Anorectal and Pelvic Floor Disorders Flashcards
What is the function of the anorectum?
Control of defaecation
Maintenance of continence
What does the anorectum need for function?
Pelvic floor
Rectal compliance
Intact pelvic neurology
Describe the anorectum
Has 3 rectal folds - superior, middle and inferior
There are anal columns
Pectinate line
What are haemorrhoids?
Swellings containing enlarged blood vessels that are found inside or outside of bottom
They are painless and can cause bleeding
What are haemorrhoids caused by?
Straining - constipation
What is the treatment for haemorrhoids?
Laxatives for constipation
Rubber band ligation
Surgical - HALO, Anopexy, haemorrhoidectomy
Explain an anal fissure
A tear or ulcer that develops on lining of large intestine near the anus
Pain, bleeding and feels like passing glass splinters
What is the treatment for anal fissure?
Laxatives for constipation
GTN/Diltiazem and Lignocaine
Surgical - botox which relaxes sphincter so blood supply can heal the fissure
Sphincterotomy
What should you be aware of in chronic anal fissure?
Anal cancer
What is a perianal abscess?
Cavity in the anus fills with pus
Excruciating pain and signs of sepsis
What are the risk factors for perianal abscess?
DM, BMI, immunosuppression and trauma
What is the treatment for perianal abscess?
Antibiotics if septic
Incision and drainage of pus
Do not go looking for fistulas
Describe a fistula in ano
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
What are the types of anal fistulas?
Extrasphincteric, suprasphincteric, trans-sphincteric, intersphincteric and submucosal
What is the treatment for anal fistulas?
Difficult to treat
Seton - drain sepsis in fistula tract
Sphincter preservation techniques
Lay open - beware in women
Explain anal cancer
Is painless, causes bleeding, indurated
Reg flag signs
FIT test positive
What are routine investigations for anorectal disorders?
PR exam, proctoscopy, rigid sigmoidoscopy, colonoscopy, CT colonoscopy, CT scan and MRI rectum
What are special functional investigations for anorectal disorders?
Colonic Transit studies, anorectal manometry, endoanal USS, defecating proctogram, anoscopy and EUA
What are pelvic floor disorders?
Collection of symptoms related to defaecation
Obscure symptomatology
Social limitation
What are the causes for pelvic floor disorders?
Child birth related
Other causes - surgery, abuse, perianal sepsis, LARS - low anterior resection syndrome
Who does pelvic floor disorders affect?
Predominantly women
2 groups - parous women which is largest group and symptoms related to pregnancy
All other patients including men
What are the other reasons for pelvic floor disorders that are not parous women?
Surgical misadventure
Neurological/ CT disorders
Psychological/ behavioural issues
What are some broad disorders?
Chronic constipation
Faecal incontinence
Mixed disorders
Chronic pelvic pain
Explain chronic constipation
Difficulty or reduced frequency of evacuation
Types - dietary, drugs, organic, functional
What are some drugs causing constipation?
Aluminium antacids, antimuscarinics, antidepressants, antiepileptics, antipsychotics, antispasmodics, calcium and iron supplements, diuretics, opioids and verapamil
How is chronic constipation assessed?
Exclude sinister pathology by colonoscopy/CT, bloods, qFIT, coeliac serology and faecal calprotectin
Colonic transit studies, defaecating proctogram
When should chronic constipation be treated?
Most want sinister pathology excluded
Aggressive dietary management, ensure adequate water intake, life style optimisation
How is chronic constipation treated?
Start with regular laxatives
Ensure compliance
Consider combination therapy
Other - peristeen irrigation system and Qufora irrigation
What are second line drugs in chronic constipation?
Prucalopride for women only
Lubiprostone for all adults
Linaclotide for IBS
What are the surgical options for slow transit?
Subtotal colectomy with end ileostomy
Subtotal colectomy with ileorectal anastomosis
What are the types of faecal incontinence?
Passive - Internal sphincter defect
Urge - Rectal pathology, functional
Mixed - prolapse
Overflow - constipation
How is faecal incontinence assessed?
Clinical exam, anorectal physiology, endo-anal USS and defaecatory proctogram
What is looked at in PR exam?
Peri-anal skin, resting anal sphincter tone, rectocoel, paradoxical contraction pubirectalis, haemorrhoids, prolapse
Explain an anal manometry
Tests anal muscles by inserting balloon inflated with air or water to test rectal function
What does an anal manometry measure?
Anal sphincter function, functional length of anal canal, pressure in response to cough and during defaecation, recto-anal inhibitory reflex
Explain EAUS of high anal canal
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
Describe a defaecating proctogram
Best modality
Provides info on pelvic floor motility, muscles, morphology, compensated or decompensated function and internal hernias
MRI proctogram is more time
What is the management of faecal incontinence?
Aggressive conservative measures - low fibre diet, loperamide, pelvic floor exercises, EMG, irrigation and anal plug
What are surgical interventions for faecal incontinence?
Sphincter repair and correct anatomical defect
Sacral nerve stimulator
Anal bulking agent for passive FI - permacol, gatekeeper, sphinkepper
What are some mixed disorders?
Rectocoel - passive loss of stool from being trapped due to incomplete evacuation
Internal rectal prolapse - symptoms of obstructive defaecation and FI
Explain chronic pelvic pain
Multiple behavioural/ psychological issues
Determine cause of pain
EUA, pudendal nerve block, regular enemas
Should we use mesh or not?
No - stringent patient selection
Biological mesh if required
Absorbable sutures and tissue glue
What is treatment for rectal prolapse?
Rectopexy if fit and active patient
Do not attempt repair without training
