Anal Pain Flashcards
Acute Anal Fissures
Clinical
• Pain during defecation -> tearing pain
• Bleeding
− Streaks of blood on stool
− On toilet paper
• Persists for minutes to hours after defecation throbbing and aching pain
Acute Anal Fissures
Aetiology
Constipation: Forceful dilation of anal canal
Acute Anal Fissures
Pathogenesis
• Vicious cycle: tearing-pain-spasm
1. Acute tear
2. Pain
3. Causing an increase in sphincter tone -> which progresses to spasm -> ischaemia -> decreased healing potential
Acute Anal Fissures
Characteristics
12 (10% anterior midline) and 6 o’clock (90% posterior midline)
Fissure
Acute Anal Fissures
Differential
- Chron’s disease
- Anal Ca
- TB (rarely)
Acute Anal Fissures
Management
• Conservative: WASH
⎫ W: warm water, shower or sitz bath after bowel movements
⎫ A: analgesia
⎫ S: stool softener
⎫ H: high fibre dietChronic Anal Fissures
Clinical
• Pain during defecation -> tearing pain
• Bleeding
− Streaks of blood on stool
− On toilet paper
• Persists for minutes to hours after defecation throbbing and aching pain
Chronic Anal Fissures
Aetiology
Constipation: Forceful dilation of anal canal
Chronic Anal Fissures
Pathogenesis
• Vicious cycle: tearing-pain-spasm
1. Acute tear
2. Pain
3. Causing an increase in sphincter tone -> which progresses to spasm -> ischaemia -> decreased healing potential
Chronic Anal Fissures
Characteristics
12 (10% anterior midline) and 6 o’clock (90% posterior midline)
- Fissure
- Inflammatory polyp inside
- Sentinal pile outside (inflammation fibrosis skin tag)
Chronic Anal Fissures
Differential
- Chron’s disease
- Anal Ca
- TB (rarely)
Chronic Anal Fissures
Management
• Conservative: WASH
⎫ W: warm water/sitz baths after defecation
⎫ A: analgesia (topical e.g. remicane jelly INSIDE anus)
⎫ S: stool softener
⎫ H: high fibre diet
• Pharmacology
⎫ Topical CCB (nifedipine) 10mg/NO + remicane jelly
♣ Placed inside anus
♣ S/E: dizziness (hypotension)
⎫ Injected botulinum toxin (inhibits Ach relax the sphincter muscle increased blood flow + healing)
• Surgery (failed medical therapy; contraindication to medial therapy)
− Lot’s procedure (dilate sphincter)
− Lateral (TO ULCER) internal sphincterotomy (of involuntary i.e. internal muscle)
⎫ Disadvantage: 5% risk of fecal incontinence
Anorectal Abscess
Clinical
- Severe, throbbing, anal pain + tenderness
* Worse with straining
Anorectal Abscess
Risk Factors
Host: immunosuppression
• DM
• Corticosteroids, chemotherapy
• Chron’s disease
Micro-organism
Contamination
Anorectal Abscess
Aetiology
• Trauma
− Abrasions (scratching)
− Penetrating
• Non-trauma
− Hair follicle
− Fissure
− Haemorrhoids
Anorectal Abscess
Aetiopathogenesis
- Crytoglandular theory
− Infection cryptotitis OR trauma (from stool)
− Oedema
− Obstruction of drainage of anal gland (apocrine glands – scent)
− Stasis
− Bacterial overgrowth
− Abscess of anal gland (in interspinteric space) - Spread
− Vertically downward (perianal)
⎫ Horizontally laterally (ischiorectal)
− Vertically upward (supralevator)
− Horizontally medially: submucosal, intramuscular
Anorectal Abscess
Micro-organisms
- E. coli
- Proteus
- Streptococci
- Staphylococci
- Bacteroides
- Anaerobes
Anorectal Abscess
- Supralevator Abscess
- Intramuscular Abscess
- Submucosal Abscess
- Perianal Abscess (60%)
- Intersphincteric Abscess (5%)
- Ischiorectal Abscess (20%)
Anorectal Abscess
Complications
Fistula-in-ano
Anorectal Abscess
Management
Acutely
• Analgesia
• Antibiotics (if immune-compromised)
• Surgery
− Drainage
− If associated fistula fistulotomy (reduce recurrence rate)
Post-op wounds/prevent recurrence
• Sitz baths/ water after defecation
Fistula-In-Ano (Perianal Fistula)
Clinical
- History of an abscess + drainage
- Watery/purulent discharge + pruritus
- Recurrent episodes of pain (if fistula fills with pus + bursts)
Fistula-In-Ano (Perianal Fistula)
Aetiopathogenesis
• Abscess -> bursts in 2 directions:
− Anal canal
− Externally into the skin
Fistula-In-Ano (Perianal Fistula)
Classification
(diagnose? Probe, hydrogen peroxide, MRI)
• Course: shape: internal opening
1. Goodsall’s rule
− If the external opening is anterior, the fistula usually runs directly into the anal canal
− If the external opening is posterior, the fistula usually curves to the posterior midline of the anal canal
• Course: fistulous tract
− Superficial
− Intersphincteric: The tract begins in the space between the internal and external sphincter muscles and opens very close to the anal opening
− Transspincteric: It then crosses the external sphincter and opens an inch or two outside the anal opening
− Extraspincteric: The tract begins in the space between the internal and external sphincter muscles and turns upward to a point above the puborectal muscle, crosses this muscle, then extends downward between the puborectal and levator ani muscle and opens an inch or two outside the anus
− Supraspincteric: The tract begins at the rectum or sigmoid colon and extends downward, passes through the levator ani muscle and opens around the anus
Fistula-In-Ano (Perianal Fistula)
Management
Definitive
Conservative -> fibrin glue
Surgery
• Fistulotomy
− Does not involve external sphincter
1. Primary fistulotomy: unroof tract from external to internal opening, allow drainage, heals by secondary intention
− Involved external sphincter
1. Staged fistulotomy : skin and fat are divided but the muscles are left intact
2. Seton suture: a circular drain called a seton is placed from the external opening, through the tract and internal opening and brought out of the anal canal. It is then tied to itself as a loop
− Why?: risk of incontinence high if muscle cut as it is already compromised
− MOI: allows abscess to drain and to contract down. It also keeps the tract and external site open so that a new abscess is much less likely to develop
• Fistulectomy: excision of tract
− Disadvantage: associated with 3 x higher risk of flatulence + incontinence, therefore not first line
Post-op wound/reduce risk of recurrence
• Hygiene
− Sitz baths (OR just water if you can’t – for a couple of minutes)
⎫ After defecation
⎫ Water + salt, savlon, chlorhexidine
⎫ 30 mins
− Gauze after wash
