Anorectum: Douleurs Anales Flashcards
What is “rectite inflammatoire”?
Une inflammation limitée à 15 cm de l’anus
Can be caused by UC or Crohns —> UC = proctitis
Dx during colonoscopy…
- An ulcerated mucous membrane
- Blood vessels not visible
What can cause a “rectite infectieuse”?
Viral: Herpes, HPV
Bacterial: chlamydia, gonorrhoea, syphilis
Fungal: candidase
What is rectite radique?
Results from irradiation to treat prostate, uterine or rectal cancer
Characterized as:
- A fibrous proliferation causing an abnormal and palpable stiffness on a rectal examination.
- A proliferation of small blood vessels in the scar tissue. These vessels are fragile and manifest themselves by painless rectorragies.
Physiopathology of solitary rectal ulcers:
Repeated trauma associated with defecation, such as an invagination of the rectum, which sometimes results in an external prolapse that is evident on external physical examination
Insertion of foreign bodies
Important to ddx from cancer, syphilis and Crohns
What is an anal abcess?
An abscess is a collection of pus in a closed cavity created by the infectious destruction of tissue
Clinical presentation of rectal ulcers:
The anal abscess will be characterized by four clinical signs classically declined in Latin:
- Rubor: redness, due to the vasodilatation of the vessels of the adjacent tissues.
- Tumor: swelling, due to oedema and the increasing volume of bacteria that proliferate
- Calor: warm to the touch, due to vasodilatation
- Dolor: pain on palpation
Note: On palpation, an abscess may appear solid due to the high internal pressure.
How are anal abcesses characterized?
According to location:
Intersphinctérien
Périanal
Ischio-rectal
Supralevateur
How does pain “work” in anal abcesses?
L’abcès anal débute habituellement par une infection d’une glande anale sous-cutanée située à la ligne pectinée ou “ligne dentelée”. La douleur spasme les sphincters et l’infection pénètre les tissus puis traverse les sphincters
How are anal abscesses tx?
Golden rule: an abscess must be drained (i.e. opened) to empty the pus it contains and thus release the pressure. Antibiotics alone, without drainage, are to be avoided, as they do not penetrate the pressure-affected tissue around the abscess, nor the pus in the abscess itself.
What is an anal fistule?
A fistula is an extra-anatomical path between two epitheliums (Frequent complication of anal abscesses)
Clinical presentation of anal fistules:
Chronic leakage of pus or fecal fluid from the fistula that stains your underwear.
The fistula originates at the jagged line of the anal canal and ends in the skin at the site of surgical drainage (or spontaneous drainage site).
If the skin heals, stool will initiate a recurrence of the abscess.
How are anal fistules tx?
Insert a suture into the fistula (Seton’s suture) and leave it in place for weeks. The thread keeps the fistula open (prevents the recurrence of abscesses) and causes the path to heal
- Fistulotomy: surgical procedure that opens the fistula’s path. The fistula will first heal at its deepest portion to gradually heal.
What is Fournier’s gangrene?
Severe perineal infection
What are some clinical manifestations of Fournier’s gangrene? (3)
Crépitus: gaseous gangrene produced gases that can be felt when palpating —> patients life is at danger at this point
Necrosis: visually evident, skin is white, purple or ecchymotic —> capillaries don’t refill after being palpated
Septic shock: hypotension, tachycardia, anuria (nonpassage of urine)
How is Fournier’s gangrene tx?
Antibiotics and debridement of tissue
“Colostomie de derivation” —> pour dériver les selles de la plaie béante qui résulte du débridement chirurgical des tissus dévitalisés
What is a sinus pilondal? (de nid de poils)
Thus, a pilonidal sinus is a path that opens to the skin through one or a few tiny orifices, and contains hairs at its deep closed base.
Favours the formation of an abscess when the hairs are colonized by skin bacteria.
Edema secondary to the initial inflammation closes the skin orifice and causes a very painful abscess
What is a sinus?
An extra-anatomical path that is “one-eyed”.
The sinus has a single opening, unlike the fistula which has an opening at each end
How are pilonidal sinuses tx?
Drain abscess (acute phase)
Elective resection of the sinus including the hair follicle
What are haemorrhoids?
veines hémorroïdaires internes et externes qui s’engorgent de sang lors de la défécation ou lors d’efforts physiques avec manœuvre de Valsalva
What are non-thrombosed internal haemorrhoids?
Internal haemorrhoidal veins dilate with time and age and sometimes prolapse outside the anus when defecating
Become palpable when the anus is wiped clean
Clinical presentation of non-thrombosed internal hemorrhoids?
Grade I : pas de prolapsus, mais palpable au toucher rectal
Grade II : réduction spontanée après la défécation
Grade III : réduction manuelle nécessaire
Grade IV : prolapsus récidivant ou constant
How are non-thrombosed internal hemorrhoids tx?
Barron Ligature: Haemorrhoidal tissue is sucked with an applicator and an elastic band is applied. The haemorrhoid and its redundant mucosal tissues become thrombosed and necrotic, usually within 5 to 7 days
DO NOT DO ON A CIRRHOTIC PATIENT W/ PORTAL HYPERTENSION
What are thrombosed internal haemorrhoids?
Acute coagulation of blood in a chronically dilated hemorrhoid that prolapses outside the anal sphincter
The sphincters compress blood-soaked hemorrhoid by the strain of defecation and the blood then clots
The visual examination is diagnostic: a mass is visible at the anus.
Usually the volume is much greater than that of a thrombosed external haemorrhoid.
Since the hemorrhoid is of internal origin, but visible outside the anus, it is commonly referred to as internal-external haemorrhoidal thrombosis
Clinical presentation of thrombosed internal hemorrhoid:
Sx follow this characteristic sequence:
- Sudden appearance of the painful mass
- Max. pain for 48 hours
- Pain that gradually diminishes over 4 to 10 days
How are thrombosed internal haemorrhoids tx?
If less than 48 hours since pain started: surgery to remove clot
If more than 48 hours: medical treatment
- Siege baths
- Fibre supplements
- Emollient to facilitate stool evacuation without Valsalva
- Ointment: topical analgesic and steroid, not very useful.
- Injection of a local anaesthetic: not really used because of its short duration of action.
What are external hemorrhoids?
Engorgement of veinous plexus under external anal epidermis
What are thrombosed external haemorrhoids?
Sometimes the venous content under pressure thromboses.
Visual examination is diagnostic: a dark clot is visible under the thin epidermis at the outer edge of the anus. Looks like a blueberry in colour and volume.
Since the epidermis is innervated, it is painful to palpate. A simple excision under local anesthesia will relieve the patient, but without treatment, it will resolve spontaneously in a few days.
What is an anal fissure?
small tear in the thin, mucosa that lines the anus —> sometimes can become chronic with passage of hard stools, some patients don’t eat to avoid the pain (can be extremely painful)
How are anal fissures tx?
- Siege baths
- Emollient
Relaxation of the internal sphincter:
- Ointment with nitroglycerin 0.2 %.
- Ointment with diltiazem 0.2%.
- Ointment with nifedipine 0.2 %.
- Injection of botulism toxin (Botox) into the internal anal sphincter, which paralyzes it for three months, with the risk of suffering from incontinence, but with the benefit of allowing the fissure wound to heal
Last resort: surgery can be used —> anal dilation and/or partial internal sphincterotomy
What are genital warts? (condylomes acuminés)
sexually transmitted infection caused by certain types of human papillomavirus (HPV) that causes proliferation of growths around the anus
other than the danger of passing to partners… they can cause itching and pain
How are genital warts tx?
Eradication of warts:
- Podophylline
- Trichloroacetic acid
- Electrocoagulation and excision
- Cryotherapy
- Laser
- Immunomodulator (ex: Imiquimod)
What is prurit anal? (itching)
It is a sx of something… can be primary (idiopathic), hygienic, or secondary to another pathology
Physical examination is essential. The presence of certain lesions will indicate the choice of treatment, or a rectal examination will allow us to discover a tumour lesion or a haemorrhoidal prolapse.
What are some of the most common secondary causes of anal itching?
- Allergies
-
Dermatological disease
- Contact dermatitis
- Psoriasis
-
Skin infection
- Tinea circinata
- Herpes simplex
- Sarcoptes scabei (scabies)
- Pediculus pubis
- Inflammation
- Gynaecological pathologies
- Anorectal pathologies
Important questions to ask regarding prurit anal:
- Medical and surgical history
- Duration, timing, severity and recurrence of the itch over time
- Use of antibiotics
- Vaginal infections
- Anal intercourse
- Partial incontinence
- Anorectal pathologies
What are some epithelial tumours of the anorectum?
Adenocarcinoma: cancer of the muqueuse rectale
Transitional carcinoma of the anus: muqueuse transitionnelle
- (ligne dentelée —> peau pileuse du périnée)
Epidermoid cancer: keratinized squamous epithelium, can be In situ or infiltrating
Maladie de Bowen: carcinome épidermoïde intraépidermal
Maladie de Paget: carcinome extramammaire
Clinical presentation of epithelial tumours of the anorectum:
Pain
Plates or nodules
Scrotal and inguinal lymphadenopathies: systemic lymphatic drainage, not to the digestive lymphatic network.
Tx of epithelial tumours of the anorectum:
Chemo, radiotherapy, surgery (local or abdominoperineal resection —> anus, rectum, and sigmoid colon are removed)
What are some non-epithelial tumours of the anorectum? ( types)
Melanoma, sarcoma, and lymphoma
