Anorectal and Pelvic Floor Disorders

Question 1

What is the function of the anorectum?

Answer 1

Control of defaecation
Maintenance of continence

Question 2

What does the anorectum need for function?

Answer 2

Pelvic floor
Rectal compliance
Intact pelvic neurology

Question 3

Describe the anorectum

Answer 3

Has 3 rectal folds - superior, middle and inferior
There are anal columns
Pectinate line

Question 4

What are haemorrhoids?

Answer 4

Swellings containing enlarged blood vessels that are found inside or outside of bottom
They are painless and can cause bleeding

Question 5

What are haemorrhoids caused by?

Answer 5

Straining - constipation

Question 6

What is the treatment for haemorrhoids?

Answer 6

Laxatives for constipation
Rubber band ligation
Surgical - HALO, Anopexy, haemorrhoidectomy

Question 7

Explain an anal fissure

Answer 7

A tear or ulcer that develops on lining of large intestine near the anus
Pain, bleeding and feels like passing glass splinters

Question 8

What is the treatment for anal fissure?

Answer 8

Laxatives for constipation
GTN/Diltiazem and Lignocaine
Surgical - botox which relaxes sphincter so blood supply can heal the fissure
Sphincterotomy

Question 9

What should you be aware of in chronic anal fissure?

Answer 9

Anal cancer

Question 10

What is a perianal abscess?

Answer 10

Cavity in the anus fills with pus
Excruciating pain and signs of sepsis

Question 11

What are the risk factors for perianal abscess?

Answer 11

DM, BMI, immunosuppression and trauma

Question 12

What is the treatment for perianal abscess?

Answer 12

Antibiotics if septic
Incision and drainage of pus
Do not go looking for fistulas

Question 13

Describe a fistula in ano

Answer 13

Small tunnel that develops between the end of the bowel and the skin near the opening of the anus
Peri-anal sepsis, pus discharge and faecal soiling

Question 14

What are the types of anal fistulas?

Answer 14

Extrasphincteric, suprasphincteric, trans-sphincteric, intersphincteric and submucosal

Question 15

What is the treatment for anal fistulas?

Answer 15

Difficult to treat
Seton - drain sepsis in fistula tract
Sphincter preservation techniques
Lay open - beware in women

Question 16

Explain anal cancer

Answer 16

Is painless, causes bleeding, indurated
Reg flag signs
FIT test positive

Question 17

What are routine investigations for anorectal disorders?

Answer 17

PR exam, proctoscopy, rigid sigmoidoscopy, colonoscopy, CT colonoscopy, CT scan and MRI rectum

Question 18

What are special functional investigations for anorectal disorders?

Answer 18

Colonic Transit studies, anorectal manometry, endoanal USS, defecating proctogram, anoscopy and EUA

Question 19

What are pelvic floor disorders?

Answer 19

Collection of symptoms related to defaecation
Obscure symptomatology
Social limitation

Question 20

What are the causes for pelvic floor disorders?

Answer 20

Child birth related
Other causes - surgery, abuse, perianal sepsis, LARS - low anterior resection syndrome

Question 21

Who does pelvic floor disorders affect?

Answer 21

Predominantly women
2 groups - parous women which is largest group and symptoms related to pregnancy
All other patients including men

Question 22

What are the other reasons for pelvic floor disorders that are not parous women?

Answer 22

Surgical misadventure
Neurological/ CT disorders
Psychological/ behavioural issues

Question 23

What are some broad disorders?

Answer 23

Chronic constipation
Faecal incontinence
Mixed disorders
Chronic pelvic pain

Question 24

Explain chronic constipation

Answer 24

Difficulty or reduced frequency of evacuation
Types - dietary, drugs, organic, functional

Question 25

What are some drugs causing constipation?

Answer 25

Aluminium antacids, antimuscarinics, antidepressants, antiepileptics, antipsychotics, antispasmodics, calcium and iron supplements, diuretics, opioids and verapamil

Question 26

How is chronic constipation assessed?

Answer 26

Exclude sinister pathology by colonoscopy/CT, bloods, qFIT, coeliac serology and faecal calprotectin Colonic transit studies, defaecating proctogram

Question 27

When should chronic constipation be treated?

Answer 27

Most want sinister pathology excluded Aggressive dietary management, ensure adequate water intake, life style optimisation

Question 28

How is chronic constipation treated?

Answer 28

Start with regular laxatives Ensure compliance Consider combination therapy Other - peristeen irrigation system and Qufora irrigation

Question 29

What are second line drugs in chronic constipation?

Answer 29

Prucalopride for women only Lubiprostone for all adults Linaclotide for IBS

Question 30

What are the surgical options for slow transit?

Answer 30

Subtotal colectomy with end ileostomy Subtotal colectomy with ileorectal anastomosis

Question 31

What are the types of faecal incontinence?

Answer 31

Passive - Internal sphincter defect Urge - Rectal pathology, functional Mixed - prolapse Overflow - constipation

Question 32

How is faecal incontinence assessed?

Answer 32

Clinical exam, anorectal physiology, endo-anal USS and defaecatory proctogram

Question 33

What is looked at in PR exam?

Answer 33

Peri-anal skin, resting anal sphincter tone, rectocoel, paradoxical contraction pubirectalis, haemorrhoids, prolapse

Question 34

Explain an anal manometry

Answer 34

Tests anal muscles by inserting balloon inflated with air or water to test rectal function

Question 35

What does an anal manometry measure?

Answer 35

Anal sphincter function, functional length of anal canal, pressure in response to cough and during defaecation, recto-anal inhibitory reflex

Question 36

Explain EAUS of high anal canal

Answer 36

In men thin arc of muscle from deep part of EAS can be seen anteriorly In females deep part not seen, not be taken for rupture

Question 37

Describe a defaecating proctogram

Answer 37

Best modality Provides info on pelvic floor motility, muscles, morphology, compensated or decompensated function and internal hernias MRI proctogram is more time

Question 38

What is the management of faecal incontinence?

Answer 38

Aggressive conservative measures - low fibre diet, loperamide, pelvic floor exercises, EMG, irrigation and anal plug

Question 39

What are surgical interventions for faecal incontinence?

Answer 39

Sphincter repair and correct anatomical defect Sacral nerve stimulator Anal bulking agent for passive FI - permacol, gatekeeper, sphinkepper

Question 40

What are some mixed disorders?

Answer 40

Rectocoel - passive loss of stool from being trapped due to incomplete evacuation Internal rectal prolapse - symptoms of obstructive defaecation and FI

Question 41

Explain chronic pelvic pain

Answer 41

Multiple behavioural/ psychological issues Determine cause of pain EUA, pudendal nerve block, regular enemas

Question 42

Should we use mesh or not?

Answer 42

No - stringent patient selection Biological mesh if required Absorbable sutures and tissue glue

Question 43

What is treatment for rectal prolapse?

Answer 43

Rectopexy if fit and active patient Do not attempt repair without training