscess
Inflammatory bowel disease
• Examination- mainstay of diagnosis
• -general
• -perineum
• -acutely tender swelling at anal verge- Perianal fluctuant swelling in
Ischiorectal fossa, external openings +/- discharge needle aspiration
DRE
acute inflammatory pain may preclude further exam
Proctoscopy- internal opening of fistula bulging abscess – lntersphincter,
submucous, ischiorectal
 INVESTIGATION
Clinical presentation and co-morbid condition of patient determine the
extent of investigation
General
FBC, Aspirate for m/c/s
others- RBS, Urinalysis, RVS, Mantoux test, VDRL test
Specific
EUA- investigation, Trx
Sigmoidoscopy,
Colonostomy.
 INVESTIGATION
Radiological investigation
• indicated in Patients with recurrent abscesses or abscess associated
with complex fistula
-Sinography/fistulography
-Transrectal/Transanal USS
-Contrast study –Barium enema, upper GI series
-CT Scan
-MRI ( endorectal coil)
 TREATMENT
• Principle of treatment
-sepsis control by adequate drainage of abscess
- preservation of faecal continence
- no place for use of antibiotics only,
- site of abscess determines direction of
drainage and subsequent mgt
- pain relieve and choice of anaesthesia
 TREATMENT
• Perianal- I &D ,cruciate incision , deroofing of abscess cavity
• Ischiorectal – 2 stage procedure; 1st- I&D, cruciate incision, deroofing
of abscess
2nd stage- EUA for fistula opening& Trx of fistula, if no fistula light
packing with gauze,
• Submucosal – opening with sinus forceps(proctoscope)
• Intersphincteric and intramuscular- internal sphincterotomy
 TREATMENT
• Supralevator- through the rectum
• Horseshoe abscess- drainage through midline incision
posterior to anus/rectum + counter drainage place in each
ischorectal fossa
• Treat underlying conditions or co-morbidities.
COMPLICATIONS
• Complications of dx/Complications of the treatment
-acute – urinary retention, bleeding, faecal impaction, thrombosed
haemorrhoid
- Fistula
-Recurrent abscess
-Necrotizing infection of the perineum
-Faecal incontinence
-Cancer of fistula tract- rare
- Septicaemia
 FOLLOW-UP
• Sitz bath
• Digital examination
• Healing expected by 6wks
• Recurrent/non-healing- indication for more investigation to R/O
fistula
• Wound dressing
 FISTULA-IN-ANO
• FISTULA – IN – ANO is a track lined by granulation tissue or
epithelium connecting the anal or rectal mucosa with the perianal
skin.
• This is usually the chronic phase of Anorectal abscess.
• Anorectal abscess and fistula are largely different phases of same
disease.
AETIOPATHOGENESIS.
• IT is linked to that of anorectal abscess.
1. Via pyogenic infection of anal crypts --> intersphincteric abscess.
2. Via a badly drained anorectal abscess whatever its aetiology
3. Granulomatous conditions: TB, Amoebiasis, Actinomycosis,
Schistosomiasis, Lymphoma, Ulcerative colitis, Crohn’s disease.
4. OTHERS : - Cancers of the anorectum.
- Previous surgical & obstetric operations with infected badly
healed perineal wounds.
 Classification:
A. Based on position of the internal opening
• High – at or above the anorectal ring.
• Low - Below the anorectal ring.
1 . High fistula – pelvirectal (supralevator),
- High intersphincteric,
- High submucous.
 2. Low level fistula – Submucous
- Subcutaneous
- Intermuscular(low anal).
B. Based on plane of the tract – Park’s classification.
1 . Intersphincteric – most common, tract confined to this
space.
 Classification.
2. Trans-sphincteric – Tract connects the inter-sphincteric tract
to the ischiorectal fossa passes through the external sphincter.
3. Supra- sphinteric – Tract loops over external sphincter &
perforates the levator ani.
4. Extra-sphincteric – Tracts from rectum to perianal skin,
external to the sphincter complex.
 Clinical Features.
• PERIANAL DISCHARGE: Seropurulent fluid, faeces, flatus.
Usually initially a boil ( peri anal). The discharge maybe
intermittent with superficial healing.
• PAIN – Pus accumulation, Fissure-in-ano.
• There maybe other histories suggestive of aetiology of the
preceding anorectal abscess.
 Examination.
• OPENING- Usually elevated, indurated, some times inflamed
exuding pus.
Maybe healed over & seen with difficulty.
• INTERNAL ORIFICE – in the anorectum
Salmon-Goodsall’s Law illustrated
 INVX
• FISTULOGRAM – Identifies tract of fistula & also complex
fistulae
• OTHERS – As in Anorectal abscess
 TREATMENT.
1. LOW LEVEL FISTULA:
 Fistulotomy – with deroofing.
 Fistulectomy – Anterior non inflammed & non infected fistula.
 Park’s operation – drains intersphincteral region by internal
sphincterotomy, then lays open the part lateral to the external
sphincter.
 TREATMENT – High level fistula.
1. SETON: Main track into the rectum is identified and a stout
silk or linen ligature(SETON) is passed through it and tied
loosely around the remaining part of the external anal
sphincter.
2. Two- staged treatment.
 COMPLICATIONS.
• Sepsis.
• Anal incontinence.
• Psychological depression.
 HAEMORRHOIDS
• Symptomatic anal cushions.

• Haemorrhoidal venous cushions are normal structures

• of anorectum and universally present in all persons.
 AETIOLOGY
• Constipation • Colon cancer
• Pregnancy • Portal hypertension and
• Obesity anorectal varices
• Prolonged sitting • Inflammatory bowel disease
• Chronic diarrhea • Rectal surgeries
• Chronic cough • Familial
• Straining e.g. in BPH, CaP • Smoking
 CLASSIFICATION
• Internal haemorrhoids
• External haemorrhoids
• Mixed haemorrhoids
• GRADE I painless bleeding, no prolapse.
• GRADE II prolapse on defecation that reduces spontaneously.
• GRADE III prolapse that has to be digitally reduced
• GRADE IV Permanent Prolapse.
 CLINICAL FEATURES
• Painless bleeding
• Anal Prolase
• Perianal Pruritus
• Perianal pain
• Skin tags
• P/R Examination
 INVESTIGATION
• Proctoscopy
• Sigmoidoscopy
• Colonoscopy
• Others
 TREATMENT
• Conservative
- Sitz bath
- High fibre diet
- Topical analgesics
- Stool softeners
 Minimally invasive techniques
• Rubber band ligation
• Sclerotherapy
• Coagulation
• Electrocautery
• Cryosurgery
• Use of Laser
 Surgery
• Haemorrhoidectomy – open or closed
• Stapled haemorrhoidopexy
 COMPLICATIONS OF HAEMORRHOIDECTOMY
• EARLY: • LATE
 Haemorrhage  Anal stenosis/stricture
 Acute urinary retention  Incontinence
 Anorectal abscess
 Anal fissure
 COMPLICATION OF HAEMORRHOIDS
• Strangulation and thrombosis
• Ulceration
• Gangrene
• Fibrosis
• Anorectal abscess
• Portal pyaemia
• Massive lower GI bleeding
 DIFF DIAGNOSIS
RECTAL PROLASE
RECTAL/ANAL CANCER
ANAL WARTS
RECTAL POLYPS
PERIANAL ABSCESS
IBD
 ANAL FISSURE

• A painful linear ulcer in the longitudinal axis of the lower anal

canal.
• Occurs commonly in the midline.
• Posterior fissure more common in males while anterior fissures
commoner in females.
• Lateral Fissures are usually due to IBD, AIDS, TB, etc.
• Aetiology: Hard stools, Haemorrhoidectomy, IBD.
 CLASSIFICATION/PATHOLOGY
• ACUTE
• CHRONIC

• Acute Fissures- a deep linear wound with exposed anal

sphincter or granulation tissue.
• Chronic Fissures – linear ulcer with induration of the lateral
edges, has a proximal hypertrophied anal papilla and distal
sentinel pile.
 TREATMENT
• CONSERVATIVE – Pharmacologic sphincterotomy using topical
agents like GTN, Diltiazem, Nifedipine ointment, Botox.

• OPERATIVE – Internal sphincterotomy, Anoplasty, Classic

Excision.
 RECTAL PROLASE

• Defined as circumferential descent of the bowel through the

anus,
• Types
– 1. Incomplete or mucosal prolapse
– 2. Complete Prolapse
• Aetiology
– Increase intra-abdominal pressure
– Change in bowel habit
– Atony of anal canal
– Prolapsing haemorrhoids
– Hind gut motility disorder
– Central nervous system disease.
• TREATMENT
– Non-operative
– Operative
• COMPLICATIONS
– Ulceration and haemorrhage
– Irreducibility
– Rupture of the prolapse
• Differential diagnosis
– Prolapse rectal polyp
– Intussusception protruding through the anus
 ADDITIONAL READING
• PILONIDAL SINUS
• PERIANAL WARTS
 CONCLUSION
• BENIGN ANAL CONDITIONS commonly occur, patients usually
present when symptoms are unbearable,
• There are varied differentials of benign anal conditions.