Benign Conditions of the Anal Area

Question 1

What questions are key to ask a patient if they present with a problem of the anal area?

Answer 1

• symptom duration?
• First episode?
• Bleeding – fresh? Dark? mixed with stool? Dripping in the toilet or just on the paper?
• Pain – sharp/dull? How long does it last?
• Anything protruding through the back passage?
• Associated discharge?

Question 2

What are haemorrhoids?

Answer 2

• Enlarged vascular cushions in the lower rectum and anal canal

Question 3

HOw do patients present with haemorrhoids?

Answer 3

• Painless bleeding
• Fresh, bright red blood, not mixed with stool, usually on the paper
• Perianal itchiness
• No change in bowel habit
• No weight loss

Question 4

Describe the findings on examination of a patient with haemorrhoids

Answer 4

• External inspection can be normal
• Maceration of the perianal skin
• Obvious haemorrhoids if 3rd degree
• Digital Rectal Exam – normal, unless thrombosed

Question 5

Describe the classical position of haemorrhoids

Answer 5

• corresponds to branches of the superior haemorrhoidal artery
• 3 , 7 and 11 o’clock position with the patient in the lithotomy position

Question 6

What investigations can be used for haemorrhoid diagnosis?

Answer 6

• PR examination
• Rigid sigmoidoscopy
• Proctoscopy
• Flexible sigmoidoscopy in pts >50 yrs

Question 7

How are haemorrhoids managed?

Answer 7

• Mx if Symptomatic
• Sclerosation therapy (5% phenol in almond oil)
• Rubber band ligation
• Open/stapled haemorrhoidectomy
• Haemorrhoid artery ligation (HALO) procedure [completed under spinal or GA]

Question 8

What are the two types of rectal prolapse?

Answer 8

• Partial (anterior mucosal prolapse)

- Complete (full thickness)

Question 9

How does a patient normally present with a rectal prolapse?

Answer 9

• Protruding mass from anus
• especially during defecation
• May reduce spontaneously
• Bleeding and passing mucus per rectum is common
• Examination usually shows poor anal tone

Question 10

How is a complete anal prolapse managed?

Answer 10

• Many pts = too frail for surgery
  => bulking agent and education on manual reduction

Surgery:

• Delorme’s procedure
• Perineal rectopexy
• Abdominal rectopexy
• Anterior resection

Question 11

How is incomplete prolapse treated in children vs in adults?

Answer 11

• In children – dietary advice and Tx of constipation

- In adults – treatment similar to that of haemorrhoids

Question 12

What is an anal fissure?

Answer 12

• Tear in the anal margin
• due to passage of a constipated stool
• Usually in the midline posteriorly
• but may be occasionally anterior
• Multiple fissures may be due to Crohn’s disease

Question 13

How do patients present with an anal fissure?

Answer 13

• Acute severe anal pain
• following episode of constipation
• “Glass passing through the back passage”
• Pain lasts for up to 30 mins after defecation
• Bright rectal bleeding

Question 14

How is an anal fissure treated?

Answer 14

• Dietary advice
• stool softeners
• Pharmacological sphyncterotomy (0.3% GTN oint, 2% Diltiazem oint) PR for 6 weeks
• Lateral sphyncterotomy
• Botox injection

Question 15

What is meant by a fistula-in-ano?

Answer 15

• Abnormal communication between two epithelial surfaces

- internal opening in anal canal and one or more external openings on the peri-anal skin

Question 16

What conditions can cause a fistula-in-ano?

Answer 16

Rarely caused by:

• Crohn’s disease
• TB
• carcinoma

Question 17

How can a fistula-in-ano be investigated?

Answer 17

• Examination Under Anaesthetic of anorectum
• Rigid sigmoidoscopy, proctoscopy
• Flexible sigmoidoscopy
• MRI

Question 18

How is fistula-in-ano treated?

Answer 18

• Surgery (Two stage procedure)

Question 19

What are the complications of treating a fistula-in-ano?

Answer 19

• Pain/Bleeding
• Incontinence of flatus or stool
• Recurrence
• Further surgery